Albino Kalolo, MD, MSc(Public Health), EV2010 from Tanzania
Poor people face a variety of barriers when accessing health care in Sub-Saharan Africa. Some of these barriers could no doubt be eliminated if poor people were actually more aware of health policies, as a lack of information often leads to undesirable results such as delayed medical treatment, improper health seeking behaviours, and even foregoing medical treatment. This situation contributes to morbidities and mortalities among this group of poor people that could otherwise be avoided, at least to some extent. The example of a lady in her late 30s called “Sikitu” (a Swahili name, which literally means “Nothing”), provides a snapshot of how things are on the ground. Sikitu is a widow living with her four children in a village in Southern Tanzania.
Sikitu had symptoms of cervical cancer when she went to see a doctor in a public district hospital. The doctor later on referred her to the cancer institute in Dar es Salaam for further treatment on account of advanced cervical cancer. After physical examination, Sikitu asked the doctor: “How much should I pay you for all these services I have received?’ The doctor replied: “Cancer services in this country are offered for “free” (without payment) like other chronic diseases such as HIV/AIDS and tuberculosis; you are not supposed to pay directly to the doctor if there are associated costs”. Sikitu was surprised to hear that and was pretty much speechless when she reflected on what has been happening to her and other poor people. She went home and sold the few goats she had to get money for her travel and living expenses (when she will be receiving treatment in Dar es Salaam). A few days later, before travelling to the city for treatment, she went back to see the doctor (ready for the journey) in order to collect the referral documents. She offered him some cashew nuts, as a gift. Then she burst into tears. When asked why she was crying, she explained that she had been coming to the hospital almost every month for the past year or so, to see a certain doctor. She had always paid the doctor after the service but the problem was still going on despite the fact that some procedures had been performed on her. She was scheduled to come again regularly for follow-up visits and was required to pay some money whenever she accessed services. She was very surprised that this time (because the usual doctor was travelling) she was attended free of charge, informed of her problem and referred to the big hospital for further care.
Sikitu’s story is by no means an exception in Tanzania and in other sub-Saharan African countries that still have user fee policies in place, but is just the tip of the iceberg. Many poor people are unaware of user fee exemption policies. Many people, especially the poor, have been denied access to health care and live now in extreme poverty because of lack of information about user fee exemption policies. Corrupt practitioners take advantage of this knowledge gap, induce demand and ask for informal payments (bribes) from their (mostly poor) clients.
There are several reasons as to why ordinary citizens often lack information on available health policies. The (trademark) top-down approach of policy formulation that denies active participation of ordinary citizens in setting the agenda and overseeing the implementation of policies, contributes to this gap. Moreover, the absence of pressure groups that can hold the government accountable if these policies are not addressing ordinary citizens’ problems plays a major role. These two major reasons are interrelated in Tanzania: the political atmosphere in my country (characterised by the dominance of one political party) has for a long time supported a top-down approach and limited democratic practices – in the past civil society organisations (CSOs) that weren’t affiliated to the ruling party were even banned. However, since the end of the 80s (when there was a severe economic crisis), regulation of CSOs has changed as a result of conditional ties of international aid. The same process also led to the introduction of a multiparty system in 1992.
So the situation is slowly changing, for the better, even if until recently Tanzania could be characterized as a “de facto one party state in a context of multi-party elections”. Little by little, citizens are more empowered (at least in other social sectors) due to actions of CSOs and opposition political parties. In fact, even in the health sector, there have been some active local CSOs that work as ‘health policy entrepreneurs’ such as Sikika, but they have not been vigorous enough to push forward an agenda that promotes poor people’s access to information (in order to empower them to advocate for their health rights). Nevertheless, Sikika has shown the way by using research evidence as an advocacy tool for quality health services in partnership with other local CSOs. Sikika’s activities are geographically confined, though, mainly focusing on urban areas. The capacity of the organization also needs to be improved. Many international NGOs are also working in the country, but it is very complex to understand how they relate to the government and local CSOs, and not the focus of this editorial. More importantly perhaps, the recent emergence of strong opposition political parties that have been challenging the status quo is seen as a window of opportunity. Many of them promote the health sector agenda in their election manifestos for the coming general elections (scheduled for 2015).
It is unfortunate, however, that until now there has never been a serious attempt (and mass movement) to change the current situation that creates major inequalities in the society in terms of access to health care, unlike in other sectors such as education and land rights. This is probably because health activists have never worked in unity to address such issues, and health worker unions are too fragmented to put successful pressure on decision makers and address such inequalities (apart from isolated doctors’ strikes that have typically been suppressed by authorities). The government on the other hand tries to make sure that health issues do not feature in mainstream party politics because of their potential sensitivity; they therefore find ways (sometimes barbaric ones) to suppress initiatives that appear to advocate the right to access health care or that suggest mechanisms which promote equity (not that Tanzania is alone in this – the crackdown on civil society is, unfortunately, a global phenomenon). However, things are finally changing, and it could very well be that the ‘access to health care’ agenda will feature quite prominently in the 2015 general elections, even more so because a series of mediatised actions have happened in the health sector recently such as persistent doctors’ strikes to demand good working conditions and the kidnapping and torture of the frontline leaders of these movements.
Since realities on the ground and research evidence have already demonstrated the inequalities caused by user fee policies and the fact that people are unaware of exemption procedures (or sometimes they are aware but there exists no functioning (social and legal) framework that can support them in the fight for their rights), it seems high time for health activists ( individuals, CSOs and political parties) to join hands and advocate the right to health and work towards boosting citizens’ awareness and empowering them to know their right to health care. They can also start advocating the abolition of user fee policies like in other Sub-Saharan African countries. Obviously, they can and should also jump on the global UHC bandwagon to make universal health coverage a reality in Tanzania.
As Jim Kim noted in his speech at the World Health Assembly earlier this week, “Now is the time to act. WE MUST BE the generation that delivers universal health coverage.”