James Ellison Department of Anthropology Dickinson College ([email protected])

First-Class Health: Amenity Wards, Health Insurance, and Normalizing Health Care Inequalities in Tanzania In 2008, a government hospital in southwest Tanzania added a “first-class ward,” which, unlike existing inpatient wards defined by sex, age, and ailment, would treat patients according to their wealth. A generation ago, Tanzanians viewed health care as a right of citizenship. In the 1980s and 1990s, structural adjustment programs and user fees reduced people’s access to biomedical attention. Tanzania currently promotes “amenity” wards and health insurance to increase health care availability, generate revenue from patients and potential patients, and better integrate for-profit care. In this article, I examine people’s discussions of these changes, drawing on ethnographic fieldwork in the 2000s and 1990s. I argue that Tanzanians criticize unequal access to care and health insurance, although the systemic structuring of inequalities is becoming normalized. People transform the language of socialism to frame individualized market-based care as mutual interdependence and moral necessity, articulating a new biomedical citizenship. [amenity wards, health insurance, biopolitics, neoliberalism, rights]

In 2008, in rural southwest Tanzania, the district medical officer (DMO) at a government hospital I first visited in 1993 showed me a nearly completed “firstclass ward.” Unlike existing wards, defined by sex, age, and ailment, this ward would provide first-class care to patients able to pay first-class costs. The new ward initially surprised me, despite Tanzania’s late-20th-century embrace of capitalism. A generation ago, under ujamaa socialism, Tanzanians viewed health care as a right of citizenship. In the 1980s and 1990s, people protested structural adjustment programs (SAPs) that reshaped government responsibilities and biomedical care with capitalism. The current health system, associated with Tanzania’s political and economic liberalization, assumes wealth disparities and unequal access. In this article, I examine the interconnected developments of elite wards and health insurance schemes promoted since the late 1990s that define people by wealth, residence, and mobility. Both are designed to generate revenue from people’s health needs and they are becoming more widely accepted than were initial market reforms, as people reshape their belonging in the state. Citing people’s discussions of MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 28, Issue 2, pp. 162–181, ISSN 0745C 2014 by the American Anthropological Association. All rights 5194, online ISSN 1548-1387.  reserved. DOI: 10.1111/maq.12086

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biomedical care and insurance, I argue that, as new inequalities in the biomedical system become normalized, categories that ostensibly shaped the policies— wealthy/poor, national/rural, insured/uninsured—emerge in a new biomedical citizenship. Tanzania’s liberalization and a seemingly relentless expansion of “scientific capitalism” (Ferguson 2006:78) shape biomedical care around individual wealth. Forpay care and privatization exclude some people and create or exacerbate inequalities, but today Tanzanians, the Ministry of Health and Social Welfare (MoHSW), and international financial institutions (IFIs) frame these policies as necessities with elaborate economic, historical, and ethical justifications. People criticize inequalities in health care—by being astonished at the first-class ward’s costs, for example. But they tend to expect that some will be excluded from levels of care by inclusion in a changing biomedical order. People envy the better care available to those who can afford it, without necessarily condemning the system through which they buy it. These ethical understandings emerge via new biopolitical technologies, including elite wards and health insurance, changing the relationships of citizens, as patients and potential patients, to the state. Tanzanians in the 1990s recalled health care as a right, part of Tanzania’s “selfreliance” (kujitegemea in Swahili).1 Ujamaa socialism posited family-hood as a basis of national belonging that involved mutual interdependence and shared responsibility. Julius Nyerere, Tanzania’s first president and ujamaa’s architect, argued that citizens’ relative contributions and mutual assistance would resolve inequalities, much like what happened within families and villages. Although health care was not a core concern in the adoption of socialism in 1967, by 1969 government approaches to health care, influenced by Chinese models, emphasized rural health centers staffed by rural medical aids and village health workers (Iliffe 1998:201– 203). Mission hospitals delivered fee-based care, but in 1980 Tanzania eliminated for-profit services (Benson 2001:1905). These ideals reflected post-independence optimism and international emphasis on primary care, but they were challenged by Tanzania’s struggling economy and increasing pressure from multilateral lenders to open the country to outside economic interests. Tanzania instituted cost sharing in the 1980s and user fees in 1993 to help “recover” costs of patient care—and to transfer financial responsibility for care to citizens. Politicians dubbed the time “changes” (mageuzi) and introduced broad political and economic reforms to supplant ujamaa, including reducing government spending on health care. Ujamaa measures to create equitable access to health care by constructing facilities within 5–10 km of all citizens, prioritizing underserved areas, fell dormant, while market-driven construction of for-profit facilities increased (Benson 2001:1905–1906). “Decentralisation by devolution” in the 1990s pushed health care planning, budgeting, and management onto local government authorities—districts and regions, overseen by the prime minister’s office. “Health sector reform” called for increased “partnership” with private interests and reduced government involvement in health care provision. New capital flows and profit-making opportunities followed privatization, as the health care system became increasingly dependent on foreign capital through contingent loans, NGOs, and business interests. Previously proscribed private pharmacies flourished, many as profit-making ventures (Kamat and Nyayo 2010:628). User fees, in Tanzania as

