BACKGROUND:

1.1 The history of health care financing in Tanzania
Soon after independence in 1961, the Government aimed at building her human capital by isolating factors that were labelled as “major enemies of development” that is ignorance, diseases, and poverty. Among other strategies disease as an enemy was fought by a massive increase in health facilities, free health care services, and free training of staffs in few available institutions owned by the government. The government fully funded the provision of health services through taxation. The Arusha Declaration of 1967 promoted the free care for all as the national policy. Later on in 1977 private for profit practice was banned which continued up to 1991.All these health sector reforms aimed to increase universal access to social services to the poor and those living in marginalized rural areas (1,2).

In 1980s the nation went through severe economic crisis, which highly affected the management and financing of social services including health care services. Shortage of drugs, equipment and medical supplies, deterioration of the physical health infrastructure including electricity supply, water and sanitation at the health care facilities; poor management and regulatory framework; low staff morale due to low wages was among the challenges due severe underfunding (3).

In struggle to rescue the national economy and pressure from International Monetary Fund (IMF) and World Bank (WB ) Tanzania adopted the Structural Adjustment Policy (SAP) of 1980s (4). In early 1990s, cost sharing was adopted in the health sector reforms that changed the financing system from free services to mixed financing mechanisms. Other aspects of reforms included decentralization of health services; encouragement of private sector to complement public health care. All these aimed at improving the quality and quantity of health services and increase in equity in health accessibility and utilization (5).

Introduction of user fees in effort to rescue the health system which were failing due to financial constraints posed a great financial burden to the poor and other vulnerable groups as most of them could not afford to pay for health services, and hence demand to health care dropped significantly (6).

In order to promote equity in getting health services, after the introduction of the user fee, equity-seeking mechanisms were put in place to protect the poor and other vulnerable groups such as elders, pregnant women and children who were unable to pay the fees; it was also meant to address the loss of income and wealth due to large unexpected medical expenditures amongst other groups. In other words, these mechanisms aimed at ensuring no group is left behind by enhancing equity in accessing health care services (7).These initiatives include the establishment of a public exemption and waiver system, introduction of Community Health Fund (CHF) and establishment of a National Health Insurance Fund (NHIF) (8).

1.2 Insurance Coverage in children, African Context
Health care coverage among children is of paramount importance as the future generation. Children are classified as among the vulnerable or at risk groups hence financial protection is necessary to enhance health care utilization and hence better health outcomes in children. Health Insurance and Exemption system applies in most African Countries for children specifically MCH services and basic health care for children under 5 years of age to provide financial protection (9).

However, Insurance coverage for children in low and middle income countries takes a mixed pattern with lack of insurance programmes targeted specifically to children as it is the case in most developed countries. Children in LMICs are mostly covered under the umbrella of dependents where a parent or guardian contributes into the scheme with a number of dependents behind mostly spouse and children (10).
In Ghana children under 18 years are exempted of premium fees for enrolment into the National Health insurance scheme. This is an example of low and middle income countries where children are specifically and directly incorporated into the national insurance scheme and are provided with special cards by the scheme in an effort to move towards universal health care coverage. The impact of health insurance in Ghana has been evident where health care utilization increased together with improved health outcomes like dropping of child mortality rate (11).