How much does Tanzanian healthcare cost?

Following a couple of beers with an old friend, and a few words of encouragement, I’m feeling a little inspired. And inspiration is something I need to tackle the topic health spending. But, feeling the boldness of my beers, I want to start with this headline.

TANZANIA CAN AFFORD TO SPEND VERY LITTLE ON HEALTH.

I’m going to spend the next few hundred words showing how this is true and why I think this is unlikely to change for the near future. 

To start with, a story: I have just spent a fascinating week in Bugando Hospital in Mwanza, on the south east shore of Lake Victoria. It is one of four tertiary referral centres in Tanzania and is a huge 1,000 bed hospital. I was also lucky enough to spend the week observing the ITU facilities, and learning to how ultrasound is applicable in a resource limited setting (as it turns out it is an hugely useful tool).

As I rounded (that’s a US term I just learnt) on the ITU patients we came to a 42 year old man with tetanus. He was going to pull through, but not after some weeks on the ITU, requiring intubation and paralysis. I reflected on this and thought – “Wow, this is an example of truly international standard care, in Tanzania and providing the best possible chance that this man will make it”. But how affordable is this?

So this man, when he comes to leave hospital, will be left with a bill on his bed that somehow he and his extended family will be asked to pay for. In many ways this puts him in a similar position to the gentleman I described previously with ascites, but i’m not going into the user fees question just now. The main point I want to make is that keeping someone alive for four weeks on an ITU, in any setting, is damn expensive. Before factoring in costs of oxygen, nursing and paralysis drugs lets look at a simple example, this man developed a hospital acquired pneumonia and was treated with Ceftriaxone at a cost of $12 for 7 days. Although in the US or UK the cost might be a nearer $150, which in relative terms (GDP/average incomes) is significantly more than in Tanzania, this is still a considerable expense for the patient and the service. 

I want to put this case example in context of the Tanzanian Health Budget. From the HealthSector Strategic Plan III (2009-2015) the projected health spend for 2011/12 is $1,182 million dollars. Of this, $1,062 million is likely to be available. Effectively the Tanzanian Department for Health will have approximately 1 billion USD to spend in 2011. This might seem like a lot of money, but to put it on other figures in Tanzania spends $72 per person, per year on health – according to WHO 2006 statistics. And also lets also reiterate something, these figures include the costs of developing a social welfare system – a budget separate in many developed countries. We will see shortly how these figures compare internationally.

But before we do, lets have a think about whether these figures are accurate for the amount that the average Tanzanian family spends on health per year? The short answer is that they almost certainly underestimate expenditure. They don’t account for informal health payments, either through informal user fees or through traditional healers. They don’t account for privately funded NGO’s which can provide vertical (although some funding for this is included in the "health basket fund") or system based support for health programmes either locally or nationally. In fact, a study by OPM of health expenditure in Sierra Leone found by triangulated household survey that estimates were three times greater than what was previously thought.

However, even if these figures were triple what they are now, how would they compare to the ‘global north’?

In 2007, the US spent $7,290 per person on health. In the same year, the UK spent $ 2,992 (total is over £100 billion!). The proposed merger of Barts and London hospital (where I used to work!) with Newham and Whipps Cross would create a trust with a budget of £1.1 billion pounds. In short the National budget of Tanzania is two thirds that of a large (soon to be foundation) trust in the UK. And, just to move between sectors and add more comparative spice: How does the Tanzanian health budget compare to the top bonuses in the banking world? I’d guess at not too far different…

To achieve a comparative spend on health, per capita spending in Tanzania, not taking into account any changes in population or inflation, would have to increase 100,000% to match the US, and over 40,000% to match that of the UK (or put another way, its per capita budget is 2.4% of the UK’s). In the short-term achieving comparable spending is not a realistic goal.

Looking internally, how much is being spent on externally funded research within Tanzania? The short answer is that we don’t know, but for an idea of some figures we do know: a recent BMJ article gave focus to an HIV prevention trial with a research grant of $37 million, a recent trial in Uganda comparing fluconazole treatment regimes in Cryptococcus (of which much of the information was already known) had a budget of $13 million. Personally I’d be fascinated by knowing how, once you combine all of the trials and all of the foreign based PhD’s in Tanzania, is being spent in these areas. I’d wager that it would be at least 20% of the countries health budget.

