Country Focus: TANZANIA’S HEALTHCARE SYSTEM

By BENJAMIN OPUKO

Tanzania is a pre-demographic dividend country with a high population growth rate and a large number of young individuals. In 2017, the population was estimated to be 57.3 million, with women comprising 50.5% of the total population. Over the past three decades, Tanzania's population has grown steadily and is predicted to double in size by 2040. The majority of the population is under the age of 19, while the working-age population (i.e., individuals between the ages of 20 and 59) is expected to increase by 2050.

However, Tanzania faces significant health challenges, including high rates of child and maternal mortality, as well as infectious diseases such as HIV/AIDS, tuberculosis, and malaria. Despite economic growth, poverty remains widespread, particularly in rural areas, and access to healthcare is a significant barrier. The healthcare system faces numerous challenges, including underfunding, chronic staff shortages, and a lack of medical technology.

The government has made progress in improving health services, but the quality of healthcare facilities remains low by global standards. The government has a universal healthcare program, but the scarcity of facilities means that private medical insurance may be necessary for comprehensive coverage, including medical evacuation to countries with higherstandard facilities.

Overall, Tanzania's healthcare system ranks at 156th place on the WHO league table, with healthcare financing dependent on contributions from international donors. Despite the challenges, Tanzania is working towards achieving middleincome country status while continuing to improve access to quality healthcare for all its citizens.

Current Public Spending On Health Is Insufficient To Provide Access To Quality Services To All

There is a compelling argument that the current public spending on health is insufficient to provide access to quality services to all Tanzanians. While there has been a modest increase in per capita health spending across all public sources, from US$23.6 to US$28.5 between 2010 and 2017, this increase is merely keeping pace with population growth. The funding gap that exists is preventing the provision of basic healthcare services to the whole population, which is necessary to achieve universal health coverage.

Given that Tanzania is a pre-demographic dividend country with a rapidly growing and youthful population, the current public spending on health is even more inadequate. The adolescent population is projected to grow from 12 million in 2015 to 25-33 million by 2050, putting significant pressure on the healthcare system. If this gap in funding is not addressed, it will lead to an increase in out-of-pocket expenditure for healthcare, which will drive many Tanzanians into poverty.

The World Health Organization (WHO) recommends a minimum health expenditure of 6% of GDP to provide basic health services. However, Tanzania's health expenditure accounts for just 5.6% of GDP, translating to US$51 per capita, which is significantly lower than the recommended amount. This underfunding has led to a shortage of health workers, inadequate health infrastructure, and limited access to medical technology, all of which contribute to low-quality health services and limited access to care. To address this issue, the government has implemented reforms such as decentralization and payment-for-performance policies. These efforts are likely to have a positive impact on the health outcomes of the population and improve the overall functioning of the healthcare system in Tanzania. However, more must be done to ensure that all citizens have access to essential health services, particularly in the areas of maternal and child health.

Increased Per Capita Health Expenditure Still Falls Short Of Growing Demand

Tanzania is making noteworthy strides toward improving its healthcare system, as evident from the increase in health expenditure per capita. In 2019, the health expenditure per capita in Tanzania was US$40, indicating a substantial improvement from US$13 in 2000. The average annual growth rate of health expenditure per capita in Tanzania during this period was 6.91%, which is a positive sign of progress. It is crucial to continue increasing health expenditure per capita to ensure access to quality healthcare for all Tanzanians. Therefore, it is critical that the Tanzanian government increases public spending on health to provide access to quality services to all. A well-funded health system is necessary to provide pre-emptive care, treatment, and management of diseases and prevent health emergencies. This can be achieved through the implementation of sustainable health financing models and social health insurance schemes, which mobilize both public and private resources to enable equitable and sustainable health financing to achieve universal health coverage.

