**Abstract**

In many low-mid income settings, accessibility of health services remains inadequate and inequitable. These observed disparities in accessibility are particularly evident for oral healthcare services. The access to oral healthcare is influenced by the responsiveness of the health system, including availability of human resources for health, oral health facilities' infrastructure, geographical distribution, equipment and materials as well as community's awareness and affordability of the provided services. The evolution of oral healthcare access in Tanzania; from the early postcolonial phases of independence to current transition that the country is undergoing from low to a low-mid income economy is presented. The major health policies' transition from "Free Healthcare" services to "Cost-sharing" and ultimately to "Health Insurance" are presented within the context of their influence towards oral healthcare access.

**Keywords:** Access, Oral Health Services, Economic, Utilization

### **1. Introduction**

Being healthy is a prerequisite for enjoyable and productive life of any human being. It is an invaluable resource for all human activities and is considered one of the fundamental basic rights. Attaining and maintaining health is a complex endeavor. At its most basic level, it requires an individual to have access to health information which is necessary to prevent diseases and demand care when needed. A bit more complicated is the ability to obtain timely, responsive, adequate, appropriate, and accessible health services whenever in need. Despite the importance of oral health to general well-being, many countries have not managed to avail equitable healthcare services to all their citizens. The factors responsible for this regrettable situation vary greatly across and even within countries. Generally, the prevailing health situation of a specific setting is an outcome of the historical background, policies, and sociocultural issues. This brief chapter presents the various stages of provision of healthcare access in Tanzania within the context of major health policy implementations and unique historical perspectives underpinning the evolution of oral healthcare services within the country.

### **2. Accessibility of Oral health services in Tanzania**

The United Republic of Tanzania was formed in 1964 following a union between Tanganyika and Zanzibar. It is one of the East Africa countries of the African Great

Lakes region. It borders to the north by Uganda; the northeast by Kenya; to the east by Comoro Islands and the Indian Ocean; to the south by Mozambique and Malawi; to the southwest by Zambia; and to the west by Rwanda, Burundi, and the Democratic Republic of the Congo. It is 945,087 km<sup>2</sup> in size inhabited by more than 60,000,000 people (2021 United Nations estimates). The country consists of about 125 ethnic groups with a wide range of traditions and customs.

From the year 2020, Tanzania started to be classified as a lower middle-income country. This highlights tremendous development strides that the country has made in its 59 years of existence as an independent state. Nevertheless, like many other countries found in sub-Saharan Africa, Tanzania experiences a high proportion of the global disease burden, but also have an insufficient number of human resources for health. Furthermore, the health system is burdened due to the high prevalence of communicable and rapidly increasing rates of non-communicable diseases. Despite the marked improvements in increasing access to healthcare services, they remain inadequate and inequitably distributed. These impediments become amplified several folds with respect to oral care services. Oral healthcare facilities are disproportionately distributed geographically, have exceedingly limited human resources and few facilities that provide the services.

Healthcare accessibility is a broad concept and does not simply imply ability to visit a health facility as need arises. Affordability of health services, Availability of health facilities and services, Appropriateness of provided health services according to need, Adequacy of the provided services as well as Accessibility in terms of reachability and geographical considerations are all pertinent factors which determine health service accessibility. Oral health service provision in many areas within the country is limited to predominantly emergency care. There is insufficient provision of restorative care, and lack of sustained preventive care which is the cornerstone of controlling all the major oral diseases.

Currently, Tanzania does not have a mandatory health insurance policy. Therefore, accessing oral health services and overall financing of the health system relies mostly on out-of-pocket payments (cash payments at the point of health service). It immediately becomes noticeable that in settings such as this, with high poverty levels, requiring cash at the point of health service provision prohibits many from accessing it. Overtly, where large proportions of the population are poor, a requirement of cash in lieu of access to healthcare may lead to considerable accessibility issues.

