An assessment of the implementation of community health fund‘s exemption policy: a case of Lindi municipal council in Tanzania

Like many other African countries, Tanzania has been implementing user fee policy in its health sector since the 1990s. Accompanying user fee, mechanisms were designed that exempted the poor from paying user charges. Empirical evidence indicates that exemption policies in Tanzania have not been effectively implemented. However, while studies on the implementation of pro- poor exemption policies exist, most of them have been very descriptive in nature. Existing studies have mainly focused on understanding the performance and outcomes of the exemption policies. Relatively, very few studies have systematically documented the actual process of implementing exemption policies. Using policy analysis framework, this study documents the actors involved in setting exemption criteria at the local level, criteria used to identify the poor and the process adopted by the poor people in getting exemptions, as well as contextual factors that influence the implementation of the exemption policy at the district and facility level. Both qualitative and quantitative approaches have been used in the study. The main findings indicate a number of shortcomings of policy implementation, particularly the lack of specification of criteria by which the poor could be identified made it difficult for local government officials and health workers to grant exemptions. In addition, ineffective enforcement mechanisms and low level of public awareness made it difficult for the poor to demand exemptions. Consequently, the pro-poor exemption policy could not achieve the intended outcomes. There must be simple guidelines that are clearly communicated to health care providers, village and ward leaders, and beneficiaries; and a system for monitoring and evaluating the policy. Furthermore, it is imperative to focus attention on policy implementers, who are capable in implementing the policy in ways that policy makers had not intended.