The Effects of User Fee Exemptions on the Health System in Tanzania

Abstract Background User fee exemptions have been widely promoted in low- and middle-income countries to increase healthcare utilization and advance universal health coverage. In Tanzania, exemptions are granted to pregnant women, children under five years, individuals aged 60 and above, and patients with chronic illnesses, especially in public health facilities. Although user fee exemptions are widely recognized as an important mechanism to safeguard poor and vulnerable populations against catastrophic payments, their broader implications for the health system performance remain insufficiently evaluated. Objectives This study explored the effects of user fee exemptions on the Tanzanian health system, focusing on key health system building blocks, namely health financing, service delivery, and access to medicines. Methods This is a case study that employed a qualitative approach. Data were collected through in-depth interviews and document reviews. The ensuing qualitative data from interviews were analyzed thematically, while data from documentary review were subjected to content analysis. Results Findings revealed that due to user fee exemptions, health facilities lost additional revenues that were key to improving the quality of health care. For example, health facilities often ran out of drugs and medical supplies. In addition, reduced revenue impaired the ability of health facilities to extend health infrastructures to accommodate the influx of patients. Although the government subsidized health facilities, the subsidies were not timely disbursed and, sometimes, were not provided at all. Conclusion Although user fee exemptions have made health services accessible to the poor and vulnerable groups, they have equally disrupted other essential functions of the Tanzanian health system. To address these challenges, the government should increase subsidies to under-resourced health facilities and strengthen health insurance schemes as a sustainable mechanism for health financing. In addition, the government should ensure the timely disbursement of funds to health facilities.