The paradox of the cost and affordability of traditional and government health services in Tanzania

Since the introduction of user fee systems in the government health facilit ies of most African countries, which shifted part of the burden of financin g health care onto the community, affordability of basic health care has be en a much discussed topic. It is sometimes assumed that in areas where high levels of spending for traditional treatments are common, people would be able to pay for basic health care at governmental facilities, but may not b e willing to do so. However, examining willingness to pay and ability to pa y in the broader context of different types of illness and their treatment leads us to a very different conclusion. in the course of a medical-ethnogr aphic study in south-eastern Tanzania, we found evidence that people may in deed be willing, but may nevertheless not be able, to pay for biomedical he alth care - even when they can afford costly traditional medicine. In this article, we suggest that the ability to pay for traditional treatment can d iffer from ability to pay for hospital attendance for two main reasons. Fir st, many healers - in contrast to the hospital - offer alternatives to cash payments, such as compensation in kind or in work, or payment on a credit basis. Secondly, and more importantly, the activation of social networks fo r financial help is different for the two sectors. For the poor in particul ar, ability to pay for health care depends a great deal on contributions fr om relatives, neighbours and friends. The treatment of the 'personalistic' type of illness, which is carried out by a traditional healer, involves an extended kin-group, and there is high social pressure to comply with the re quirements of the family elders, which may include providing financial supp ort. In contrast, the costs for the treatment of 'normal' illnesses at the hospital are usually covered by the patient him/herself, or a small circle of relatives and friends.