*2.3.1 Moving away from "free" health in oral health*

Cost-sharing is the term used to describe a co-payment scheme in which a user of a particular service contributes a certain amount towards its utilization. In the Tanzania health system context, users were expected to "top-up" on governmentsubsidized health services [5]. Cost-sharing was the first instance of introduction of user fees within the history of the United Republic of Tanzania. The rationale for its introduction was to increase the awareness of treatment costs and limit injudicious use of health services by the consumers. It also allows the healthcare users to function as contributors towards financing of their health system. Considering the slow economic growth and narrow taxable base for raising of required revenues, the idea appeared to have a lot of merit in context. Indeed, through cost-sharing and increasing government expenditure and investment in health generally, and oral health specifically- significant improvements have been made in recruitment and training

of oral health personnel within the last fifteen years. Furthermore, many oral health facilities countrywide have been refurbished and equipped to modern standards.

However, as is usually the case, the actual reality of user-fees has now been shown to be more complicated than the fiction initially envisioned. Objective, multi-country assessments have shown that the introduction of user fees had increased health system revenues only modestly, but significantly reduced the access of low-income and underprivileged people to basic social and health services [6]. Furthermore, when assessing the impact of health expenditures of individuals, it was revealed that smaller proportions used dental services compared to medicines and outpatient care. A possible interpretation of this observation is that dental costs per visit may be too high that the households actively avoid them [7].

Removal or reduction of user fees has been found to increase the utilization of treatment and preventive services; however, it has also been shown to negatively impact service quality, especially in situations where the supplementing sources of health finances are to be derived from the government. On the other hand, introduction or removal of user fees was associated with rapid and immediate changes to the service utilization patterns [8]. Matee and Simon conducted a study in Tanzania to compare dental attendance and service utilization a year before and after introduction of user fees. There was a noted 33% reduction in dental attendance immediately after the introduction of user fees. The reasons for such a finding are potentially numerous, and it is difficult to ascertain the change in dental attendance solely due to the policy change regarding user-fees. Nevertheless, this study does highlight the rapidity with which utilization rates may change upon manipulation of financial barriers to healthcare use [9].

Poor countries and poor people that most need protection from financial difficulties are the least protected by cost-sharing policy and may prevent them from accessing needed care. To address this, provisions have been made and waivers placed for those identified as destitute or unable to pay for the services. However, difficulties remain on how to accurately and timely identify these individuals. At low incomes, out-of-pocket spending for healthcare is high on average and varies from 20 to 80% of the total cost of health service utilization [10]. Out-of-pocket payments place the burden of healthcare funding on an individual and translate into health service use, and hence benefits, being distributed according to ability-to-pay rather than need for healthcare [11].

One of the prominent effects of the cost-sharing policy can be vividly illustrated by the dental visit and service utilization patterns of the Tanzanian populations. A significant proportion of Tanzanians have oral symptoms but have never attended oral health facilities. More than 90% of all dental visits in Tanzania are due to symptoms, and frequently these symptoms have been present for a long duration prior to attendance. It is only when the symptoms become excessively severe or interfere with daily functions is attendance made. Upon attendance, most of the treatment utilized for dental caries is tooth extractions- even in situations where restorative care was amenable. In all these scenarios depicted, one factor can be drawn linking them together- a need of payment of health services prior to receiving health services. Therefore, although cost-sharing may have some positive consequences towards oral healthcare utilization, careful consideration needs to be made to tailor an optimum out-of-pocket payment structure [12]. What is undeniable too, is that in order to protect the most vulnerable and needy of the population, cost-sharing policy remains inadequate and inappropriate in the long term.

#### **2.4 Health insurance**

#### *2.4.1 Moving towards "prepayment" model*

Health insurance is defined as insurance against the risk of incurring medical expenses among individuals. Tanzania established the National Health Insurance

#### *Accessing Oral Healthcare within a Context of Economic Transition DOI: http://dx.doi.org/10.5772/intechopen.98615*

Fund (NHIF) through the Act of Parliament No. 8 of 1999 and officially began functioning in June 2001. The program was initially intended to cover public servants, although currently there are provisions and service packages which allow for self- enrolment of any individual/groups of individuals. The public formal employee pays a mandatory contribution as a percentage of their monthly salary with a government-matched percentage.

This program covers the principal member, spouse and up to four children below 21 years who are legal dependents. Unlike other health insurance models which may require a separate dental insurance; NHIF also provides oral healthcare services as part of the benefit coverage for its members. Initially, NHIF only offered very rudimentary oral health services, predominantly emergency care and some surgical procedureshowever, it has steadily improved over time- and currently offers a wide range of services including complex restorative, prosthodontics and even orthodontic care. The usual caveats with accessibility remain, despite elimination of cost as a barrier. Utilization of oral services covered by NHIF will still largely depend on whether the oral health facility nearest the benefactor has the requisite skilled oral personnel and equipment to provide them.