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elsewhere, reduced people’s access to biomedical care (Birn et al. 2009:549–550), and people vigorously opposed paying for a previously assumed right. People I spoke with in the 1990s did not discuss biomedical care under ujamaa as uncomplicated and idyllic; they had ambivalent recollections, assisted by official discourses of mageuzi. Expanding foreign debts and a shifting global political economy challenged ujamaa. Domestic revenues could not support the biomedical care system, which relied heavily on foreign interests. Government hospitals—particularly rural hospitals—tended to be resource-poor, some with antiquated or broken technologies and insufficient personnel to meet needs. Patients complained about poor care and failed ujamaa ideals; even in the time of mutual obligation, money and position could bring better care. Yet market reforms were widely criticized—because of corruption and because a citizen’s right to care was an actually articulated memory. Today, rather than village-like interdependence, people expect that individual rights to care depend on wealth, residence, and mobility, signaling an emerging biomedical citizenship. To understand these changes, I draw from my fieldwork in Rungwe district in 2011, 2008, and 2005 while co-directing a field school addressing health, nutrition, culture, and political economy with Karen Weinstein, a biological anthropologist (Ellison 2013). In addition to my unstructured and semi-structured interviews, participant observation, and many informal interviews, conversations, and observations in a range of contexts, we completed a survey of every household in one village, borrowing partly from Tanzania’s Demographic and Health Surveys (e.g., URT 2011). My long experiences in the district, where I lived for two years in the mid-1990s doing ethnographic fieldwork, contributed to my observations, questions, and interpretations through my language skills, familiarity with places and phenomena. I discuss in this article knowledge about local culture and friendships and relationships, some extending over two decades. Explicitly unequal care facilities and health insurance in Tanzania operate as technologies of power through which people reshape their sense of self (Horton 2007:296), highlighting an emerging biopolitics. I use biopolitics to refer to the “practical and moral consequences” of biomedicine and associated technologies entwining “medical, social, and political interests” (Lock and Nguyen 2010:1) in processes that operate on people’s bodies and define populations for management and control (2010:24). Biopolitics is a broad concept that concerns the generation and organization of knowledge that brings people into particular kinds of relationships with governance and how people understand and shape these relationships. Anthropologists have used the concept to examine diverse relationships often only indirectly linked with the state, as in my analysis of violence becoming intimately involved in relations of gender, ethnicity, and social status in Ethiopia (Ellison 2012). Medical anthropologists and medical sociologists are increasingly attentive to biopolitics in the confluence of biomedical knowledge and technologies, the moral and political–economic structuring of biomedical systems, and self-making (e.g., Kaufman and Fjord 2011), what some have termed “the Foucauldian turn” (Clarke et al. 2010:5). Such scholarship, influenced by Michel Foucault’s concept of “biopower,” frames power as mobile and embodied in people’s “practices and norms,” rather than being “exclusively the domain of the state, a mode of external social control, or exclusively punitive” (Clarke et al. 2010:5). Power, in this view, is

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dispersed through technologies like hospital wards or insurance schemes and works productively with how people transform their selves. Although some scholars have criticized uses of biopolitics that imply “top–down” determinism (Ellison 2012:40– 41; Whyte 2009:11), my ethnographic approach emphasizes various people’s everyday experiences, understandings, and shaping of Tanzania’s biomedical system. Biopolitics provides an alternative to interpreting non-use or criticism of biomedical facilities and insurance as resistance. Rather than people rejecting imposed institutions and policies because they belong to a particular social category or accepting such institutions and policies due to false consciousness, Tanzanians engage in complex interactions with the health care system (e.g., Tibandebage and Mackintosh 2005:1386). For most people, elite wards mean new inequalities and foster alienation but they also represent changed realities. Participation in health insurance plans is anemic relative to official goals. It is also costly, especially for relatively poor rural farmers; still, even many uninsured farmers talk about insurance becoming part of the path to care. Core questions I address here are how people debate these changes and discuss a normal terrain of biomedical care, how people frame desirable health care and its future, and what these things indicate about people’s changing ethicality and citizenship in Tanzania today. “Biomedical citizenship” underscores the importance of the state in biopolitical relationships that center on biomedical care and affiliated technologies (Becker 2007:303; Horton 2007:294), in this case the first-class ward and new health insurance schemes. Biomedical citizenship expands Adriana Petryna’s (2002) concept of “biological citizenship,” devised to explain people’s ethical claims on the Ukraine state after being affected by radiation from Chernobyl. Petryna (2010) and others seek to understand people’s engagement as citizens, potential citizens, or those excluded from citizenship, examining the forces operating on individuals and populations and also the processes of subjectivation—of people enacting selves at the frontiers of politics, biotechnologies, and biomedicine. IFIs, NGOs, and businesses are today intimately involved in these processes (Ferguson 2009:168), in their entanglements with the state that reshape and redefine care. Joao ˜ Biehl (2004), writing about AIDS, pharmaceuticals, and activists in Brazil, captures a similar emerging biomedical citizenship. In new practices of self-reporting, universal registration, and efforts to reduce health care and welfare costs, Biehl (2004:117) identifies human rights as becoming “biomedical rights” sought through the state and a newly moralized market. Immanent to the process are new forms of exclusion—of those unable to afford new therapies—that become normalized, even among people critical of the system. Biehl (2004:124) powerfully conveys this new biomedical citizenship when quoting a care-seeker who explains that sufferers who cannot buy new treatments want to die. These examples, and my own findings, emphasize how people reshape their selves in relation to the state and changing biomedical care.