A study by USAID and Health Policy Plus on the Costing of Tanzania's Health Sector Strategic Plan V (HSSP V), 2020/21-2025/26 found that the yearly costs of health services in Tanzania are expected to increase from Tsh.3.7 trillion in 2021 to Tsh.6 trillion in 2025 (US$1.6 billion to US$2.6 billion), with a total five-year cost of Tsh.24 trillion (US$10.4 billion). The study revealed that the financial resource requirements are greatest for human resources for health and for infrastructure, which comprise 81 percent of the total health systems costs and 40 percent of the HSSP V overall. By the end of the HSSP V, there will be an expected 117,000 health service providers, a 21 percent increase over the estimated 97,000 at baseline. The study also revealed that logistics and governance represent about 10 percent of the total HSSP V costs.

(Source: USAID and Health Policy Plus on Costing of Tanzania’s Health Sector Strategic Plan V, 2020/21–2025/26).

If effectively implemented, the HSSP V is expected to save more than 200,000 additional lives and avert over 400,000 disability-adjusted life years by expanding services beyond current levels. The plan will also avert more than 100,000 child deaths, nearly 20,000 maternal deaths, and more than 40,000 stillbirths. In addition, it would reduce the probability of dying from an NCD between the ages of 30 and 70 and achieve more than 400,000 additional healthy life years beyond what could be achieved by maintaining current coverage of NCD and mental and neurological services interventions.

UNIVERSAL HEALTH INSURANCE (UHI) BILL TO SHIELD LOW-INCOME EARNERS

The Tanzanian government is currently discussing the Universal Health Insurance (UHI) Scheme Bill, which aims to provide affordable

THE

COSTS OF

SERVICES IN healthcare to low-income earners and the elderly. The bill proposes making the scheme mandatory for all Tanzanians, with an annual fee of Tsh. 340,000 (US$146) for a standard package covering a family of four. Currently, only 14.7% of Tanzanians are registered with a health insurance scheme, leaving 85% of the population without coverage.

ARE EXPECTED TO INCREASE FROM TSH.3.7 TRILLION IN 2021 TO TSH.6 TRILLION IN 2025 (US$1.6 BILLION TO US$2.6 BILLION), WITH A TOTAL FIVE-YEAR COST OF TSH.24 TRILLION (US$10.4 BILLION).

The government aims to enroll 15 million people in the scheme, with the cost of covering 4.5 million elderly individuals being covered by the government. The law will be rolled out in phases whereby the first one runs from 2023 to 2026. The second phase, which runs between 2026 and 2028, will also involve the informal sector through business and driving licenses while the third phase will be implemented in 2029.

The proposed health insurance plan will provide coverage for up to six family members per household, with the Tanzania Insurance Regulatory Authority (TIRA) responsible for overseeing the insurance and identifying citizens who cannot afford to pay, who will then be supported by the government. The bill makes it compulsory for citizens to have health insurance to access various services such as driving licenses, motor vehicle insurance, advanced secondary education or college admission, and more. As part of the plan, it is suggested that the Community Health Fund (CHF) be disbanded due to its perceived shortcomings in delivering inadequate services that do not align with the fees charged, as well as a lack of interest from the public to participate in the fund.

However, the proposal to make health insurance enrolment mandatory in Tanzania has sparked debate, particularly because it has been suggested that services may be denied to those who do not enroll. As a result, the bill has elicited opposition from some quarters, with the dissenting voices calling for more time to debate the proposed law. However, the Health Ministry argues that the increasing burden of treating non-communicable diseases in the country has necessitated the reform of the national scheme. For instance, cancer cases in Tanzania have been rising steadily by 42,060 cases per year, resulting in higher treatment costs. In 2022, NHIF spent Tsh.35.44 billion (US$15 million) on kidney ailments and Tsh.4.33 billion (US$1.8 million) on the treatment of cardiovascular diseases.

From a financial perspective, the NHIF is by far the largest insurance scheme in Tanzania, with over Tsh.480,000 million (around US$206 million) in annual revenue. Despite having an annual revenue of over US$206 million, the scheme's surplus has decreased each year since 2014/2015, from Tsh.148,000 million (US$63.27 million) down to Tsh.32,000 million (US$13.68 million) in 2017/2018 leading to concerns about its long-term financial viability. The potential loss of cross-subsidy and the inability to extend health insurance coverage to the entire population of Tanzania will become a reality if the scheme’s annual surplus continues to decline. This could pose a major financial challenge for the future of the health insurance system in Tanzania.