Nevertheless, formally employed workers constitute about one-quarter of the total workforce in Tanzania. In recognition of this, in 2001, the Community Health Fund (CHF) Act mandated CHF implementation in all districts of mainland Tanzania. The aim of this fund was to provide health insurance to communities which were largely informally employed and thus not captured by the NHIF Act. The CHF is a districtbased micro-health insurance scheme whereby members of the respective communities prepay for health services and the scheme receives a "matching grant" from the central government, which is equivalent to the premiums paid by the enrolled households [13]. Unlike NHIF which is mandatory, CHF is a form of voluntary communitybased health insurance. CHF usually exist within localized communities, most often in rural areas: members make small payments to the scheme, often annually and after harvest time, and the scheme covers the fees charged by local health services [14]. CHF covers a slightly wider range of people and has been the predominant form of health insurance, although it is considered to have the least favorable benefit packages. The scheme generally only covers outpatient care at primary health-care level- although efforts are underway to improve the overall package offered to benefactors. Generally, this scheme continues to be plagued by low enrolment and dismal retention rates.

When people are enrolled into a health insurance scheme, they gain several rights regarding their healthcare. "The expectations of patients are that membership of the insurance scheme gives them rights and makes them customers of the healthcare providers" [14]. Therefore, it becomes exceedingly demoralizing when their health service expectations are not met. Generally, health insurance, particularly through NHIF, has significantly increased accessibility to oral healthcare services in Tanzania. The assurance of purchasing power has allowed a flourishing of private dental practices and increased motivation in training of oral health personnel within the country. However, careful consideration is needed to ensure that this democratization of access does not lead to greater oral healthcare inequities especially among the informally (majority) employed population.

#### **2.5 Future perspectives**

#### *2.5.1 Universal healthcare*

Universal health coverage (UHC) is the availability of quality, affordable health services for all when needed without financial impoverishment. Tanzania's aim of achieving universal health coverage is provided in the nation's 4th Health Sector

Strategic Plan (2015–2020). The plan provides for a new health financing strategy aimed at helping the country attain the goal by addressing the existing segregate health insurance market through providing health insurance to all citizens. The goal is underpinned in the nation's 5th Health Sector Strategic Plan (2020–2025). Expected outcome and impact of Universal Health Coverage is improved access, coverage, and quality of health services.

Developing effective mechanisms for identifying and protecting people with very low incomes is critical in Tanzania. Even if user fees were completely abolished, as is happening in a growing number of African countries, it would still be necessary to identify people with the lowest incomes to protect them in relation to other financing mechanisms (e.g. to partly or fully subsidize their health insurance contributions). In addition, if universal coverage is to be achieved, it is necessary to explore ways of achieving funding pools that are as large and integrated as possible, to maximize income and risk cross-subsidies and to allocate pooled resources in an equitable way [11].

#### *2.5.2 Probable implications on oral health outcomes*

According to the World Health Organization there are three main goals for a healthcare system: good health, responsiveness to the expectations of the population, and fairness of financial contribution [15]. While the first objective, overall improvement of health, is self-explanatory the other two require more clarification. Responsiveness addresses the question of how far the healthcare system responds to people's expectations of it. The concept of fairness can be defined as "the highest possible degree of separation between contribution and utilization". It demands financial responsibility to vary according to ability to pay, and access to the healthcare system to vary according to healthcare needs irrespective of ability to pay [16].

Health insurance for all Tanzanians is foreseen to facilitate access to healthcare services. Expectantly people will no longer have to endure health problems or to wait until the situation is beyond bearable before consulting a health facility. Generally, Tanzanian population's oral health is predicted to improve in diverse aspects.

Availing Health insurance for all Tanzanians is expected to ease accessibility of oral healthcare. Easy access will optimistically facilitate a shift of the reason for visiting a dental clinic from pain or potentially pain situation driven to regular dental visits for check-ups and observance to follow up schedules. In a long run plausible positive outcome will be early diagnosis of oral diseases, efficacious management and ultimately better prognosis and generally improved oral health of all citizens.

## **3. Conclusions**

Tanzania has made significant strides in improving and expanding oral healthcare accessibility of her people. This progress has been achieved through implementation of various policies embedded within the evolution of the social-political context in the country. The current trajectory of oral healthcare delivery system clearly highlights the unsustainability of the status quo. Adoption of universal health coverage and health insurance for all in the near future seems promising in easing access to oral healthcare.

### **Acknowledgements**

We are grateful to the support offered by Muhimbili University of Health and Allied Sciences. (MUHAS).

*Accessing Oral Healthcare within a Context of Economic Transition DOI: http://dx.doi.org/10.5772/intechopen.98615*
