Journal of Aging Research and Healthcare
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Research Article | Open Access
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  • Facilitators and barriers to health care access among the elderly in Tanzania: A health system perspective from managers and service providers.

    Gasto Frumence 1       Tumaini Nyamhanga 1     Amani Anaeli 1    

    1Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Tanzania.

    Abstract

    Tanzania is among the developing countries experiencing rapid growth of an ageing population, which has an implication in healthcare expenditure especially in resource poor settings where majority of elderly people cannot afford to pay for the cost of accessing health services. The country has developed the Tanzania National Health Policy (2007) and National Ageing Policy (2003), which, among other things, recognize the importance of having a healthcare system that provides free basic services to the vulnerable elderly population.

    This study aimed at exploring health service providers’ and managers’ perspectives on the factors facilitating or prohibiting access to health services among elderly people in Tanzania.

    The study adopted a qualitative approach and data were collected using semi-structured interviews. A total of 24 in-depth interviews were conducted with district healthcare managers, heads of public healthcare facilities, and health service providers. The data generated were analysed for themes and patterns.

    The results show that Tanzania’s healthcare system has made some efforts to implement the national exemption policy to ensure better access to health services for the elderly. Some of these efforts include: having in place a system to identify and exempt elderly people from paying for health services and giving them special priority during treatment. However, there are some barriers hindering elderly people’s access to health services. Among others include: lack of specific consultation rooms and doctors for serving the elderly, and lack of sufficient drugs and other medical equipment in most government-owned healthcare facilities.

    In summary, the healthcare system has created a good environment for the implementation of exemption policy aiming at enhancing accessibility of health services among the elderly population in the country. However, such environment cannot function effectively without addressing the identified barriers. It is recommended that the government should allocate adequate human and non-human resources to the healthcare system to enable it to function effectively, including the provision of health services to the elderly.

    Received 28 Oct 2016; Accepted 07 Apr 2017; Published 19 Jun 2017;

    Academic Editor:Saeed Talebian, University of Rochester, Aab Cardiovascular Reaseach Inst., United States.

    Checked for plagiarism: Yes

    Review by: Single-blind

    Copyright©  2017 Gasto Frumence, et al

    License
    Creative Commons License    This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Citation:

    Gasto F, Tumaini N, Amani A (2017) Facilitators and barriers to health care access among the elderly in Tanzania: A health system perspective from managers and service providers.. Journal Of Aging Research And Healthcare - 1(3):9-18.
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    DOI10.14302/issn.2474-7785.jarh-16-1354

    Introduction

    In the African setting, older men and women make significant contributions both at the family and community levels. For example, in the African continent it is estimated that about 64 per cent of men over sixty years of age are still working both in the formal and informal sectors (1). Most of the older women who live longer by 17 years than older men also continue to perform domestic and subsistence activities, including farming activities. Elderly people in Africa have an added burden of taking care of grand children whose parents have migrated to urban centres searching for employment opportunities or have died as a result of HIV and AIDS pandemic (1).

    However, despite their significant contribution both at the family and community levels, majority of the elderly experience high degrees of impoverishment, abuse, discrimination, violence and inability to access and enjoy their entitled basic rights, including health services (1). Majority of the elderly people in African countries, including Nigeria, Sudan and Tanzania, suffer from non-communicable diseases, including cardiovascular disease (2). The situation is worse in the African rural areas where majority of elderly people live (1).

    Elderly in Tanzania

    Ageing is defined differently in different settings. For the purpose of this study, the Tanzanian context definition, which is also used in other African countries, has been adopted. Ageing is defined as “A biological process which has its own dynamic, largely beyond human control. The age of sixty years and above, roughly equivalent to retirement ages in Tanzania, is said to be the beginning of old age” (3).

    Most elderly people live in rural areas where they get exposed to extreme poverty, vulnerability and absence of the necessary infrastructure to guarantee the attainment of their basic needs, including access to health services (3). According to HelpAge International, (a global network of non-governmental organizations that supports elderly people to claim their rights), elderly people in Tanzania are also facing other problems including stress, market forces and change in cultural norms as family care and respect which they used to enjoy are often being weakened (3). This may be attributed by most rural to urban migration of young people who were responsible of taking care of the elderly in their communities.