Locating Elite Wards Biomedical care in Rungwe district exists in a national structure, “a typical pyramidal referral system” (Maluka et al. 2010:753; URT 2009:12), through which, in theory, patients obtain increasingly sophisticated care as they move from villages,

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to wards (comprising multiple villages), to the district hospital, and to a regional referral hospital in Mbeya, an hour away. Rungwe district has 37 government-run dispensaries (zahanati), village-accessible outpatient facilities intended to provide health promotion, preventive care, treatment for common ailments, and basic rehabilitation, staffed with health workers sufficient to those needs, but not including doctors. There are also three government health stations (vituo vya afya), hospitallike facilities that can admit up to 20 people for overnight care and are capable of referring—and in theory transporting—patients to hospitals for more specialized care.2 Catholic, Lutheran, and Moravian churches operate health stations, which can be more expensive but also better equipped and more trusted than governmentrun facilities (Tibandebage and Mackintosh 2005). In addition to the government district hospital, people seek care at two internationally supported church-affiliated hospitals. Given the state’s relationship to “traditional” healers (Langwick 2011) and efforts to include them and medicine purchases from shops as insurance transactions through “public-private partnerships” (URT 2009; World Bank 2011:16, 45), the biomedical system spreads deeply into people’s lives. The DMO oversees the district hospital, at the edge of Rungwe’s main town; as a principal link between the district and national health policy, he coordinates efforts of all three hospitals. The district hospital is bustling during the daytime. People crowd outpatient areas waiting for care or lab results. Perennially closed gates separate the hospital from roadside shops and venders selling produce and other goods to families bringing meals to patients. The DMO estimates the hospital sees 400 patients a day, and he emphasizes woeful staff shortages, as if illustrating Tanzania’s “severe human resource crisis”—with sufficient qualified staff to meet just 35% of need, particularly affecting rural districts (URT 2009:11, 29). Workload pressures and pay were among a dozen reasons behind doctors’ strikes in Tanzania in 2012. The DMO has some direct involvement in patient care, but his time is largely consumed with hospital and district administrative tasks. He leads the Council Health Services Board (CHSB), a district committee with representatives from the health care community and local government that meets monthly at the hospital. The board responds to national and regional initiatives, addresses emerging health-related situations in the district, and implements programs through a Comprehensive Council Health Plan. The board also oversees outreach to villages, such as promoting health insurance, through dispensaries and village government offices. The district hospital presents a “palimpsest” (Wendland 2010:116) of construction and additions—many following international funding priorities—superimposed on the hospital’s layout, but the first-class ward, a few dozen steps from the women’s and the men’s wards, signals new realities. Part of a global neoliberal trend in which patients can pay more for better, more “personalized care” (RylkoBauer and Farmer 2002:485), “amenity wards” in eastern Africa serve an emerging wealthy clientele and generate revenue for hospitals through user fees (Republic of Kenya 2008). Such wards are becoming common in Tanzania: A district neighboring Rungwe sought bids in mid-2011 to build one; newspaper articles occasionally mention them.3 This ward’s actual name is the “Grade A Ward,” although the DMO and others sometimes use the unofficial—and strikingly appropriate—English label “first class.” Older wards are rectangular dormitories in which patients and

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caregivers can view and be viewed by an entire ward, with nursing stations at the ends. This lack of privacy may have cultural aspects, but it also expresses economical design. The Grade A ward, by contrast, is a series of private rooms with new beds, tables, chairs, monitoring equipment, and televisions. Large windows separate a nursing station from a central waiting area with a couch and television. The starkly fewer Grade A patients receive far more direct attention than is possible in other wards. An overnight stay in the Grade A ward costs 10,000 Tanzanian shillings, about six dollars, far beyond the means of most people in the district.4 One night in the Grade A ward equals a year’s cost for up to six people to enroll in the Community Health Fund (CHF), a prepayment insurance scheme. A new “Grade B Ward,” at 5,000 shillings for a night, is less private and less well furnished than the Grade A ward but more so than the other wards. Hospital staff and patients group these new wards in part by referring to other wards, where an overnight stay costs 2,500 shillings, as the “ordinary wards” (wadi za kawaida), or as one woman in a village phrased it, “the wards of lots of people, who are poor.” Ambivalence about the Grade A ward is common. In 2008, the DMO answered my question about its purpose with a shrug and a half-grin, later explaining that there are people today who can afford and want this kind of treatment, which could generate revenue for the hospital. In 2011, he still had ambivalence about the ward in juxtaposition to district health concerns. Tanzania will not meet the Millennium Development Goals related to health, and among the 70-plus percent of the population who live in the countryside, indicators for childhood malnutrition have been worsening since 2005 (URT 2010:9). The leading reasons for hospitalization— posted in wards—include diarrheal problems and malaria, both associated with poverty and nutritional stress. The ward so clearly instantiates wealth disparities that people of widely differing social and economic position routinely mention these. Relatively wealthy people often express greater-good legitimizations, framing the Grade A ward as a necessity, albeit for a restricted clientele. Poorer people—those living in villages and whose livelihoods are often centered on farming; people who will probably never receive care in that ward—articulate a more blunt perspective: “the rich people’s ward” (wadi ya matajiri). Poorer people often steer conversations about the ward to other health care inequalities. In one memorable conversation, Godwin Mwaikombe, a village resident, farmer, and entrepreneur in his late forties, segued directly from the rich people’s ward to the hospital’s new morgue. As we sat in his house, he grew agitated recounting the dichotomous treatment of the dead: Rich people who die in the Grade A ward are put into a refrigerator (wanapeleka kwenye fridge), he exclaimed, treatment denied others. Moments later, he corrected himself to say that anyone who dies at the hospital can be placed in the morgue. He then described the state-of-the-art morgue as the envy of the country; even the regional commissioner’s (mkuu wa mkoa) corpse would be sent there. This inversion of statuses, in which a rural district hospital surpassed the urban referral hospital in the regional commissioner’s domain, so angered the commissioner, Godwin said, that he sacked the health minister, a parliamentarian from Rungwe who facilitated the morgue’s creation.

