Social protection in an electorally competitive environment (2): The politics of health insurance in Tanzania

This paper analyses the introduction and expansion of health insurance schemes in Tanzania. Health insurances were introduced around year 2000 as part of a more general health reform process aimed at improving access to health services. The paper argues that the health insurances were driven by a policy coalition of bureaucrats and transnational actors, who, inspired by international trends, framed reforms as a way for the ruling party to live up to one of its core priorities since independence, namely, improved and, eventually, universal access to health services. The introduction of insurances was expected to help mobilise funds and improve the working of the health care system for this purpose. However, judged by their modest design and slow implementation, the ruling political elite remained ambiguous about health insurances. Politically, a fast rollout was perceived to be risky. Similar political considerations may explain the reluctance to expand health insurance coverage through a mandatory scheme that bureaucrats and development partners have propagated recently. The rejection of the initial design for such a scheme came as a surprise to the policy coalition, which did not enjoy the same access to key decisionmakers as in the past. Concurrently, and driven by increased electoral competition, the ruling party has increasingly focused on improving access through the expansion of physical health infrastructure. This has the additional advantage of being highly visible among the rural majority of the population, who overwhelmingly vote Chama Cha Mapinduzi (CCM). This is our second paper on social protection in Tanzania.