    In Tanzania, the number of people aged from sixty years and above is 5.6% (4), and 7% of these are unemployed, meaning that they are not engaged in any economic activity (5). The Tanzania National Ageing Policy was developed in 2003 with several specific objectives aimed at ensuring that the country’s older people are recognized, provided with basic services and given the opportunity to actively participate in the daily activities of the community. One of the specific objectives of this policy is to create a conducive environment for the provision of basic services such as health services to older people. Other specific objectives also aim at ensuring that the welfare of the elderly is protected by allocating resources to enable them participate in income generation activities as well as empowering families so that they can offer sustained support to older people (3).

    The Tanzania national policy on ageing recognizes that various groups of the elderly including farmers, fishermen, livestock keepers and the unemployed are vulnerable because they are not covered by any kind of social security protection which could support them in meeting their basic needs, including health services, especially after they are unable to undertake any kind of income generating activity.

    Despite having the National Ageing Policy in Tanzania, generally older people experience a number of difficulties in an attempt to meet their basic needs, including access to health services. Anecdotal data from unpublished reports indicate that such difficulties include lack of social and economic support from family members and ineffectiveness of the exemption mechanisms for elderly people’s access to health services. Furthermore, limited ability to pay for the health services and poor quality of health services – including longer waiting periods – hinder access to health service for the elderly. The ability of the elderly to remain healthy and independent requires the provision of a supportive environment, including access to quality healthcare. The government of Tanzania has deployed a least one or two Social Welfare Officers in each district council office, and one Social Welfare Officer in some of the regional and district hospitals who are responsible, among other roles, to assess the eligibility of elderly people in accessing free healthcare services because of their old age and inability to pay for the services. Both the district and the hospital Social Welfare Officers are supposed to work together especially when the identified poor elderly needs a referral to the district hospital. In this case, the village leader writes a letter to introduce the poor elderly person to the District Social Welfare Officer, who in turn will assess the referred elderly person and write another letter to the district hospital. At the district hospital, the Hospital Social Welfare Officer is responsible for assessing and keeping records of all individuals, including the elderly, who are eligible for exemption (6). However, there is very limited information available about the elderly despite the efforts made to ensure their access to health services: generally, not enough literature has been systematically documented (7) to show how the healthcare system in Tanzania has created or failed to create an enabling environment for older people to access health services, especially after the launch of the national policy on ageing. This study aimed at exploring the healthcare system facilitators and barriers to healthcare access among the elderly in Tanzania from the viewpoint of healthcare managers and service providers.

    Methods

    Data collection for this study spanned from April to June 2015. It employed purposive sampling technique to select 24 key informants including the following: 4 Healthcare Managers from regional referral hospitals; 6 Healthcare Managers from the District Medical Office and Council Health Management Team, and a total of 8 heads of healthcare facilities (health centres and dispensaries). In addition, 6 service providers responsible for ensuring social welfare, including the granting exemption to elderly from paying for health services at the regional and district hospitals, were also interviewed. Study participants were asked about their perspectives focusing on facilitators and barriers of orderly people’s access to health services. In-depth interview with key informants was the main method of data collection. Two researchers (one faculty and one graduate nurse) conducted the interviews; one researcher facilitated the interview while the other recorded the proceedings, noting key themes and monitoring verbal and non-verbal interactions. The interviews lasted between 45 and 90 minutes.

    Data analysis

    All interviews were audiotaped, allowing the original material to be reviewed in the preparation of the record of the interview proceedings. The interviews were conducted in Kiswahili in order to facilitate communication. The authors used qualified translators from Tanzania to translate transcribed data from Kiswahili into English to facilitate data analysis and extraction of the quotes during the writing of this paper. Thematic analytical approach was used to analyse the data. This approach allowed the researchers to go back and forth reading the transcribed qualitative data (8) when searching for emerging themes that compare with the phenomena under investigation(9). All authors jointly analysed the qualitative data by reading through the field notes/transcribed data as well as reviewing the documents. The triangulation of data was adopted during the whole process from collecting the information to its analysis. This means that the documentary reviews supported the emerging themes from the field notes and transcribed data. The researchers also used inductive coding to identify the key emerging concepts, which later on were analysed to compare and contrast them. Finally, all similar concepts were grouped together to form categories which were later classified into themes.

    Ethical issues

    Ethical approval was obtained from the Muhimbili University of Health and Allied Sciences. The regional and district authorities from Lindi and Mtwara regions/districts, as well as the ward and village government leaders granted local clearance for this study.