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Leaving aside the accuracy of Godwin’s narrative—a regional commissioner cannot sack a health minister—he powerfully expresses two seemingly contradictory perspectives. He conveys distrust that people lacking sufficient wealth, such as his family and neighbors, would have access to new technologies and improved care within an explicitly unequal biomedical care system. At the same time, he shows awe toward high-quality biomedical care and powerful people’s abilities to obtain it, expressing pride about a facility that he also describes as excluding him. This linking of wealth with desired biomedical care is becoming characteristic of Tanzania’s biomedical system, with the creation of elite amenity wards and current efforts to promote health insurance.

Health Insurance as a Biopolitical Technology Tanzanians are targets of an extensive effort to introduce health insurance by advocates who cite health challenges like those that worry Rungwe’s DMO. The CHF is intended to encourage people to use government outpatient care facilities, with a goal of also including nonstate providers. Health care reformers praise Tanzanians’ increased use of hospitals as indicating that people are choosing to seek (and pay for) biomedical care. The increase also reflects more people having health needs they are encouraged to satisfy at a growing number of for-pay biomedical facilities, and it involves disparities. Mbeya region has the second lowest rate of outpatient department attendance per capita (0.44)—well below Tanzania’s target for 2015 (0.80) (URT 2010:11–12). Only 40% of births in the region are attended to in a health facility, just half of the 2015 target (URT 2010:15–16). Much more critical attention has been paid to user fees under SAPs than to health insurance (but see Critical Anthropology of Global Health Interest Group 2009; Horton 2011). Beyond improving biomedical care, the current push for health insurance is linked with amenity wards to generate revenue from people’s health needs, manifesting a global effort by IFIs (Preker et al. 2007). User fees and prepayment insurance schemes, primarily the National Health Insurance Fund (NHIF, Bima ya Afya ya Taifa) and the CHF, generate roughly 30% of Tanzania’s health system financing (URT 2010:20–21). Interest in community-based health insurance, like the CHF, grew after the 1978 Alma Ata primary care conference (Birn et al. 2009:547). In Tanzania in the 1980s, the World Bank and the IMF viewed health insurance as a way to make health care a “‘productive’ commodity” (Benson 2001:1905), along with user fees and increased proportions of private care providers. Today’s champions of health insurance cite successes in Ghana and Rwanda, where much of the population buys insurance and the private sector is increasingly involved in insurance and biomedical care (e.g., World Bank 2011:6, 34–35, 50). Community-based insurance like the CHF exists in a spectrum of health insurance models, from private voluntary insurance to universal social insurance, and although it is more progressive than some models and is promoted to help the poor, its ends involve market efficiencies and autonomous biomedical selves. In simplified terms, insurance schemes use probabilities to ensure income exceeds payouts, with the parties involved effectively betting on the “risk” that an enrollee will make a claim during a year (Bassett and Kane 2007:361ff; Bernard 2011:27). Health insurance is individualizing, based on a person’s payments, management of a person’s

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policy, and treating illnesses as individual rather than public health concerns. It is part of an ongoing downward push of “responsibilization” (Foley 2010), moving responsibility for health away from governments and toward individual citizens. More than risk sharing to secure care, health insurance is about individual selves becoming responsible as potential patients, and ultimately it must be profitable to succeed—particularly as it relates to increasing privatization. Health insurance, in this formulation, is about making people available, through their health needs, to businesses. Tanzania’s CHF is not-for-profit, but health insurance is central to PPPs in the domain of financing. The World Bank (2011) and the International Finance Corporation (IFC 2008) promote health insurance to help governments direct stable “revenue streams” to private sector health care providers as an incentive for their participation in “the business of health care.” In this view, governments cannot adequately provide for their citizens’ health needs, whereas private, for-profit providers can “improve performance,” if governments avoid “burdensome intrusion” (World Bank 2011:25, 67). The goal of universal coverage is fundamental to creating a “predictable revenue stream for providers, which improves the business case for increased investment in the health sector” (World Bank 2011:67). That is, in return for guaranteed revenue from citizens, business interests will invest in the biomedical system. The Tanzanian government currently subsidizes the CHF, but these broader goals are in part what motivate enrollment campaigns. Rungwe district started its CHF in July 2006, following late-1990s communitybased health insurance trials in other districts (Musau 1999). The CHF was modeled on the NHIF, which parliament established in 1999 to cover government employees in public and private facilities and designed for private insurers to administer (Turshen 1999:151, n. 63). In July 2009, Tanzania moved CHF coordination and technical support under the NHIF. That same year, CHF management and promotion shifted to the Tanzania Network of Community Health Funds (TNCHF)— an NGO with ties to the government, foreign donors (particularly the Deutsche Gesellschaft fur ¨ Technische Zusammenarbeit and the Swedish Agency for Development and Cooperation [SDC]), and major churches. Alongside wealth-based amenity wards, different CHF and NHIF enrollment costs and coverage organize citizens into wealth/biomedical care categories, analogous to racialized responses to cholera in Venezuela creating the publics they targeted (Briggs 2003). NHIF enrollees are government employees, who generally have far greater income than most people in Rungwe district, establishing wealth/insurance tiers. An NHIF enrollee pays a monthly fee—which Dr. Elias Mapunda, a CHF administrator in Rungwe district, estimated at 17,000 shillings— that increases based on salary. Jonathan Mwankenja, an elected leader in district government, explained that he and his colleagues receive “expenses” (posho) of around 120,000 shillings per month, from which “three percent is deducted to pay for [NHIF coverage]. That’s three percent times twelve, it’s something like 40,000,” he said, adding, “That’s a lot of money.”5 The NHIF covers more procedures than the CHF and it pays for Grade B inpatient care. (Neither plan covers a stay in the Grade A ward.) “If you need to have an x-ray or an ultrasound,” Mwankenja said, “and you have CHF, then you will have to pay for these, as the CHF does not cover them. If you have the NHIF,

