Hospital side hustles: Funding conundrums and perverse incentives in Tanzania's publicly-funded health sector

Meredith G. Marten, Noelle Sullivan*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Following three decades of international financial institutions implementing austerity measures in sub-Saharan Africa, many health systems remain chronically underfinanced. During this period, countries like Tanzania have moved from a post-independence vision of a strong social sector providing free care for citizens, to a model of increased privatization of public health facilities, shifting the burden of self-financing to individual health facilities and the constituents they serve. Drawing on longitudinal ethnographic research and document analysis undertaken between 2008 and 2017 within three publicly-funded hospitals in north-central Tanzania, this article examines the actions and perspectives of administrators to explore how novel shifts towards semi-privatization of public facilities are perceived as taken-for-granted solutions to funding shortfalls. Specifically, hospital administrators used “side hustle” strategies of projectification and market-based income generating activities to narrow the gap between inadequate state financing and necessary recurrent expenditures. Examples from publicly-funded hospitals in Tanzania demonstrate that employing side hustles to address funding conundrums derives from perverse incentives: while these strategies are supposed to generate revenues to sustain or bolster services to poor clients, in practice these market-based approaches erode the ability of publicly-funded hospitals to meet their obligations to the poorest. These cases show that neoliberal ideas promoting health financing through public-private initiatives offer little opportunity in practice for strengthening health systems in low income countries, undermining those health systems' ability to achieve the goal of universal health care.

Original languageEnglish (US)
Article number112662
JournalSocial Science and Medicine
StatePublished - Jan 2020


  • Austerity
  • Health equity
  • Health systems financing
  • Health systems strengthening
  • Hospital ethnography
  • Neoliberalism
  • Tanzania

ASJC Scopus subject areas

  • Health(social science)
  • History and Philosophy of Science


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