    Results

    The analysis of data has generated a number of themes which have been categorized into two groups: Health systems facilitators: the existence of a system to identify and exempt eligible elderly persons from paying for health services; elderly people get treatment priority over others; and, the allocation of local funds to support health service provision for the elderly.

    Barriers: lack of special doctors for elderly persons, lack of special consultation rooms for the elderly, lack of sufficient drugs and other medical supplies and equipment, inadequate funds, late supply of drugs and other medical supplies to the healthcare facilities, and low understanding of the criteria qualifying the elderly for healthcare fee exemption.

    Health systems factors facilitating elderly people’s access to healthcare services

    The existence of a system to identify and exempt eligible elderly persons from paying for health services

    Interviewed District Health Managers and heads of healthcare facilities in the study area reported that the district councils and health facility management have put in place mechanisms for identifying elderly people in the community who are eligible for exemption from paying for health services as per the national exemption policy. According to the interviewed key informants, the councils have employed Social Welfare Officers who work at the district and regional hospitals to ensure, among other things, that people aged sixty years and above who cannot afford to pay for health services get access to these services free of charge. One of the district healthcare managers expressed the following:

    ‘The council has instructed all Ward Development Committees to work together with village leaders to identify and register all elderly people who are sixty years and above, and they are poor, for eligibility to get health services free of charge.’ ( district level KI # 2)

    Another District Health Manager added that:

    ‘At the district and regional hospitals, there are Social Welfare Officers whose role is to receive elderly people who have identity card from their villages, register them and ensure that they receive free health services.’ ( district level KI # 4)

    The study respondents further reported on the absence of social welfare officers to execute exemption procedures at the lower level healthcare facilities, such as in health centres and dispensaries. To fill this gap, every facility management at the lower levels has put in place a system whereby the elderly would submit to the health facility the cards that identify them as eligible for free health services and all responsible healthcare workers at the facility have been instructed to provide them with free services.

    ‘Usually all the elderly who come to the facility with their identify cards receive free health service.’ (Facility Level KI # 3.)

    The elderly people get treatment priority over others

    The key informants for this studyreported that the healthcare facilities have introduced a mechanism in which whenever elderly people visit the facility, they are given special priority over other groups of patients in receiving health services. Therefore, they would always receive services without queuing; or, they would be provided with services through their special separate window. This strategy aims at reducing waiting periods for the elderly to receive the services.

    ‘At this facility, when an elderly person comes, he/she gets services immediately without waiting for longer periods. Even other members of the community know about this system.’ (Facility Level KI # 6).

    Another respondent said:

    ‘If there are many patients at the dispensing room, I usually ask other patients to allow elderly persons to receive drugs first, followed by other patients.’ (Facility level KI # 3).

    One key informant emphasized that:

    At the reception of our health facility, we have a poster showing that elderly people are given priority. One of the posters states that ‘ mpishe mzee ’, (literally meaning ‘let an elderly person be served first’).’ (Regional Hospital Health Manager KI # 1)

    The Allocation of local funds to support service provision for the elderly

    In one district, the key informants reported that the council management which oversees the implementation of health services in the district has instructed the Facility Management Team to allocate some of the income generated from Community Health Funds to support the facility in the provision of health services to elderly people who are exempted from paying for health services.

    ‘… All elderly persons are covered by the exemption policy; they are not supposed to pay for the health services. The District Council pays for the services for the elderly through Community Health Funds. Such funds are generated at the primary healthcare facilities (health centres and dispensaries).’ (Facility level KI # 9).

    Health systems barriers hindering the access of elderly people to health services

    Lack of specific consultation rooms and doctors for the elderly

    The interviewed participants from the regional, district and lower level healthcare facilities claimed that the hospitals, health centres and dispensaries do not have special consultation rooms and physicians for attending the elderly. According to the respondents, elderly people suffer from a number of aging related diseases such as diabetes, lung disease, enlarged prostate, depression, hypertension, and other cardiovascular diseases. Malaria and pneumonia were also mentioned to be common health problems affecting most elderly persons in the study area. Nevertheless, the lack of trained physicians to specifically serve the elderly was mentioned as the main challenge as remarked by the following key informants:

    ‘Despite the fact that we have shortage of medical doctors, but the situation is even worse in most of our hospitals because we do not have physicians specialized in treating and caring for the elderly.’ (Regional Health Manager KI # 2).