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they are covered. NHIF covers everything, all services,” he added, proudly. The NHIF creates a “national insured” who can obtain care throughout the country, whereas CHF limits enrollees to their home district. “The CHF is for your community,” Mwankenja explained. But rather than a preexisting organic unit, insurance produces this community. The CHF is aimed at Tanzania’s majority rural population. People without insurance pay directly for biomedical services, starting with a 1,000-shilling entry fee (kiingilio) followed by treatment and medicine costs. Dr. Mapunda, the CHF administrator, contends that entry fee wrongly implies entitlement to “all the care for free.” Instead, he and his colleagues refer to the fee system as “papo kwa papo”— like quid pro quo: “As you are seen, you pay” (unapoonekana, unapotoa). CHF holders do not pay the kiingilio. Nor do they pay directly for much common care, although co-payments are often required. CHF enrollment costs 10,000 shillings per year (but varies by district), which can cover six family members, presented normatively as a household (kaya) with a monogamous man, his spouse, and four children ages five to 18—children under five being entitled to free biomedical care. In practice, the family and insurance coverage work in many ways, such as a woman enrolling herself and her children. Rather than paying 10,000 shillings at once, a person can pay two installments—but, contrary to popular understanding, care is covered only when one has paid in full. The Swahili name for the CHF—Mfuko wa Afya ya Jamii, literally “the pocket/safekeeping for the health of society”—suggests efforts to normalize health insurance.6 Most people refer to the CHF as “insurance” (bima), whereas health sector and CHF workers often use its formal name. Mfuko means pocket, bag, or purse. Dictionary definitions before the 1980s include places to keep money, like a basket and a traveling bag (e.g., Johnson 1969 [1939]b:276). More recent dictionaries reflect usage as a collection of money (Baraza la Kiswahili la Zanzibar 2010; Taasisi ya Uchunguzi wa Kiswahili 1981). Synonyms for mfuko, documented in the 1990s, are all forms of bags or pockets (Mohamed and Mohamed 2004 [1998]:140), not insurance. Insurance as a word and concept existed in Swahili in the early 20th century as bima (Johnson 1969 [1939]a:294), without the word mfuko.7 Naming insurance mfuko appears meant to popularize it. Few people in villages buy health insurance, although many say they want to once they have the money, linking it with modern realities. The MoHSW has an enrollment target of 30% of Tanzanians by 2015 (URT 2009:84), although only 5–10% currently have health insurance (URT 2010:21, 2011:48–50; World Bank 2011:51). The DMO estimates 10% coverage in Rungwe district, which matches our findings. Other data indicate enrollment declines following limited early enthusiasm (e.g., Musau 1999:D10; SDC/TNCHF 2010). Poor people often avoid health insurance elsewhere in Africa (Jehu-Appiah et al. 2011:163), a concern of CHF pilot studies (Musau 1999) and reviews (Bultman et al. 2012). Cost is the main reason people offer for not enrolling. CHF advocates present community-based insurance as sustainable risk sharing for the poor, barring “adverse selection” (i.e., more people enrolling who need care than who do not) (e.g., Musau 1999). Average out-of-pocket health expenses, they observe, exceed enrollment costs. But enrollments have never approached sustainable levels, and Tanzania necessarily subsidizes the CHF. Public health

