printer printer Click on the green icon on the right
In Tanzania, ’death doesn’t wait’ for the poor to raise money
by Stephanie Nolen
27 February 2005

BUSWELO, TANZANIA — In the golden light of late afternoon, Anna Kasiana lies on a grass mat in her swept dirt yard, reading a Kiswahili edition of the Bible. There is a small pile of shelled beans beside her, the product of her afternoon’s work.

She has a thin, smooth face, but her long neck is marred by the bulging protrusion of goiter, as if she were a small snake that swallowed a mango. She has had goiter, an enlargement of the thyroid gland caused by an iodine-deficient diet, for 16 years. In the past two years, the enlargement has become so big that she struggles to turn her head, to use her shoulders, sometimes even to speak.

Once a busy woman, she spends more and more time on the mat in her yard, praying.

Ms. Kasiana, 50, knows what would fix her goiter problem: a simple operation at the hospital in the nearby city of Mwanza. But the treatment would cost 28,000 Tanzanian shillings, and the idea of ever saving that much money, the equivalent of about $31, elicits a dark, bitter, little laugh. “I’ve been trying to save it for five years.”

People in Tanzania, where the average annual income is $356, must pay for health care. Consultation at a local clinic costs about $2; opening a file at a hospital costs $5. These small fees raise only a fraction of the country’s annual health budget, but critics say they serve to keep a huge chunk of the population from having basic care.

The Tanzanian government instituted the fees at the behest of the World Bank more than a decade ago, but faces a growing chorus of demands to cancel them. In Tanzania, the bank has sensed the tide of public opinion and recently said the fees should go, but continues to advocate user fees for health care in dozens of impoverished countries.

Supporters say user fees raise money for the system, cut down on abuse and give people a sense of ownership. People such as Ms. Kasiana say all they do is keep the poorest people out of the clinics.

Ostensibly, health care for pregnant women and children under 5 is free in Tanzania, as is treatment for people living with HIV-AIDS.

It’s supposed to be free, but in reality it doesn’t happen; people don’t know. And even if they do know, they are told there are no drugs [for those who are not paying] and they feel that they don’t have the right to demand them,” said Maimuna Kanyamala, co-ordinator for a women’s advocacy group in the area called Kivulini.

Clinic staff demand fees because they are badly paid and overworked. An estimated 40 per cent of health-care jobs in Tanzania are unfilled, with the greatest shortages in the rural areas. Clinics often lack the most basic drugs, in part because of distribution problems but also because clinic staff steal them and sell them on the black market.

We have only this village dispensary, and usually there are no drugs,” said Daniel Royce, an 80-year-old farmer in Buswelo. “We have to go to the private hospital, but I don’t have the funds to pay that. So if death is coming I have to die. Death doesn’t wait until I raise the money.

The Tanzanian government says the fees raise funds for services. However, while few local councils keep good records on how much they take in, NGOs estimate that as little as 3 per cent of the country’s $325-million health budget last year came from user fees.

International donors, led by Britain, are beginning to pressure the government to drop the fees.

Canada’s position is to support that of the Tanzanian government; Ken Neufeld, head of the local office of the Canadian International Development Agency, noted that there is “a certain irony” in the fact that Canada thus supports user fees for health care.

The U.S. Congress passed a law last year that requires U.S. representatives to international financial institutions such as the World Bank and the International Monetary Fund to oppose user fees for education and basic health. Nonetheless, in Tanzania, the United States Agency for International Development continues to support health-care fees.

The U.S. law did help to propel the bank to switch from blanket demands for “community cost sharing,” to a case-by-case review. But on the ground, the change has been felt more strongly in education than in health care.

Today, the World Bank team in Dar es Salaam says the fees should go. “It’s country specific, and in Tanzania we are not advocating user fees in health,” country director Judy O’Connor said.

She said the government argument that if health care were free, the system would be abused and exploited by people with money is a weak one. “There are parts of this country where there are no rich people, and everything you do is pro-poor.

The bank’s latest innovation is something called the Community Health Fund. Under this plan, local people can pay 10,000 shillings (about $11) a year to enroll and then can use the system without charge. Councils that run the funds get matching grants from the bank.

But this form of subsidized health insurance is also beyond the means of many of the people who most need access. In areas where the funds were piloted, fewer than 5 per cent of people joined.

Source: The Globe and Mail (, Toronto, Saturday, February 19, 2005.

Stephanie Nolen