The authors have declared that no competing interests exist.
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.
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
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
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 “
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
In Tanzania, the number of people aged from sixty years and above is 5.6%
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
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.
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
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.
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.
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 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.
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.
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.
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:
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:
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:
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 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:
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:
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
Mamdani and Bangser
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
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
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
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
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.
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.
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.
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.