Increasing Investments In Healthcare Bring Tanzania Closer To Realizing Uhc

Significant progress has been made in Tanzania's healthcare system. The number of health centers has increased from 8,449 in 2019 to 10,067 in 2022, and the government has invested TSh20 billion per month (US$ 8,550,662) to ensure essential medicines are available in health centers, with 67 percent coverage achieved as of December 2022. The government has also upgraded medical facilities by installing modern equipment such as X-rays, CT-Scans, and MRIs, and constructing Emergency Medical Departments (EMDs) and Intensive Care Units (ICUs) to improve service delivery. These developments have brought Tanzania closer to realizing Universal Health Coverage (UHC).

The Tanzanian government has prioritized investing in health infrastructure and human resources, with a focus on rural regions. Recent budgets have allocated funds for upgrading and building health facilities. For example, in 2020/2021, the Tanzanian government earmarked US$387.9 million for its healthcare sector as it advances towards achieving universal healthcare. Out of this amount, US$155.5 million was allocated for developmental projects aimed at facilitating the implementation of health improvement initiatives. The government has further allocated Tsh. 1,109 billion (approx. US$474 million) for the sector in 2022/2023. The Government of Tanzania has identified some key issues as a priority in the 2022/23 budget, including strengthening the delivery of vaccines for children under the age of five and enhancing the quality of health services delivery in the country. Also, the 2018-19 health sector budget included provisions for upgrading and building health facilities, including the construction of 67 new district hospitals. The government's Health Sector Strategic Plan V also shows a long-term commitment to further investment in health facilities.

Though a hindrance still remains. UNICEF's Budget Issue Paper for Health in Tanzania reveals that low per capita budgetary allocation for Tanzania's health sector has become a significant hindrance to achieving universal health coverage. Between FY 2017/18 and FY 2021/22, the nominal health budget allocation decreased from 9% to 7.3% of the total government budget, falling below the 15% required by the Abuja Declaration. This has caused a reduction of 11% in per capita allocation, from TSh 38,211 (approx. US$17) to TSh. 33,873 (approx. US$15), which is far below the recommended benchmark of TSh 199,094 (approx. US$86.27) required for achieving universal health coverage. These budgetary cuts have had significant impacts on healthcare service delivery, making it difficult to provide affordable and accessible health services to Tanzanian citizens. Without an increase in budgetary allocation, the goal of achieving universal health coverage in Tanzania may remain elusive.

These low budgetary allocations have slowed healthcare service delivery, as seen in significant variations in intra-LGA per capita budget allocations in FY 2021/22, with Njombe receiving the highest per capita allocation TSh 35,292 (US$15.08) and Simiyu region receiving the lowest of TSh 8,874 (US$3.80). Curative care services received the largest proportion of the health sector budget for FY 2021/2022 (26%), followed by district hospitals (22%), preventive services (13%), and dispensaries (10%).

MIND THE GAP: TANZANIA'S HEALTH SECTOR STILL NEEDS IMPROVEMENT DESPITE GOVERNMENT EFFORTS

Despite the efforts made by the Government of Tanzania to improve the efficiency of the health sector, a gap remains. The high recurrent expenditure on salaries in Tanzania's healthcare system can be detrimental to the system's effectiveness and the provision of quality care.

IN NUMBERS

98,987 THE TOTAL NUMBER OF MEDICAL STAFF REQUIRED IN TANZANIA IN 2019/2020

The allocation of 79% of the recurrent budget to salaries between FY 2019/20 and FY 2021/22, on average, indicates that the healthcare system has limited funds to address critical areas such as infrastructure development, medical supplies, and equipment.

The shortage of medical personnel, such as doctors, nurses, and other healthcare workers, is a significant concern for Tanzania's healthcare system. The total human resources required for health was 212,193 in 2019/2020, yet the actual number was only 98,987, indicating a 53% staff shortage. The shortage of medical personnel can lead to longer waiting times, lower quality of care, and even unnecessary deaths. For instance, in 2016, an estimated 45,000 deaths were due to poor care quality and many involved conditions that could be addressed in primary care in Tanzania.