    Another key informant expressed the following:

    ‘The system for serving our elderly people could be efficient if we had enough medical doctors and assign special doctors for them.’ (District Hospital Health Manager KI #4).

    Inadequate funds allocated for financing healthcare services to the elderly

    Participants for this study reported that the funds allocated to the district health systems both at the regional hospitals, district hospitals and lower level healthcare facilities to deliver health services are largely inadequate. For instance, they said that the funds allocated for purchasing drugs and other medical supplies are always insufficient, making very difficult for the healthcare facilities to provide quality and efficient health services in their respective catchment areas. One interviewee said the following:

    ‘Funds allocated to the District Health Departments to provide healthcare services have never been enough. In this district for instance, we have many elderly people who are covered by the exemption policy but there are no specific funds allocated to cover the expenses for such services.’ (District Health Manager KI #1).

    Another respondent said that:

    ‘The funds allocated to the hospital to cover for one year, may cover only for six months.’ (District Hospital Health Manager KI #4).

    Late supply of drugs and other medical supplies to the healthcare facilities

    The interviewees reported further that sometimes the funds allocated to the districts are disbursed late to the recipient authorities.In addition, the delay in the delivery of drugs and other medical supplies by Medical Store Department (MSD), the national agency responsible for supplying drugs and other medical supplies to government-owned healthcare facilities, was also reported by respondents as another challenge. According to the respondents, this situation compromises the healthcare facilities’ ability in providing health services to various patients. In most cases, the elderly are the most affected ones because of their inability to afford private health services. One respondent said the following during the interview:

    ‘Sometimes the healthcare facilities receive drugs and medical supplies very late, a situation which causes sufferings to our patients particularly the older poor people ………because most of them cannot afford to pay for health services.’ (District Health Manager KI #3).

    Lack of sufficient drugs and medical supplies

    Majority of the key informants for this study reported that all healthcare facilities owned by the government do not have adequate drugs and medical supplies to support the provision of health services to all patients including the elderly.The key informants further explained that this barrier is a result of insufficient funds allocated to the healthcare facilities to finance the provision of health services in their respective areas.

    ‘The main problem facing elderly people is that most of the prescribed drugs are not available at the dispensing room because the budget allocated for purchasing drugs is always insufficient…. Therefore, elderly people are often told to buy drugs from the private medical stores.’ (Regional Health Manager KI 5).

    The informants were emphatic about the lack of adequate medical supplies and equipment, adding that some of them are not functioning. Most of them concluded that the shortages affect patients in many government-owned healthcare facilities with one of them saying that:

    ‘The X-ray machine is not functioning for three months while the full blood picture machine is not functioning for seven months now…. This situation greatly affects our patients, including elderly.’ (Regional Referral Hospital Manager KI 2).

    Low understanding of the criteria qualifying the elderly for healthcare fee exemption

    Healthcare managers at both regional and district levels were concerned about the people’s low understanding of the criteria qualifying elderly people for healthcare fee exemption. In this case, the managers reported that the exemption policy stipulates that only elderly people who are poor and cannot afford to pay for health services should be considered eligible for receiving free health services. However, participants noted that in practice every elderly person who is sixty years and above, including those who can afford to pay for the health services, take advantage of the exemption policy. This situation compromises the quality of service delivery in most healthcare facilities since the meager financial resources are spent in serving patients who do not deserve the exemption. During an interview with one participant, the following was said:

    ‘…You will find that any person who turns sixty years and above, rich or poor, wants to be exempted from paying for health services. This is really a burden for the healthcare system.’ (Social Welfare Officer KI #2)

    Discussion

    This study explored Health Managers’ and Service Providers’ perspectives on health system facilitators and barriers to healthcare access among the elderly in Tanzania’s public healthcare facilities. The study has illustrated that the health system has made some efforts to implement the national exemption policy by ensuring that elderly persons aged sixty years and above receive free health services. Some of the identified factors that facilitate elderly people’s access to health services include: having in place a system to identify and exempt elderly from paying for health services; giving priority to the elderly during treatment; and, allocation of locally generated funds from community health funds to support service provision to elderly persons.

