Substantial lost Revenue
The information collected from facility income statements and Comprehensive Council Health Plan shows that district hospitals lost substantial amount of revenues mainly from delivery, pharmaceutical, laboratory and medical consultation services. Table 3, of Annex 1 summarises the revenues lost from medical consultation services in District Hospitals A, B and C.
Findings also indicate that free delivery services in public health facilities greatly contributed to the decline of revenues. Table 4 of Annex 2 shows revenues lost due to free delivery services against revenues collected from user fee charges.
Furthermore, pharmaceutical services lost substantial revenues along with other free services granted by district hospitals. Table 5 of Annex 3 presents the revenues lost due to user fee exemptions against the revenues collected from user fee charges.
Besides pharmaceutical, free laboratory services also depleted revenue in district hospitals. Table 6 of Annex 4 summarises revenues lost against the revenues collected from laboratory services in District hospitals.
Apart from District hospitals, Health centres also experienced a significant loss of revenues from free medical consultation, pharmaceuticals, delivery and laboratory services. Table 7 of Annex 5 presents the revenues lost against the revenues collected in Health Centre A, B, C, D, E and F. Moreover, delivery services led to substantial revenue losses. Table 8 of Annex 6 summarises revenues lost against fund collected from user fee. Furthermore, Table 9 of Annex 7 and Table 10 of Annex 8 presents loss of revenues in pharmaceutical and laboratory services respectively in Health Centres.
Similar findings were commonly reported by respondents during interviews. Respondents underlined reasons and consequences of lost revenues in health facilities. Respondents reported that funds were lost because majority of service users did not pay for the services. They underlined that exempted groups such as children under 5, pregnant women and people above 60s were most users of health services. Respondents also reported that there were no mechanisms in place to subsidize facilities for the lost revenues. This is exemplified by one respondent:
“Our facility loses substantial funds by implementing user fee exemptions. This is because groups such as children under 5 years, pregnant women and elders above 60 years use more free services; and there are no any deliberate mechanisms from either central or local government to reimburse our facility for the lost revenues” (ID with Health Manager, District Hospital A).
Respondents frequently reported that loss of revenues was one of the reasons for poor service provision in public health facilities. Health managers reported that they were not able to allocate funds to the projects which they sought would improve service delivery. Respondents also underlined that some facility infrastructures were dilapidated, and needed serious renovation but health facilities had no sufficient funds. Respondents emphasised that renovation and construction of new infrastructures depended on internal sources of revenue, including user fee charges. some respondents narrated thus:
“Sincerely, user fee exemptions are a deadlock in service delivery although it benefits some poor and most vulnerable groups. User fee exemptions drain big revenues from the health facilities. If lost revenues were collected, they would help the facility management to improve infrastructures. We are not able to renovate our buildings because our facility does not generate sufficient funds. As you know children, pregnant women and elders do not pay although they are the most users of the health services” (ID with Health Manager, Kilosa District Council).
Other respondents added:
“You know, our facility fails even to expand wards in order to admit more patients. In fact, our facility wards are too small to allow additional beds; and this is why you see some patients sleep on the floor or even share beds. If you ask our Hospital Administrators what is the solution to this problem, they reply that the facility faces a significant shortage of funds. Many patients are exempted and thus they do not pay for health services” (ID with Service provider, District Hospital B).
“We have many plans which we sought to implement to improve facility infrastructures. We planned to build offices, a waiting shed, and to extend wards but we failed because the funds we collect are not enough. We do not receive funds from the district council even for minor repair of our buildings. All costs associated with maintenance and running offices are the responsibility of the facility. For now, the facility is unable to do it because majority of service users do not pay for the services” (ID with Health Manager, Mbarali District Council).
In the same line of argument, health managers reported that lost revenues made health facilities to accumulate many unpaid arrears to staff and service suppliers. It was the view of the health managers that some health facilities were not able even to pay extra duty allowances to staff. Some respondents narrated that:
“Our staff claim their extra duty allowances for several months. We know their claims are genuine, and we would like to pay them on time. However, we cannot do this because we don’t have funds. The little funds we collect from user fee and other sources are not enough to settle staff allowances. This situation demoralises some staff although they don’t complain openly” (ID with Health Manager, District Hospital B).
“Frankly speaking, sometimes we undermine the rights of our staff for not giving their rights on time. In fact, our staff have been claiming their extra duty allowances for a long time. Some claims have taken more than six months since workers submitted to us, but we have not paid them. In fact, we don’t know when we shall pay them because right now, we have no money. Whenever we try to collect funds from services, we fail to reach targets simply because the majority of our service users do not pay, thus causing huge revenue loss” (ID with Health Manager, District Hospital A).
Some service providers confirmed that they had not been paid their extra duty and on call allowances for a long time. This is exemplified by some respondents, thus:
“We have been called several times to attend to patients outside normal working hours. Sometimes, we are called when we go to bed. Instead of sleeping, we come to the facility and attend to patients. We expected to be paid these allowances immediately. But if you ask the Matron, she says the facility has no money. In fact, it is discouraging” (ID with Service provider, Health D).
Another respondent added:
“We are demoralized because we work hard but paid less. We don’t get even extra duty and other allowances on time. Sometimes, we think to quit but we ask what if we leave this job? Will we get a better job than this? In fact, the situation is even difficult in private hospitals. We hear from our friends complaining that the situation is worse than what we face. My friend, let me tell you this, we have no other options” (ID with Service provider, Health Centre C).