Health System

Structure of the health system

Administratively, it is important to understand that Tanzania is the union between Tanganyika (Tanzania Mainland) and Zanzibar, and the Tanzanian National Health Policy prescribes the health services provision for Tanzania Mainland only. Tanzania Mainland is divided into 21 administrative regions, with a further subdivision into 106 Districts with 121 Council Authorities. Under this structure, the provision of health services is divided into 3 levels: National, Regional and District. Each district is furthermore divided into divisions, wards, villages and ‘vitongoji/mitaa.’

The ministry of health, through the regional secretariat, supports and facilitates the implementation of health services at the council level. It works according to a pyramidal referral system operating upward from the lowest (village) level. The types of services provided at each level, arranged from the bottom upwards, are as follows:

• Village level: Village health posts
• Ward level: Community dispensaries
• Divisional level: Rural health centers
• District level: District/District designated hospitals
• Regional level: Regional hospitals
• Zonal level: Referral/Consultant hospitals
• National level: National and specialized hospitals

Beneath the health system of Tanzania is a socialist regime, which prescribes certain roles, values and functions to the government with regard to services it renders to its society. The Tanzanian health system views government as the major provider and financier of health services, with a particular emphasis on the provision of primary health care services.

Provision of health care, particularly in the rural areas and facilities, was adversely affected after the economic recession in the 1970s and 1980s, which resulted in an overall deterioration of health care services. This led to the Tanzanian government introducing Cost-Sharing in 1993 and following that, instituting other financing options such as a National Health Insurance and a Community Health Fund.

Although there are provisions for health insurance in some form, the “scope of commercial health insurance is very limited and there is a growing experience of community-based pre-payment schemes”. Thus, Tanzania is known more for its Community Health Fund (CHF) schemes, with the introduction of a mandatory health insurance being initiated in the early 2000s, which “made it compulsory for all public servants to become a member of the National Health Insurance Fund (NHIF)”. The next phase envisions the extension of this health insurance to formal sector employees in the private sector via health insurance contributions to the National Social Security Fund (NSSF). The objectives of these policies are, in the first instance, to establish a reliable method of enabling employees to contribute towards their own health, while also improving accessibility and the quality of health services in both the private and public sectors.

In general, the health services are heavily based on national government financing, with some tax-based funds through local government council tax collection and other earnings. Although the central government remains the main financier of health services in Tanzania, the financing of health is supported by local government and service provision, voluntary agencies and faith based organizations, executive agencies, community contributions and development partners. There is an aspect of out-of- pocket financing under community contributions, where communities might be “encouraged to contribute through user-fees in health facilities to complement the government financing”.1 The Community Health Fund (CHF) is viewed as an effective “tool for mobilizing voluntary community involvement and participation in supporting their own health,” whereas the Health Insurance Scheme is seen as a “mechanism to ensure medical protection of employees in the formal sector.”1

When we consider the state of the health system in comparison to other countries, Table below indicates that health expenditure per capita has declined since 2006, although it is quite positive that health expenditure as a percentage of government expenditure has risen from 14% in 2006 to 18% in 2009. This implies a shift of health expenditure away from the population to the infrastructure and resources needed to provide health. Government has thus stayed in line with their commitment in 2003 for the health sector allocation to reach 14% of budget share. It is interesting that out-of-pocket expenditure on health has increased as a percentage of private expenditure on health, whereas it has declined in total.