One can expect that poor people especially, may face financial difficulties because of required out-of-pocket payments for oral healthcare services. Many people in sub-Saharan countries only go to oral health facilities after a prolonged period of wait-and-see. Their first points when seeking oral healthcare may be folk remedies, traditional healers or over the counter drugs from drug stores. Reluctance in usage of formal oral healthcare services is usually due to several accessibility challenges including lack of, and uncertainty regarding the financial resources that would be required to obtain treatment for their health problem, low levels of knowledge regarding their ailment (and the corresponding care), as well as poor attitudes towards available oral healthcare.

Even in situations whereby the patients overcome these formidable financial and structural hurdles and manage to attend oral health facilities, they are not guaranteed of the best available care. Low-level oral health facilities within Tanzania, which are the first (and for some, the only) points of contact with the health system, may experience frequent medication and equipment stock-outs, are understaffed, and lack the necessary investigative tools. Generally, the most prevalent dental conditions (dental caries and periodontal diseases) are not associated with mortality. Thus, in many cases, and because of need of maximization of limited

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

resources, policymakers frequently overlook oral health; despite its strong linkages to general health and significant contribution to an individuals' quality of life.

The latest statistics from the Ministry of Health (2021) reveal that there are less than 1,000 oral health personnel working at public health facilities in the country. This figure encompasses several cadres, including dental surgeons and specialists, assistant dental officers, dental therapists, and dental laboratory technicians. Furthermore, oral healthcare services are offered in only about 5% of all available public health facilities countrywide.

### **2.1 Chronology of oral health services formation in Tanzania**

#### *2.1.1 Traditional healthcare in Tanzania (1800s and beyond)*

"Traditional medicine" is defined by WHO as sum of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement, or treatment of illnesses (WHO Executive Board EB134/24).

In Tanzania, historically traditional medicines are provided by traditional healers who are usually trusted and respected by communities. These healers are purported to have gaine insight about the medicines from their parents or grandparents. Therefore, the practice usually runs within a clan.

The various ethnic groups employ diverse traditional medicines in managing oral ailments. They include a wide assortment of tree barks, leaves or roots. Depending on the nature of the ailment, fresh traditional products may be squeezed or boiled to make solutions for drinking, ground into poultices used for topical application or boiled for medicinal steam inhalation. The products are sun dried for preservation purpose; either in their original form or ground into a powder. Treatment of oral diseases is usually done by applying a freshly ground product or powder on the area of complaint or on the oral mucosa, tooth or in the tooth cavity. Occasionally it may be in form of liquid for drinking.

Indeed, traditional medicines and remedies have persisted and continue to be utilized in high rates even with the advent of modern oral healthcare services in Tanzania. It is common to have street vendors and self-appointed healers offering various wares purported to treat all manner of oral conditions. For many people in the Tanzanian community, these traditional remedies serve as their first foray towards their quest of addressing oral health complaints.

#### *2.1.2 Modern healthcare services during colonial times (1884–1961)*

Tanganyika was a colony of Germany (1884–1919) and later a British Protectorate (1919–1961). Modern healthcare was introduced in Tanganyika during colonial time. This healthcare arrangement was primarily envisioned to suit economic, social, and political requirements of colonial rulers rather than the health needs of the native Tanganyika population [1]. Auspiciously, in the 19th century Christian missionaries brought hospitals with them among other services. The missionaries desired to give services to native communities as well [2]. Moreover, only facets of indigenous people enjoyed these health services because the missionary hospitals were few, health professionals scarce and transportation infrastructures extremely poor.

However, as missionary health services increased within the country, and partly driven by the altruistic nature of the establishments, some facilities started to offer oral care services to the local population. Due to the very real limitations during that period, the only treatment that the local population could realistically receive

was emergency care in the form of tooth extractions. Thus, for the very first time that the population is being introduced to institutionalized oral healthcare services, tooth extractions were the one and only service available. No concerted efforts were made to establish basic oral healthcare services with restorative or routine preventive components. Thus, it remains until this day to a large swathe of the Tanzanian population the belief and sentiment borne out of community-acquired historical experience that "the only cure for a tooth ache is extraction".
