STATEMENT REFUTING CONTINUATION OF USER FEES
IN HEALTH AND EDUCATION IN TANZANIA

The position of gender groups and many CSOs in Tanzania is that unconditional withdrawal of user fees in the areas of health, education, and water is necessary.  It is in these sectors that vulnerable groups, particularly women, poor men, youth, and the rural population in general, have been impacted greatly; these sectors also are the arenas in which the government could have most positively helped these groups.  Low performance in these sectors is one of the primary indicators of poverty; health and education are central to the development of the country and key to increasing productivity and economic growth.  International donor policies that intend to support the processes of development in Tanzania should support these sectors rather than targeting them for budget cuts and privatization.

Since the government, forced by the policies of the IMF and the World Bank, has embarked on policies of withdrawal of state support, women, children, and the rural poor have been most heavily indicated, and there is data that demonstrates this.  The following are some specific comments on user fees in the areas of health and education

User Fees in the Education Sector :

In terms of the decision to abolish user fees at the primary school level, while we understand that our government is constrained, we contest that removing user fees at only one level is not sufficient and not sustainable.  Even if this decision opens up the opportunity for primary school education to more students, which is not clear in and of itself, this creates an even wider gap between the number of students attending primary school and those attending secondary school.  This gap has implications for increasing inequalities in terms of both gender and class.   In addition, there is no indication that other constraining aspects related to education for poor families will be removed and no assurance that the levels of support currently provided to teachers will be maintained or increased.  On the whole, the actual amount of money returning to the sector (Tsh. 10 –12 billion) is a very small amount of money and does not offer enough hope of addressing the major issues within the education sector. 

Attendance in primary schools in Tanzania remains at low levels.  In 1995, the gross enrolment of school age children stood at 77%.  This implies that 23% of school age children had not enrolled in schools.  Since the net enrolment was 55%, then 45% of school age children were not attending school (URT:  1997, Basic Statistics in Education, p. 8).  These figures only address one issue involved in primary school education, and do not touch other areas of quality, participation, retention, achievements, and other factors.  There should be more analysis on the expected implications of this policy that addresses these other factors. 

In general, in order to encourage equality of opportunity in education, user fees must be eliminated at the secondary school and other levels.  These fees contribute to the continued marginalisation of groups and a disadvantaged status between boys and girls, urban and rural, rich and poor.  A study by TGNP shows that, out of the 39% of secondary school students attending government schools, a mere 8% come from the poorest households in the Tanzania communities and 34% are from the relatively well-off 20% in the communities (TGNP, 1998).  Research by Katunzi and Sumra (1991) and TADREG (1996) showed that the cost-sharing policy has hit hardest boys and girls from low-income families, and therefore, reinforced low participation of both girls and boys.  Therefore, user fees for secondary school have a great deal of implications when discussing reducing poverty within the country.  The implication of these costs is that only an elite group receives the necessary education to be the prime decision-makers within the country.

Cost sharing, with its implications of the allocation of fewer resources at different levels, has implications for quality, gender equality, corruption, and even more, the fact that you are depriving the majority of the people of their basic rights. In order to address serious concerns about inadequacy of access of poor Tanzanians to primary and secondary education, we recommend that the government PRSP process to be approved by the WB soon consider the following, among others:

• Cost sharing interventions should be eliminated at the primary and secondary levels.  

• Within the PRSP, including a broader examination of user fees, looking at not only the actual fee but also all the other associated factors that constrain many people. This includes recognition of the fact that costs for a secondary education include books, desk, uniform, transport, housing, and others.

• Reshuffling its current resources, in order to better finance education.

• Instituting mechanisms for private sector to contribute to education,

• If there is any need remaining, creating creative and flexible mechanisms for parents and students to contribute to the educational system, such as through loans.

User Fees in the Health Sector:

Although the government’s overall objective of providing health status for all Tanzanians remains the same, there is an increased move towards privatisation and the public health sector is increasingly deprived of vital funds, moves encouraged by the IMF and World Bank.  In this process marginalized groups are increasingly impacted.  The government with the support of the World Bank should get rid of the user fees in the health sector, as the health of Tanzanians is crucial to development of the country.  The Public Health System is the right of all Tanzanians, who contribute to government revenue. The private sector has an important role to play but the Public Health System should be the backbone of health services the country.  Otherwise the lives of the citizens would be at risk, as so many examples have begun to emerge showing this.

