Tanzania: Question Lingers Whether the Poor Enjoy Health Services in Country The Citizen (Dar es Salaam) OPINION 4 December 2007 Posted to the web 4 December 2007 Dr Hamisi Kigwangalla When it comes to talking about equity, much has been said about the distribution of wealth. But what about the distribution of health? Consider access to quality healthcare for a poor man who lives in a rural village, where the dispensary is more than 10 km away. Then compare that with a minister who is sent to England for treatment. Are these two people justly treated? Is there a just or fair process of resource allocation when it comes to health? Tanzania has seen tremendous changes in recent years. In the drive to boost economic growth, we have shifted from an equitable society to a country which has been looted of resources, with benefits flowing to an elite few. Instead of ensuring equity, our leaders keep on cutting bigger and bigger pieces of the national cake to benefit themselves and their cronies. Corruption and embezzlement of public property has become the order of the day. In the meantime, ordinary people are being reduced to victims of poverty, diseases and illiteracy. How can we address these issues, and develop a framework for achieving health equity? In the early 70's, the American philosopher John Rawls came out with a theory of political and moral justice. Rawls' theory, also known as "justice as fairness," holds that each person has an equal right to the most extensive basic liberty, so long as it is compatible with the liberty of others. In addition, he asserted that all the 'primary goods' such as health and education should be equally distributed in society. Disparities can be justified only if they are to the advantage of the worst-off. The capability of a human being to do or to be is dependent on whether he is in good health or not. Ill health reduces the functioning capability of a human being, restricting him in choosing the life he desires. Therefore health is a resource that must be equally distributed among citizens if they are to be active participants in society. Access to quality healthcare should be protected as a universal right. The principles of distributive justice require people in a community to enjoy resources equitably. In today's Tanzania, it seems we are not adhering to these principles, particularly when it comes to health. Those with higher incomes enjoy much greater access to quality healthcare than those who are worse-off. In 1993 the government of Tanzania instituted a cost sharing policy in order to face the challenges of healthcare financing, availability and quality improvement. The scheme was also intended to increase demand, ownership and participation. User charges and community health funds were sequentially established. In most cases they were left to be used locally in the facilities to complement the running cost provided by the central government. As the cost-sharing policy began to be implemented, a dilemma on how to cater for the poor arose, and therefore protection mechanisms were put in place. The so-called safety nets (exemptions and waivers) were established hand in hand with the implementation of the cost sharing mechanisms. However, the protection mechanisms seem to be non-protective in many cases: Often, the means to test who is eligible and who is not fails and the health providers are unaware of the regulations and operating modules of the mechanisms. Is there equity in health service provision if the poor are being charged? Or when the poor have to walk long distances to access services? It seems that the wealthy have more access to even the primary care that is provided in government facilities compared to the poor, though they could easily afford to pay for these services. Why then can't we change our policies into free primary care to all, as it used to be in the past? Or, why can't we make sure that we have proper mechanisms for ensuring that we correctly identify those people who cannot afford to pay for health services? The reduction of inequalities in health should become a necessary requirement of justice. Failing to achieve health equity deprives people of their rights to be active, engaged citizens or to do things they desire. That is, it weakens democracy. Thus, recent efforts to improve governance and accountability should be expanded to address health equity. The government should honour its political obligations to the people and ensure them proper protection when it comes to healthcare. http://allafrica.com/stories/200712040672.html Dr Hamisi Kigwangalla is an independent public health consultant.