    According to healthcare managers’ perspectives, a system has been created, in which community leadership – which include Ward Development Committees and the village leadership – register elderly persons aged sixty years and above who cannot afford to pay for health services. The healthcare system has also created an environment in most of the government-owned healthcare facilities which allows elderly people to receive treatment before others because of their inability to wait for longer periods. This study has also shown that district council, which oversees the operationalization of health services in the district; has instructed the management at health facilities to utilize locally generated funds through community health insurance to finance the delivery of health services to the elderly in their catchment areas.

    There are a few qualitative studies in Tanzania and Africa that have explored the health system factors facilitating elderly people’s access to healthcare services. A study conducted in Moshi Municipality in the northern part of Tanzania on the challenges facing elderly people in accessing health services in government-owned healthcare facilities reported findings which contradict the results of the current study. The results from that study indicated that there existed no system in place allowing elderly to receive treatment upon their visiting the healthcare facilities. Most of the interviewed elderly persons complained that they queued for long periods of time before they received treatment services. This is despite the fact that many elderly persons arrived at the healthcare facilities very late due to transportation difficulties (10). The differences between the findings of the current study and the one conducted in Moshi are attributable to two main factors: firstly, the Moshi study relied on the perspectives of the patients while this study sought the opinions of the healthcare providers. Secondly, the current research was conducted in Mtwara and Lindi regions in southern Tanzania whereas the Moshi study was carried out in Kilimanjaro region in the northern part of the country. This means that at the time when the Moshi study was being conducted in 2013, the District Health System in the study area had not yet established the exemption for elderly people from paying for health services, while the findings from this study have shown that the district health systems in Mtwara and Lindi have put in place a system to identify and exempt the elderly from paying for health services as well as giving them priority during treatment.

    Mamdani and Bangser (11) conducted a literature review on poor people’s experience of accessing health services in Tanzania and reported that healthcare facilities owned by the government, especially in rural areas, do exempt vulnerable groups from paying for the services although this occurs in a sporadic manner. They further noted that the procedures for identifying vulnerable groups are difficult and not clearly stipulated, which makes the exemption policy inefficient. In another study, Munishi (12) also reported that there was difficulty in the process of identifying the poor, including elderly persons, given the absence of a clearly written criteria on how the responsible community leaders and healthcare workers should determine the poor people in the community who are eligible for exemption from paying for health services. Saliba et al., (13) suggest the use of a community survey consisting of a 13-item function-based scoring system that considers age, self-rated health status, and limitation in physical function and functional disabilities in identifying vulnerable elderly people in the community. Despite their agreeing with other studies that the use of community survey is effective in evaluating the status of elderly persons, however, Saliba and colleagues (13) caution that surveys consume more time, are costly to manage, and can be overwhelmed by non-response (14–16).

    Apart from these facilitating factors, this study also revealed that there are a number of barriers that hinder access to health services among elderly persons in the study area. Lack of specific consultation rooms and doctors for serving patients aged sixty years and above has been observed as a hindering factor for elderly persons’ access to health services in many government-owned healthcare facilities. This has been attributed largely by the existing shortage of personnel in the health sector, particularly the insufficient number of medical doctors. A study conducted in 2013 (17) revealed that the lack of manpower in Tanzania is approximately 67% in the government-owned healthcare facilities and 87.5% in the private healthcare facilities. Even the present healthcare workers are greatly mal-distributed with majority of them working in the urban compared to rural areas (18). According to Munishi (12), the shortage of skilled healthcare providers in most public healthcare facilities has implications on the ability of the facilities to serve patients adequately. In Ghana, Garshong et al., (19) reported that the existing problem of shortage of human resources in the health sector, particularly in rural healthcare facilities, has largely constrained these facilities to provide better services to their patients. A study on Geriatric medicine: services and training in Africa by Dotchin et al., (20) concluded that despite the increasing numbers of elderly persons and the increasing burden of chronic diseases there are few geriatricians in African countries.