In 2018, there was one medical doctor attending approximately 26,000 to 30,000 patients per year, which is higher than the international standard of one doctor attending a maximum of 10,000 patients per year set by the WHO. Additionally, the country has a low ratio of nurses and clinical staff with 0.39 nurses and 0.26 to 0.30 clinical staff per 1000 population. The number of hospital beds per thousand people has also decreased from 1.4 units per thousand people in 1976 to 0.7 units per thousand people in 2010, representing a 50% decline, according to data from the World Bank. As a result, the WHO recently ranked Tanzania's healthcare system 156th out of 191 countries with an overall efficiency index of 0.422, underscoring the significant gap that exists in the efficiency of the health sector in Tanzania.

It is crucial to note that a well-functioning healthcare system requires adequate funding for various areas to deliver quality care. The high recurrent expenditure on salaries can starve other critical areas, leading to sub-optimal healthcare services. Therefore, there is a need to strike a balance between recurrent expenditure on salaries and other critical areas to ensure the efficient delivery of services and improve the quality of life of the population.

To address the shortage of healthcare workers, the ministry employed 3,347 and 9,262 staff in the 2020/21 and 2021/22 financial years, respectively. In addition, Tsh.8 billion (US$3.4 million) has been allocated for specialized training and customer care improvement during the current 2022/23 financial year. Furthermore, Tanzania’s Health Quality Assurance Division conducted a star rating assessment in 2018 aimed at improving service delivery in primary care facilities.

Despite the positive impact of the star rating assessment on the health sector in Tanzania, there are still significant gaps that need urgent attention to improve the quality of healthcare. First and foremost, access to healthcare remains a challenge for many Tanzanians, especially those in rural areas. This is due to a shortage of health facilities and trained medical personnel. As a result, many people continue to rely on traditional healers and home remedies, which may not always be effective.

Another critical issue is the quality of healthcare services provided by some facilities. Although the star rating assessment helped identify common gaps and raised awareness of performance issues, there are still facilities that do not meet the required standards. These facilities may lack adequate resources, trained staff, or appropriate equipment to provide quality care. Furthermore, there may be a lack of accountability and transparency in some facilities, which can lead to poor management and staff performance.

Additionally, there is a need to address health disparities and ensure that all Tanzanians have access to quality healthcare services, regardless of their income or location. Currently, many low-income individuals cannot afford to pay for healthcare services, which limits their access to medical care. This, in turn, perpetuates health disparities and can lead to negative health outcomes.

While the star rating assessment was a positive step towards improving healthcare services in Tanzania, there is still a long way to go. The government and stakeholders in the health sector must continue to work together to address the gaps and challenges that hinder the delivery of quality healthcare services. This includes addressing access to healthcare, improving the quality of healthcare services, promoting transparency and accountability, and addressing health disparities. By doing so, Tanzania can improve the overall health and well-being of its citizens and achieve its development goals.

Vast Opportunities In Healthcare For Privatesector Players To Tap Into

The United Republic of Tanzania has recently been the focus of a collaborative study between SIHI/TDR, UNICEF, and UNDP on the role of the private sector in healthcare delivery in low- and middleincome countries (LMICs). The study provides insights into how private sector engagement and interactions could be enhanced in order to improve the quality of healthcare for women and children. The study found that private sector facilities account for 30% of the total facilities in Tanzania, and a large portion of these facilities are run by NGOs or faith-based organizations (FBOs), contributing to 22% of all healthcare provision. FBO facilities are often located in remote areas where public facilities are not available, providing access to healthcare services in underserved regions.

In addition, the study found that about half of all training institutions in Tanzania are privately owned, indicating the significant role that private sector education plays in the healthcare sector. Furthermore, the study revealed that 12% of women in Tanzania give birth at private health facilities, highlighting the provides access to quality healthcare services for all citizens.