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needs—malaria or people needing much care (so-called economic free-riding [Bassett and Kane 2007:362])—threaten sustainability (Musau 1999:A-13), and enrollment fluctuations and wealth-correlated re-enrollment render sustainability phantasmagorical. Sustainability is also belied when people buy coverage using community-based contingent cash transfers (CB-CCT; Temba 2011). CB-CCTs are micro-development grants supported by the World Bank and the Japan Social Development Fund to help Tanzania’s poor meet education and health care costs. CB-CCTs provide short-term purchasing power (Ferguson 2009); they also individualize poverty and development (Timura 2011). They are temporary and contingent, whereas health insurance is an annual individual financial commitment that invites further expenses through co-payments and non-covered care. Beyond cost, the DMO related a common argument that rural people have not yet gotten used to (hawajazoea) insurance (see Preker 2007): Pre-paying insures people through the coming year, but people weigh enrollment against their recent medical expenditures. In this way, “backward-looking” characterizes the uninsured, obscuring economic factors: Rural and poor, they do not understand health care realities, in contrast to “forward-looking” people, who buy insurance. Robert Mwandobo, a 35-year-old father of four, would seem to fit this backwardlooking characterization, although he clearly understands insurance. In 2008, Robert returned to his natal village after being ill while working in another district. As we walked through the village one afternoon in 2011, Robert explained that he has “not yet cut insurance” (sijakata bima) because his previous year’s medical expenses were below CHF prepayment costs. He later said, however, that he intends to buy insurance once he has the money. He hopes a brick-making project will generate income to pay for it; he then seamlessly began discussing how the soils near his home do not support the kinds of bananas that “have a market.” In the same village, Twelu Kyusa, a 34-year-old mother of five, engages in numerous economic activities, including running a small store at her house. Such activities are beyond Robert’s abilities, due to his lack of capital. During one of our conversations, Twelu mimicked backward-looking logic, as if characterizing Robert—“Last year I was not ill, or I only occasionally get ill”—and then inverted it to argue for prepayment. “You can be surprised and become ill at a time when you don’t have money,” she said, so she pre-paid. I saw that I was ill from time to time. My children are ill sometimes. And we [she and her husband] are ill from time to time. I saw it would be better if I give the 10,000 shillings. Meaning I would pay more [otherwise]. Me, if I am ill, I’m surprised that then my child also becomes ill. Then another one also becomes ill. And so that would be very expensive. In 2009, Twelu was elected to a village health committee, for which she receives a modest stipend and participates in district efforts to promote CHF enrollment. Aside from costs and expenditure estimates, several people told me that CHF holders receive only partial treatments because prepayment hinders medical staff

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from profiting through illicit charges (see Tibandebage and Mackintosh 2005). Some explain that medical staff withhold medicines from insured patients, referring them to private pharmacies the staff own or profit from. These claims are more than rumor (Mœstad and Mwisongo 2010; Spangler 2011); they concern structurally enabled arbitrage (Vian 2010:81). With PPPs, Tanzania’s MoHSW accredits private pharmacies to sell medications and “participat[e] in consumer awareness efforts” (World Bank 2011:53), creating greater opportunities for profit-making (e.g., artemisinin-based malaria treatments cost three times more than at government facilities). Other criticisms describe troubles with medications. CHF enrollees receive medicines, people say, that “lack strength” (hayana nguvu) or are “not good” (dawa wanazotoa siyo nzuri). Others claim that CHF enrollees receive medicines that have been diluted to stretch profits. This claim reminded Mwankenja, the elected official, of venders mixing water with petrol. Similar claims—about weakened medicines and diverting patients to private pharmacies—circulated in the early days of user fees and privatization. They criticize biomedical care shaped by unrestrained capitalism. They also convey an awe of power in a paired-binary-oppositions sense: Strong medicines are available for purchase; weak medicines come through a shared program. Powerful medicines are desirable medicines. People know that different kinds of insurance—thus access to powerful medicines and better care—reflect relative wealth. Rich people obtain strong medicines at the hospital or private pharmacies, and the “rich people’s ward” offers better care. Money and better insurance give the wealthy superior mobility and access to treatment anywhere in the country. But rather than rejecting health insurance or capitalism in biomedical care per se, these criticisms concern access to care. That is, the fundamentally unequal system becomes normalized and even valorized; complaints concern individual abilities to navigate it. When I asked Godwin, the man who marveled at the new morgue, whether health insurance or hospital staff were to blame for CHF holders receiving poor or no medications, he interrupted to indicate the staff, based on their own monetary interests. Moments later, he extolled the benefits of insurance—that one could become sick when lacking money—demonstrating that he, too, understands health insurance. One criticism that is not common is that health care is a right and that insurance and profiting from health needs are in themselves flawed. Such voices exist among activists who criticize privatization (e.g., Rusimbi 2003); they advocate adding health workers, medicines, and technology to the public realm, to benefit “all, but especially marginalized people who cannot afford costly private care” (Liundi 2011). I often anticipate such criticisms and ask people about health care as a right, sometimes referring to ujamaa and debates elsewhere in the world. Authors of a recent World Bank report (2011:6)—with a very different perspective—expect ideas of health care as a right to hinder PPPs. Many people recall when biomedical care was a right of citizenship, but most do not see that as a realistic possibility today. Twelu, for example, laughed out loud for several seconds when I raised this as a possible criticism of the current system, although while laughing she said, “It’s true.” She then mused: “It’s possible that people might make that argument, but I have never heard it.”