    This study has also found that the lack of sufficient drugs and medical equipment has largely contributed to the failure to provide free health services to the elderly in most healthcare facilities owned by the government. In most cases, the only free service available is doctors’ consultation; the prescribed drugs are often out of stock and the elderly persons are asked to buy them from private pharmacies. Other studies (12,21) reported similar results that drugs are frequently unavailable, a situation that hampers the implementation of the exemption policy in the government-owned healthcare facilities. The study findings further revealed that the lack of drugs and functioning medical equipment is a result of inadequate funds allocated for financing health services in the government-owned healthcare facilities which, in turn, hinder accessibility of free health services to all eligible vulnerable populations, including the elderly. Similar findings were reported in Tanzania indicating that the central government does not provide adequate funds to local government authorities to provide health services to the people (22). This study also reported that drugs and other medical supplies were not timely supplied to the healthcare facilities, which in turn affected the delivery of health services to the patients, including elderly persons. A study on the availability of drugs and medical supplies for emergency obstetric care in a Tanzania’s rural district reported similar findings indicating that there is a delay in supplying drugs and other medical supplies to the healthcare facilities, adding that the delay has greatly affected the provision of healthcare services in various healthcare facilities (23).

     

    Moreover, the local authorities (district councils) which oversee the implementation of health service delivery in Tanzania do not have adequate and reliable sources for generating their own income that can be utilized to ensure accessibility of health services in the councils. A study carried out in Ghana on the barriers to implementing health sector administrative decentralization reported similar findings showing that the lack of adequate funds is one of the main barriers facing the provision of health services (24). Another study carried out in Uganda also found that the central government transferred insufficient funds to the districts to provide health services, which as a result constrained the delivery of the services at the district level (25).

    Furthermore, this study found that low understanding of the criteria qualifying elderly people for healthcare fee exemption has also been a barrier towards smooth implementation of the exemption policy. Some of elderly persons are not aware of the exemption procedures such as the collection of a letter from the village leadership. Such letters are important since they identify the elderly persons in need and provide evidence supporting their eligibility for exemption from paying for health services. These findings are consistent with those reported by Munishi (12) which revealed that the exemption procedures are not well understood by most elderly persons; as a result, most elderly people would visit healthcare facilities without any supporting documents to prove their eligibility to access free health services in the government-owned healthcare facilities.

     

    Limitation of the study and suggestions for further work

    This study suffers from one limitation: that, it interviewed healthcare managers who may be talking about the healthcare system from an idealistic perspective because of their being insider study participants working as healthcare workers. Therefore, they could be describing the facilitators and barriers to healthcare access among the elderly in Tanzania according to their understanding of how the system is designed to work, but not how it works in actuality. However, notwithstanding this limitation, findings from this study have provided insights into what is happening in the healthcare system in the country with regards to facilitators and barriers to healthcare access among the elderly in Tanzania. Nonetheless, it is suggested that another study with a large sample covering more districts and regions is conducted to provide a broader picture of how Tanzania’s healthcare system is prepared to ensure elderly people’s access to health services without facing any challenges.

    Conclusion

    This analysis suggests several conclusions. First, the healthcare system has recognized the importance of creating an enabling environment to enhance accessibility of health services among the elderly. Such environment includes introducing a system to identify and exempt elderly people from paying for health services, providing priority to the elderly during treatment, and allocation of locally generated income from community health funds to support service provision for the elderly. Second, the existing environment does not function effectively because of the existence of a number of barriers facing elderly people in accessing health services in the public healthcare facilities. Particularly, the lack of special consultation rooms and specialized doctors for attending to elderly persons, the lack of sufficient drugs and other medical equipment, inadequate funds allocated for financing health services for different population groups, including the elderly, at the facility level, and low level understanding of the exemption policy among elderly people are the things that impede the government efforts to provide free health services to the elderly in Tanzania. The study recommends that the central government through the Ministry of Health, Community Development, Gender and Children allocates adequate human and non-human resources to the healthcare system to enable it function effectively, including providing better health services to the elderly who face a number of aging related ailments.

    Author Contributions

    GF conceived and designed the study. GF, TN and AA supervised data collection. GF analyzed data and wrote the first draft of the paper. TN and AA commented on the first and subsequent drafts of the paper. All authors have approved the submission of the paper.

    Acknowledgements

    The authors gratefully acknowledge the Muhimbili University of Health and Allied Sciences (MUHAS), the Mtwara and Lindi regional and Mtwara, Mikindani, Mtwara Rural district, Lindi Municipality and Lindi Rural district, ward and village administrative and health offices for their administrative support during fieldwork preparation and data collection; the research assistants for their assistance during data collection; and the key informants from the regional, district and facility level who provided information for this study. The researchers are also grateful to Swedish International Development Agency (Sida) for their financial support for this study through grant number grant No. 75000516.

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