Low Medical Insurance Coverage Predisposes Tanzanians To Serious Medical Debt

Despite Tanzania's low share of GDP spent on healthcare and meager public expenditure of 39% of total health costs, the country has made significant progress in reducing the burden of outof-pocket healthcare expenses. In 2000, nearly half (47%) of the country's total healthcare expenditure was paid by individuals, but this has significantly reduced over the years. As of 2019, outof-pocket expenditures accounted for importance of private sector facilities in maternal and child health services.

The findings of this study provide important insights into the role of the private sector in healthcare delivery in Tanzania and how private sector engagement could be harnessed to improve healthcare outcomes for women and children. By working collaboratively with the private sector, the government of Tanzania can create a more robust and effective healthcare system that

22.2% of current healthcare expenditure in Tanzania, indicating a remarkable improvement.

Insurance coverage in the country is however significantly low. As of 2019, only 32% of the Tanzanian population was covered by health insurance, with a mere 1% being members of private health insurance. Besides, the existing health insurance structure in Tanzania is highly fragmented, with different small schemes targeting various

32%

In Numbers Proportion Of Tanzanians Covered By Health Insurance

population groups with the Community Health Fund (CHF), the main voluntary insurance for informal rural sector workers, only covering 25% of the population. Further to that, PharmAccess has played a significant role in improving health insurance coverage in Tanzania by working with the government and other partners to develop and implement sustainable health financing models. They have been active in Tanzania since 2006, providing technical assistance and support to improve healthcare access and quality. In collaboration with Kilimanjaro Native Cooperative Union (KNCU), PharmAccess designed and implemented a health insurance scheme for coffee farmers in the Kilimanjaro region. This scheme enrolled up to 40% of eligible members, demonstrating the potential for health insurance to expand coverage and improve equity in healthcare financing.

of how to make the premiums affordable for all socioeconomic groups while ensuring the financial stability of the national scheme.

DIRECT HEALTH FACILITY FINANCING IMPROVES PERFORMANCE OF TANZANIA’S PRIMARY HEALTHCARE SYSTEM

The provision of quality primary healthcare is essential for the economic development of a nation. In an effort to improve primary healthcare (PHC) services through fiscal decentralization, Tanzania introduced direct health facility financing (DHFF) in the 2017/18 fiscal year. The reformed Health Basket Fund in Tanzania has been a crucial program for channeling direct funds to primary health care centers, resulting in the transformation of care delivery in the country. The program has attracted investment partners and donors, including Switzerland, the Tanzanian government, and other development partners, who have strengthened the health system and improved access to quality primary healthcare services for Tanzania's 58 million inhabitants. The Direct Health Facility Financing mechanism, which was expanded through effective decentralization to both state and non-state primary healthcare providers, has accelerated Tanzania's progress towards universal health coverage and "Leaving no One Behind".

However, there is still room for further progress and improvement in the country's healthcare system. To ensure equitable access to healthcare, Tanzania can consider several strategies, such as increasing public financing for healthcare, expanding health insurance coverage, improving healthcare infrastructure, and strengthening healthcare service delivery. These steps can help to reduce out-of-pocket expenses and improve access to quality healthcare for all Tanzanians, regardless of their income level or geographic location.

Additionally, investing in preventive healthcare and health education programs can reduce the need for costly medical interventions, leading to better health outcomes and reduced healthcare costs for individuals and the government. The government aims to unify health insurance schemes into one national health insurance fund and extend coverage to the entire population, but the question remains

Initially created in 1999 as a pooling mechanism of external resources to support government efforts in strengthening primary healthcare in Tanzania, the HBF has evolved from simply financing the Sector Expenditure Frameworks at the central level to a decentralized, performance-oriented aid modality for health sector financing. One of the most impactful reforms reported by the HBF mid-term review has been the DHFF mechanism, which was piloted in 2017/18. It has enabled the direct transfer of funds from the Ministry of Finance and Planning to frontline PHC facilities, reducing leakages and enhancing the predictability and timeliness of funds received at frontline PHC facilities.

The success of the reformed Health Basket Fund is evidenced by the commitment of all eight contributing donors to continue supporting the new HBF, which focuses on expanding the Direct Health Facility Funding mechanism. The Health Facility Governing Committees have also improved community engagement in the governance of their health facilities, holding healthcare providers accountable for the quality of their services