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Moral Discourse of Insurance There is an emerging moral discourse in Tanzania about the importance of health insurance. This discourse is heard when advocates explain that poor people cannot afford health care and buying insurance can reduce out-of-pocket expenses. It is meant when people say they do not have health insurance but intend to buy it once they can afford it. It exists when a mother calculates that with health insurance two of her children can receive care simultaneously, regardless of the amount of money she has saved. The moral discourse is voiced by an avuncular elected official telling a younger, poorer village chairman that the people they represent need insurance for their health care and that people should include poorer neighbors in their policies where possible. And it is present in campaigns throughout government and capillarylike networks in the countryside, explaining that health insurance is access to health care. Promoters contend that community-based insurance like the CHF can help the poor access care by reducing their annual health spending (Preker et al. 2007; World Bank 2011). With health insurance, said Dr. Mapunda, the CHF administrator, a person has peace (tayari yuko salama) and community worries cease. He crafted an example of a rural single woman experiencing pregnancy complications and who has no money (mfukoni hamna hela). “Without being protected by insurance,” he concluded, “these are problems.” The DMO and Mapunda each also explained that a village government letter documenting a person’s indigence would substitute for coverage (see URT 2009:31). Villagers are skeptical: “Who would go and ask for such a letter?” remarked one woman. She and others say the poor are known; seeking a letter would only be humiliating. Yet, like insurance advocates, they also claim that the poor turn to family or other obligation networks to pay medical expenses. All these scenarios imply that the poor can rectify their non-insured status, underestimating the actual challenges and costs of debt. Often, in fact, Tanzania’s poor avoid biomedical care (Tibandebage and Mackintosh 2005). Poor neighbors could be brought into plans as “family” for 5,000 shillings annually, Mapunda and the DMO each said—a large sum that somebody must pay. When the elected official Mwankenja counseled a village chairman that villagers should include poor neighbors in their policies, he outlined a moral responsibility. “There are people who do not have health insurance. There are poor people, people who have lost spouses, elderly people, people unable to work. It is imperative that these people have health insurance. And so we should put them on our plans.” Mwankenja cited a health insurance seminar that advised elected officials to start CHF policies even if they already have coverage.8 He has the NHIF and his children are grown, but he should use his “extra five spaces” to help others. In these framings, unlike ujamaa discourses of self-reliance (kujitegemea) indicating a national family interdependence, a new responsibility of individuals for themselves and their neighbors vis-a-vis health insurance emerges as a moral ` obligation. In July 2011, Rungwe district implemented a “multi-sectoral” approach to increase CHF enrollments. Previously, district medical staff promoted health insurance. But after modest successes, their progress slowed. The task was overwhelming.

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The new approach, Dr. Mapunda explained, involves people from various government sectors: There is now a program to involve the people beneath the head of the district, to involve all the ward councilors in the district, to involve the heads of all the various departments in local government without relying on the health department. That is, there is a department of farming, there is a department of livestock, there is a department of education. All will be taught starting with those at the highest level, which is the head of the district council, all of them. We want to bring them inside [kuwaingiza] so that they all know what is going on to help members of society. This campaign includes elected officials like Mwankenja, who also sits on the CHSB. Mwankenja recently toured the district promoting insurance. “Don’t you remember when I was here [in this village]?” he asked a man with us. It is important to “move people forward [kuwahamisha mbele] in this way. They have to learn that they can pay now for health situations later that could cost them a lot more,” he proclaimed, echoing his community exhortations. Health insurance advocacy is now also channeled through micro-networks within villages. In the past, Dr. Mapunda would travel to each health station and dispensary, hold public meetings to explain health insurance, and encourage villagers to enroll. After each meeting, he would leave, and villagers would return to their lives without paying 10,000 shillings. He can visit villages, Mapunda explained, but local government officers live in them; it is more effective for them to promote insurance— “even house by house.” In July 2011, village governments received CHF registry books to record enrollments, which may help the district, the MoHSW, and the World Bank keep “score” (World Bank 2011:32). Village health committees—with elected representatives like Twelu—meet with district medical staff three times a year and convey CHSB information into communities. They, along with dispensary and health station staff, elected officials and district government workers, are now part of capillary networks promoting health insurance. Twelu and Mwankenja gain remuneration and social capital for their involvement with these efforts. Medical staff and doctors, who have protested low salaries, have analogous interests in the CHF. Increasing enrollments could in theory lead to more efficient care, addressing Tanzania’s new emphasis on “pay-for-performance,” part of responsibilization. It could also generate salary and budget additions. Districts budget for and organize biomedical care in relationship with the prime minister’s office and the MoHSW, and medical staff salaries are established through the MoHSW and the Ministry of Finance and Economic Affairs and approved by parliament. CHF revenues, matched with “Health Basket Funds” from international assistance earmarked for health projects (Bultman et al. 2012:24), and cost sharing contribute to budgets managed by the CHSB and Health Facility Committees (URT 2009:70)—with village representatives like Twelu—for a plethora of demands starting with each (potential) dispensary. Controlling these funds builds social capital, while connections among CHF enrollments, efficiency, and salaries are indirect. Yet it would be overly reductive to posit that the interests medical staff have in their profession, and village

