Stakeholders sound alarm on Tanzania’s health financing shortfall

Dar es Salaam. Health stakeholders have recommended the reduction of luxury expenditures, and external dependency on financing critical health programmes, speeding up the implementation of Universal Health Coverage (UHC), and increasing investment in the Human Resource for Health (HRH).

They recently shared the recommendations during a breakfast debate organised by Policy Forum, themed: Post National Budget 2024/2025: Examining the Credibility Equation of the Health Sector.

Tabling a paper presentation on the above theme, the Tanzania Gender Networking Programme (TGNP) senior resource person, Ms Happiness Maruchu, said despite recording success in different areas, including reduction of maternal, and under-five mortality, as well as teenage pregnancies, the country’s health sector was facing serious financing challenges.

She said in the 2024/25 financial year budget, the government approved Sh2.54 trillion for the sector, which is equivalent to a six percent increase compared to the Sh2.4 trillion that was approved in the preceding fiscal year.

“The current Sh2.565 trillion allocation is less than a quarter of the projected requirement by the Health Sector Strategic Plan V Cost Framework (2021/22-2025/26),” she said.

Ms Maruchu said the health sector budget’s share relative to the national budget remains below six percent for four consecutive years, from 2021/22 to 2024/25.

She said in the current fiscal year, the health sector's share is 5.1 percent, down from 5.4 percent recorded in the 2023/24 financial years, raising a serious concern over the government’s priority on the sector.

“The share is considerably lower than the 15 percent target recommended by the Abuja Declaration for African Union member states,” she said.

Sharing more insights, Ms Maruchu said the government’s health per capita spending continues to decline significantly despite the 3.2 percent recent population growth.

She said the recent World Health Organisation (WHO) data shows that health per capita spending decreased from $41 in 2018 to $39 in 2020.

Furthermore, she said as the Gross Domestic Product (GDP) percentage, health spending has been declining from 4.16 percent to 3.75 percent between 2018 and 2020, against the six percent WHO benchmark.

“Out-of-pocket health expenditure is significantly rising considering the mounting cost of healthcare services, which mostly impacts poor households and women, especially those in the informal sector,” she said.

According to her, financing was a major challenge, noting that the amount of funds disbursed to the sector was insufficient for the HSSP V 2021-26 objectives implementation.

She said many of the critical interventions, such as those under the rural water supply and sanitation program, reproductive, maternal, new-born, child, and adolescent health (RMNCAH), nutrition, HIV, gender-based violence (GBV) response, and communicable and non-communicable diseases (NCDs), are externally financed, posing a huge threat on sustainability and ownership.

“The overall sector’s budget is dependent on external funding by approximately 40 percent.

For example, in the 2024/25 fiscal year, a total of Sh416.25 billion (61 percent) of the ministry development budget is expected to be sourced domestically, while Sh263.31 billion (39 percent) will be mobilised through foreign sources, as compared to Sh430.29 billion (69 percent) and Sh302.06 billion (31 percent), respectively, as indicated in the 2023/24 fiscal year budget,” she said.

She challenged that funds allocated for the implementation of the Universal Health Insurance Act No. 13 remain significantly small.

“Delayed budget disbursement is still a major concern. For example, the Ministry of Health had only received an average of 68 percent of the Sh1.235 trillion budget by the end of March 2024 instead of 75 percent,” she said.

However, by March 2024, a total of Sh732.364 billion was disbursed as the development budget, which is equivalent to only 59 percent of the budget.

Discussing the presentation, a medical doctor and health consultant, Dr Kuduishe Kisowile, said the country’s reliance on foreign funding to address key issues such as HIV/AIDS, tuberculosis, and malaria presents a serious health threat in the country. Giving an example, she said Tanzania depends on foreign financing by 93 percent to address the plight of HIV/AIDS through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, while the Tanzanian AIDS Trust’s contribution remained seven percent only.

“We need to look at what will happen if PEPFAR and the Global Fund withdraw today. With the seven percent funding, will the country manage to maintain services provision through its funds”, she questioned.

She said revenue collections, especially in primary healthcare centers servicing over 80 percent of Tanzanians, remain relatively low, noting that referral hospitals that provide services to a small number of citizens record 70 percent to 79 percent of collection targets.

Furthermore, she said the sector was receiving inadequate funds as compared to approvals, saying of the Sh1.3 trillion approved budget, less should be expected as it happened in 2021/22 when only 68 percent of the budget was disbursed out of Sh1.03 trillion. “In the 2022/23 fiscal year, Sh1.1 trillion was approved, but only 67 percent of the amount was disbursed.

This means that only Sh42 billion was added as compared to the disbursement made in the preceding fiscal year,” she said.

Regarding the HRH shortage, she said the country was facing a 64 percent shortage, despite having an average of 30,000 to 40,000 jobless healthcare personnel due to the government's financial inability.

The utilisation of healthcare volunteers to address the challenge has proved to be inefficient because only referral hospitals can manage to recruit them and pay 50 percent of their actual salaries, leaving primary healthcare centres where the majority are attended incapable of recruiting them.

“Despite lacking the National Health Insurance Fund (NHIF) and the National Social Security Fund (NSSF) benefits, they are not given recruitment assurance and absorption in the public system,” she said.

She highlighted other challenges facing the country and most developing countries as prioritising curative measures instead of preventive services, and the small number of people contributing to the NHIF as compared to four times the number of beneficiaries.

Ms Kisowile suggested the need to increase investment in research, development, and manufacture of health commodities that have been costing the country so dearly.

Debating, Mr Moses Kulaba from the Governance and Economic Policy Centre said Tanzania was among neighbouring countries facing a challenge of budget credibility, which includes what is raised, how is raised, how is allocated, and disbursement, among others.

He said geopolitical challenges comprise changes in donors' external focus, therefore adversely affecting key issues in the health sector, including immunisation and reproduction.

“However, the debt risk is a huge one.

Many people have been asking why we are getting less of what has been allocated.

This is because of debt financing; for instance, 27 percent of revenue collection will be directed to debt servicing in this financial year’s budget,” he said.

“There are all indications that the 27 percent used for debt servicing will jump to over 30 percent in the next five years, something that will further reduce funds disbursed to the sector by 40 percent,” he added.

An independent consultant, Mr Buberwa Kaiza, suggested that the country’s demand in the health sector needs to be well-defined and that political interference in the provision of health services, which is an indication of poor governance, should be avoided.

A consultant at Ubunifu Associates, Mr Japhet Makongo, said the government should shift its concentration from increasing healthcare infrastructures to improving the quality of services to bring happiness to citizens.

Ms Beatrice Siame from the Kinondoni Hospital suggested that the government should set health sector financing goals and increase the HRH challenge, which is the heart of good health service provision.

“Transparency in the health sector budget should be increased. Citizens participation in the Nation Vision 2050 should be improved to improve the healthcare sector,” she said.