Exemption Policy or Empty Promise? Understanding Health-Seeking Behaviour Among Older Persons in Tanzania’s Lindi Region

Abstract

Health-seeking behaviour is critical for improving health outcomes among older persons, yet limited evidence exists on how exemption policies translate into actual service utilisation in resource-constrained settings. This study examined health-seeking behaviours and perceptions of free healthcare services among older persons (≥60 years) in Tanzania's Lindi Region, where implementation of the 1994 exemption policy remains poorly understood despite increasing population ageing. Employing a cross-sectional mixed-methods design, the study surveyed 369 older persons through multistage sampling across Kilwa and Nachingwea districts, conducted 17 key informant interviews with health officials and social welfare officers, and facilitated focus group discussions in four villages. Quantitative data were analysed using SPSS descriptive and inferential statistics (chi-square tests), while qualitative data underwent thematic content analysis. Findings revealed that 91.7% of respondents predominantly sought care at public healthcare facilities, with 36.4% accessing free services more than five times annually, driven primarily by affordability rather than quality considerations. Chi-square analysis revealed statistically significant associations between healthcare facility choice and age group (χ²=18.24, p=0.006), gender (χ²=9.67, p=0.022), and education level (χ²=24.56, p=0.001), indicating that younger older adults (60-69 years) were more likely to utilise public facilities compared to those aged 80+ years. However, significant service gaps emerged: while consultation (64.3%), hospitalisation (67.8%), and diagnostic services (69.1%) were perceived as accessible, 84.6% of respondents reported chronic medication shortages, expressing deep dissatisfaction with drug availability despite policy provisions. These findings empirically contribute to health equity theory by demonstrating that removing financial barriers through exemption policies is necessary but insufficient, without addressing supply-side constraints, particularly medication availability, health-seeking behaviour remains suboptimal. The study advances policy discourse by revealing a critical implementation gap between exemption policy intentions and frontline service delivery realities, suggesting that Tanzania’s pursuit of universal health coverage requires simultaneous demand-side (financial access) and supply-side (service quality and drug availability) strengthening. We recommend decentralised drug supply chain management, increased budgetary allocation for geriatric medications, streamlined exemption procedures to reduce bureaucratic delays, and community-based awareness programmes to enhance policy literacy among older persons. Without comprehensive health systems strengthening ensuring both financial and physical access to quality care, exemption policies risk becoming symbolic rather than transformative for Tanzania's rapidly growing older population.