In theory, people living in the rather remote Kilombero Valley of Tanzania have access to a rapidly growing range of health insurances. The National Health Insurance Fund (NHIF) enables beneficiaries to access health care services through a wide network of accredited health facilities. Set up for employees in the public sector, the NHIF recently diversified its portfolio to include children, students and informal sector workers. Other forms of insurance include the Social Health Insurance Benefit (SHIB) under the National Social Security (NSSF), Tiba Kwa Kadi (Tika), the Community Health Fund (CHF) and private insurance schemes. According to recent estimates, about 10 million Tanzanians are covered by health insurance of one kind or other, representing 20 per cent of the population. In addition to these insurances, the Ministry of Health grants exemptions and waivers which entitle citizens classified as vulnerable or poor to access health services. Exemptions are granted for all maternity services, children under five years and particular diseases such as TB/Leprosy, HIV/AIDS and some chronic diseases that would drain substantial income from the patients if such patients were asked to pay. Waivers target the poor and vulnerable groups of the society on grounds of ability to pay. Moreover, the TANZANIA Social Action Fund (TASAF) implements a number of initiatives targeting the poor, including cash-transfers.
This paper examines how people in the Kilombero Valley navigate through this bewildering and rapidly changing social health protection landscape. Who can and cannot/does not participate in health insurance schemes and other forms of social health protection, and for what reasons? What are the micropolitics shaping people’s desires and judgments? Drawing on ethnographic field research, we will argue that - in the midst of these changes and reforms - people remain entangled in partly overlapping webs of social and institutional power relations.