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Universal health coverage and election manifestos: Insights from the upcoming general elections in Tanzania

By Albino Kalolo
on October 9, 2015

Progress towards achieving Universal Health Coverage (UHC) has been slow in many low income countries, especially in Sub-Saharan Africa (SSA). In these settings, poor communities continue to suffer from financial hardship due to catastrophic health expenditures and many people succumb to morbidity and premature death as a result of poor quality health services. It’s clear, however, that there could be much more progress if relevant stakeholders such as governments, civil society organizations, development partners and  citizens expressed themselves forcefully and publicly on the need to (further) design and implement UHC policies. The priorities set in election manifestos and related campaign pledges could serve as litmus test for (meaningful) commitment to UHC policies of political parties in Tanzania, including the incumbent party. The increasing engagement of the young in political campaigns in SSA already sparks more discussion on UHC, among others thanks to the social media which help ignite the UHC fire, but a lot more is needed. Hopefully the young can also push SSA (and Tanzanian) politicians to kickstart implementation of the Sustainable Development Goals (SDGs). As Tanzania prepares for general elections scheduled later this month (25th October), some insights on how the UHC-agenda features (or does not feature) in party manifestos will give you a clearer idea on current UHC developments and support in Tanzania.

But first things first, what does the political constellation in Tanzania look like for the moment? Recently, four political parties joined forces as an opposition coalition, the “Coalition of Peoples Constitution” (UKAWA) led by the Chama cha Demokrasia na Maendeleo (CHADEMA). A new party,  ACT-wazalendo,  saw the light in 2014. They face the ruling party – Chama Cha Mapinduzi (CCM) – in this election. In addition to UKAWA, CCM and ACT-wazalendo, four other parties will also participate in this year’s election. UKAWA is the main challenger of CCM, though, in this contest, and ACT-wazalendo perhaps an outsider.

Regardless of the outcome of the (tough) political battle later this month, what would be the (likely) implications for the design and implementation of UHC policies in Tanzania – i.e. in terms of covering the whole population (health for all), providing financial protection and ensuring access to quality health services. Would they add value to the ongoing efforts to develop a new health financing strategy for UHC in Tanzania, if in power?  As stated above, key steps in this respect for the political parties are (1) to include UHC as a priority in their election manifesto (and subsequent campaign pledges) and (2) later on implement their pledges, as pledges without follow-up are just empty promises.

When you go through the manifestos, you notice quite some pledges promising to set up or boost existing prepayment mechanisms (health insurance) – see the respective manifestos of CCM, UKAWA and ACT –wazalendo. CCM pledges to look for feasible ways to strengthen the available prepayment mechanisms, the formal sector’s health insurance through the National Health Insurance Fund ( NHIF ) and the informal sector’s Community Health Funds (CHFs). They are however not very explicit on how this is going to happen, unfortunately, especially given the failure to reach 30% enrollment in health insurance as per targets of their 2010 election manifesto. The UKAWA coalition recognizes the massive problem of catastrophic health expenditures resulting from out-of-pocket payments and pledges to establish a public health insurance system. Their promise however also fails to provide a clear picture on how this will happen. Their manifesto doesn’t provide concrete steps to tackle the current fragmentation of the health financing system (which relies way too much on out-of-pocket spending). The ACT-wazalendo manifesto plans to revisit the NHIF law (which made health insurance for public servants mandatory), expanding coverage; however, a detailed account on the modus operandi is missing as well.

All key parties in this election promise to strengthen curative health care services, more in particular by making sure that health facilities are close to the people. CCM, for example, promises to construct a health facility in every village in the country!  Investments will go to ensuring availability of medicines, diagnostic equipment and training of health care workers. All parties touch on maternal and child health services but none of the manifestos prioritize non-communicable diseases. Prevention of diseases and promotion of healthy lifestyles is not a focus of the manifestos and ongoing campaign rallies. CCM only emphasizes malaria (distribution of insecticide-treated mosquito nets) and HIV/AIDs (prevention of mother to child transmission in particular) but does not really talk about other diseases or steps to foster health promotion. UKAWA and ACT-wazalendo touch on health promotion, but only ACT-wazalendo puts an explicit focus on prevention, without going much into detail though.

Despite the inclusion of some important aspects of UHC policies in manifestos, significant gaps persist. The most obvious gap is that none of the manifestos feature a concrete pledge to increase the budget in order to fund the UHC package properly – even the Abuja declaration target is not mentioned. Since 2010, the total health expenditure  in Tanzania has remained at approximately 7% of the gross domestic product (GDP). Only ACT-wazalendo points out that they will “ring fence” the health care budget, if in power. Moreover, it is not clear whether some of the stated declarations will actually be converted into law(s) to foster UHC once they are elected. Only ACT- wazalendo clearly states that they will revisit the NHIF act. Furthermore, none of the manifestos explain how the pledges will be reached given the lack of year to year approximate costing of their pledges, and  only UKAWA pledges to strengthen health systems research in the country to guide implementation of the UHC policies.

There’s already quite some research on moving towards UHC in Tanzania that could guide inclusion of UHC policies in election manifestos. For example, modelling by Borghi et al emphasized: “Universal coverage would require an initial doubling in the proportion of GDP going to the public health system. Government health expenditure would increase to 18% of total government expenditure”. Furthermore, lessons from similar countries that have made substantial UHC progress in recent years and decades stress the important role of political push factors emanating from the citizens ( the young demographic especially), civil society, think tanks and lobby organizations – these lessons could serve as a guide for any party that wishes to implement UHC policies, surfing on a UHC movement.

Nevertheless, the inclusion of key elements of UHC policies in the election manifestos is progress. Implementation of the pledges will be important, though, and a catalyst for wider stakeholder engagement in this agenda, in particular from civil society,  researchers and lobby organizations that support the UHC agenda in Tanzania.

We still have a couple of weeks to make that case.

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