First, we do not believe that the user fee policy in Tanzania is functioning.   There is evidence from several studies and newspaper articles to the contrary, indicating that pregnant women and rural poor are unable to access crucial medical services, although these groups are supposedly exempted.  These, especially the women, are the same groups that are doubly taxed, in that they are contributing to the future workforce of the country and then are required to pay for doing so. Women give involuntary subsidies to the health sector in various ways, including working as TBAs and caring for the infirm at home, and they should get some benefit.  The government has yet to make this connection between the health of the people and the unpaid labour of some groups such as women.  Apart from contributing to foreign exchange revenues through production and paying their taxes, they feed most of the patients in hospitals. On top of all that and cost sharing, they have to bring all important items during delivery when it is hypocritically claimed that mothers and children under five receive free treatment.

For antenatal care and childhood immunisations, the exemption seems to still be functioning.  However, for AIDS, mental illness and other diseases, fees are still imposed in one way or another.  The problem is that determination is done at the time of service.  Medicines and supplies are often not available at government hospitals, even if supposedly free, meaning that individuals have to buy from private dispensaries.  From research conducted in Kondoa district, if a maternity patient fails to pay the said amount, the normal procedure is that the patient will be given delivery services but will not be discharged until costs are met (TGNP, GBI research, 1997).

As it stands now, women pay for essential services that include cervical and breast cancer screening and treatment. These preventative measures are among the most cost-effective services. The government would be reaching most women in Tanzania if these services were funded. Donors could be asked to fund the initial equipment and supplies, but the government should be able to maintain the network through correct management and replacements.

In terms of the Health Sector Reforms, which provide more responsibilities for health sector at the local level, the vision is sound but problematic is whether the reforms would adequately confront the entrenched weaknesses in the health sector without marginalising large sectors of Tanzania’s population from health services.  Although in some few districts the CHF is working, there are many areas where it is not working, as mechanisms for ensuring its implementation have not been established. The PRSP document needs to provide coherent strategies and evidence on how the current policy is going to be affected in the real sense. It should also establish mechanisms for monitoring that this policy is currently being implemented. 

We are aware that the health reform programme has brought in a number of cost effective health interventions to be developed.  The government Budget if used effectively and according to proper priorities can meet most of the costs and donors can make important contributions since most of these are preventive or curative at dispensary and Health Centre levels. Interventions affecting infants and children such as immunisations receive much donor assistance.  The government, through the MoH, needs to install management mechanisms to ensure that equipment obtained is not lost, as well as providing annual maintenance funds and replacements when necessary.

In a country like Tanzania where communication is difficult, household surveys are expensive and cannot be done every day.  Yet those few which were done show important trends.  The most recently available is the Tanzania Human Resources Development Survey (HRDS) 1992/94 used by the Social Sector Review of the World Bank (1996).  This survey showed that people were alienated by poor services especially shortage of drugs caused partly by mismanagement and scarcity of funds.  Health workers attempted to supplement their wages through drug sales.  The current cost sharing plan is based on the assumption that with improved finances, the supply of drugs service will improve and the public system will win back patients.  However, without management reform patients will still get poor services.

Overall Comments:

From the above discussions, we propose the following:

1. The proposals on user fees on education and health sectors should be further analysed with more input from the civil society, meaning the public.  The PRSP process as it is currently drawn, does not allow for collection and use of available data and case studies from the public, meaning that the proposals are not coming from concrete experiences that are happening every day.  It is of critical importance that the PRSP processes open up and listen to the voices of the marginalised groups, such as women, youth and poor groups who will address the impacts of many of these policies, particularly the user fee.  

2. What we need is the abolition of user fees for health, education and water sectors, and the World Bank should stop making conditions on the same.  Also we are demanding that the World Bank, when it looks at issues of cost sharing, it should look at the issue much more broadly and holistically.  Experience shows that their strategies to overcome the constraints created by the effects of withdrawal of support to the social sectors come in piecemeal, e.g. special funds for education and for health.  

3. We also want to demand a more transparent monitoring and documentation of the implication of the costs of user fees and costs by donors, the World Bank, and the government.  We would like to know how many women and men, girls and boys are able to access and benefit from the provided services.  We want them to report the different types of services received by women and men, girls and boys.  This is because good services are a right and not a privilege.  

4. A greater part of the money saved when overseas countries say Tanzania can pay less interest on its loans or can pay interest later should be dedicated to education and health, while ensuring that spending from other sources remains the same or is increased.