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health committee members have in their neighbors’ health care, negates their moral engagement—like the government and pro-reform media routinely portraying the 2012 doctors’ strikes as self-interested acts directly jeopardizing patients’ health and human rights (e.g., Daily News Online 2012; Mjasiri 2012). Individual and class interests in the biomedical system exist alongside complex commitments to patient well-being and national benefit (Wendland 2011), which emerges in my conversations in Rungwe district. Medical staff articulate a moral discourse when addressing criticisms of the CHF. They view increasing enrollments as helping finance biomedical care, and some describe it as a route to expanded benefits—the only way the CHF could eventually resemble the NHIF. They express outrage over claims that insurance holders receive inferior medicines. Dr. Mapunda cited a health care provider’s obligations to the community, profession, and nation, saying it would be foolish to think one would cheat patients. He pointed to highly visible anticorruption campaigns—signs prominently displayed in hospital offices—and observed that adulterated medicines could kill, which, he said, makes the claim absurd. His response to criticisms that the CHF and NHIF are unequal is more telling of the emerging biopolitics. He characterized such critics as claiming unequal segregation—mnatubagua, the word used for apartheid. A main obstacle to CHF enrollments is people not understanding health insurance, he explained, but these critics appreciate insurance. Thus, the CHF is not essentially bad because it is insurance; rather, it is not as good as other health insurance, which indicates that critics “understand and desire that insurance would expand” (wanaelewa na wanatamani kwamba mfuko ungepanuka zaidi). Raising user fees, he suggested, would move more people to buy insurance, a foundational view with SAPs, now revitalized (Bultman et al. 2012:36; Turshen 1999:47). Health care as a shared national obligation is anachronistic, Mapunda concluded. “We simply got used to health care services being given for free,” but due to costs and structural changes, “the thing now to understand is this: it is impossible” (emphasis in the original).

Conclusion: First-Class Health The realities of Tanzania’s biomedical system are in many ways unsurprising. The MoHSW, biomedical care providers, and local health committees hope to address pressing health needs within new fiscal and structural contexts. Their stake in the new system would seem to confirm—to them and others—its power and potential to improve biomedical care. Tanzanians want effective care, regardless of their wealth or ability to borrow. They are also awed by elite amenity wards and want health insurance. Wealth buys better care, stronger medicines, and mobility, whereas uninsured implies poverty, backwardness, and potential lack of care—insidious elements of the emerging biomedical citizenship. Much global health discourse accepts health insurance and for-pay care as necessary and desirable solutions to health needs, while other models of shared responsibility and risk are becoming unfathomable. Tanzania’s accelerated embrace of profit-driven care over health care as a right brings these developments into focus. These commonsense understandings of health insurance and profit-driven care profoundly implicate an emerging biomedical citizenship, which Dr. Mapunda

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articulated when characterizing villagers’ complaints and desires. People are reshaping their sense of self and their existence as citizens in connection to health sector reform. Advocates of profit-driven care and universal coverage are not just concerned with making care accessible to the rural poor; they recognize the state’s role in producing citizens as potential-patients to fund the health system and the private health sector (World Bank 2011:137). Joao ˜ Biehl could well be describing this emergent biopolitics in Tanzania when he writes that the question confronting medical anthropology is “less about citizens’ rights or population well-being” than how “government facilitates a more direct relationship of atomized free liberal subjects of interests—homo economicus—to the biomedical market and the opening up of entrepreneurial futures” (2011:279). Refiguring people’s health needs as a financing source through insurance and amenity wards formalizes inequality and alters people’s existence as citizens. Community-based insurance and tiered wards involve wealth/health equations that help create the communities they are intended to serve. Unequal abilities to pre-pay for a promise of care and to pay other costs once care is needed or has begun are problems to address but also starting points for managing citizens. Responsibilization, shifting costs and care burdens to individuals—often to women (e.g., Foley 2010)—may clarify insurance enrollment declines in Tanzania (Mackintosh and Tibandebage 2006:244). Yet moral discourses about health insurance and people’s acceptance of a system in which wealth buys better biomedical care signal troubling new ethicalities. Tanzanians today discuss responsibility and market inevitabilities in biomedical care using a transformed language of ujamaa socialism, in which shared obligation means helping others—those willing to be helped—address individual health needs and desires in a market-based system that is inherently and explicitly unequal. The unwilling—the backward and irrational poor—create unresolved problems. These ethnographic findings show a pernicious normalization of biomedical care and health as individualized commodities and of discussion of rights to care as abstract and unrealistic. Tanzania’s example is poignant not because of nostalgia for an idealized socialism, but because Tanzanians so recently assumed health care as a right of citizenship and contested privatization. Today, Tanzanians are reshaping their moral understandings of health and care at the intersections of liberalization and citizenship. Their experiences are also inseparable from and therefore informative about global trends—the global push for health insurance; amenity wards for wealthy patients; and an overall commodification and neoliberalization of health and care. Understanding an emerging biomedical citizenship in Tanzania that normalizes first-class care can disrupt commonsense thinking about political and economic reforms, clarifying how these forces shape the present and futures of biomedical care in Tanzania and elsewhere.

Notes Acknowledgments. I am grateful to the people of [Rungwe] district; district hospital staff; students in our field schools; Karen Weinstein, Anne Lewinson, and Susan Schalge; Bradley Roller, a Dana Research Assistant; Dickinson College; audience members at the American Anthropological Association 2011 meeting; and the editors of and anonymous reviewers for Medical Anthropology Quarterly.

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1. Translations from Swahili and Nyakyusa languages are my own. People’s names are pseudonyms. 2. Tanzania’s goal is for each village to have a dispensary and each ward a health station. People in locations without such facilities readily note that these goals remain incomplete. 3. Some private hospitals already offered private rooms at greater cost. 4. In November 2011, 1,750 shillings equaled one dollar. 5. People elsewhere complain that NHIF salary deductions require them to borrow money to meet life’s expenses (Saiboko 2011; Sullivan 2011:212). 6. In Dar es Salaam, the CHF is named Tiba Kwa Kadi, “Treatment with Card,” or TIKA. 7. Musau (1999) does not refer to mfuko. 8. Newest efforts encourage enrollment with groups such as co-workers (Msimbe 2011).

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