Given that there is a strong and growing body of opinion that tropical disease have good evidence and guidelines that are in many places not applicable because drugs and resources not available. If you were running the business of improving health outcomes for SSA, how much would you consider is worthwhile spending on R+D while current practice is so poorly resourced?

To summarise, there is a huge, huge deficit in health spending in Tanzania compared to the western countries, which is mirrored across much of Sub-Saharan Africa (SSA). In Tanzania, current real-term increases in health spending are measured in double digit percentages, but the reality is that without increasing health expenditure factorially it will be impossible to impose a western style health system (with all the specialist, expensive services that it entails) as there simply won’t be the money. Some people will tell me to stop being such a pessimist about this and that i'm trying to devalue what is and can be achieved. My answer is this: Imagine the UK health system being asked to cut its budget to approximately 2.4% of what it currently spends, and ask yourself the question, could it still provide a fraction of what it currently provides? No, the healthcare we practice is too expensive, and if its too expensive for that then its too expensive for Tanzania now and for the foreseeable future.

But, why is this important now? 

Tanzania, along with other SSA countries is facing a crisis of funding for health right now. With the ease of access to healthcare information citizens are, rightly, demanding access to a high standard of healthcare. Unfortunately, in many cases, these services are something that the service cannot afford. For example, Tanzania has only a handful of CT scanners. As a citizen you are either lucky enough enough to live near a hospital that has one, in which case they are being asked to pay for this high cost service (between $100 - $120).  Or, if they live further away (or the hospital scanner is broken - such as in Bugando) they don't get that service. Essentially at the moment, the lack of funding means that either the patient pays or the service isn't provided, both of which have adverse outcomes.


A recent study of catastrophic healthcare related expenditure in Nigeria (also free PDF on web) found that, over the period of one month, almost a quarter of households in the poorest quintile (and 15% overall) experienced a health catastrophe that cost over 40% of their total non-food expenditure. The costs of healthcare are crippling those not the poorest in society, but also those in the middle classes of SSA, its not a giant leap of imagination to see what these costs are replacing, education, clothing etc. 

The case of the CT scanner also continues to highlight the quality of service that can be provided on a budget 2.4% that of the UK. In many cases the argument could be made that a head CT is of little value - there is only one neurosurgical unit in Tanzania, however for the diagnosis of infective space occupying lesions and many other situations it is of huge value.


So, what should we do about it?

This is the most difficult question that fundamentally boils down to three possible answers, spend more, spend more wisely or do nothing at all. 

For those who choose to design systems of care for resource limited care the challenge is greatest. Following an understanding that not all services available globally can be provided (at present) tough choices on rationing will have to be made. This is probably also important for those western doctors who think that helping to create a state of the art cardiothoracics centre is the most pressing issue for their country of choice, when in fact building a western style (and western costing) service right now will only be a drain and burden on a cash strapped service.  

Are we spending too much on research and not enough on actually supporting health outcomes? I would argue priorities need to be considered carefully. We need to make sure we are implementing all of the best practice we already know, and this really does mean going back to basics, for example, do all district hospitals have basic antibiotics to treat pneumonia? Or, how close are we to ensuring that all anaesthetics have adequate monitoring? But it also means making sure that if we are doing research that all resource poor countries stands a good chance of being able to implement the results. That means doing research that has the capability already in place to roll out the results. For example, from resource limited countries we know that Artesunate gives better outcomes in severe Malaria, or we know that Amphotericin B gives better outcomes in Crytpococcal Meningitis than fluconazole, but how far are we from implementing these changes to the majority of those in the countries who need it? As far as i can see in most cases a long, long way. 

The bottom line is of course money. In a world of spiraling healthcare costs Tanzania cannot and will not keep up. The fact is that its much worse, spending per capita is around 1% of that of the USA and, without the most radical of revolutions, this isn’t going to change for a long, long time.If Tanzania is to be expected to run a healthcare system that competes with western countries then budgets will need to increase (through whatever means) not by 10 or 20% but by 100 or 200%. I don't know how this funding gap can be bridged but, to me anyway, its clear that without a huge attempt at this, the changes we see will be very slow.

I want to end on a positive note. Our gentleman with tetanus will be on ITU will be on ITU for more than 4 weeks, but he will almost certainly survive as they do in most cases from Bugando. I think that makes an incredible story. Maybe in the near future we, in our western bubble, will start to look over our shoulder at resource limited countries to find out how they do things cheaper and get better, equivalent results?