Promoting universal financial protection: a case study of new management of community health insurance in Tanzania

Health Research Policy and Systems

Jane Macha²  Mariam Ally³  Gemini Mtei²  Juma Tantau¹  Suzan Makawia²  August Kuwawenaruwa²  Stephen Maluka⁵  Josephine Borghi⁴ 

[1] District Council, Singida Rural, Ministry of Health and Social Welfare, Singida, Tanzania;Ifakara Health Institute, Kiko Avenue, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78373, Dar es Salaam, Tanzania;Department of Policy and Planning, Ministry of Health and Social Welfare, Samora. Avenue/Shaban Robert Street Junction Plot no: 36/37, P.O. Box 9083, Dar es Salaam, Tanzania;Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK;Institute of Development Studies, University of Dar es Salaam, P.O. Box 35131, Dar es Salaam, Tanzania

关键词: Tanzania;    Reform;    Merger;    Informal sector;    Health insurance;    Financing;   

Others  :  809762
DOI  :  10.1186/1478-4505-11-21

 received in 2012-12-05, accepted in 2013-05-14,  发布年份 2013

【 摘 要 】

Background

The National Health Insurance Fund (NHIF), a compulsory formal sector scheme took over the management of the Community Health Fund (CHF), a voluntary informal sector scheme, in 2009. This study assesses the origins of the reform, its effect on management and reporting structures, financial flow adequacy, reform communication and acceptability to key stakeholders, and initial progress towards universal coverage.

Methods

The study relied on national data sources and an in-depth collective case study of a rural and an urban district to assess awareness and acceptability of the reform, and fund availability and use relative to need in a sample of facilities.

Results

The reform was driven by a national desire to expand coverage and increase access to services. Despite initial delays, the CHF has been embedded within the NHIF organisational structure, bringing more intensive and qualified supervision closer to the district. National CHF membership has more than doubled. However, awareness of the reform was limited below the district level due to the reform’s top-down nature. The reform was generally acceptable to key stakeholders, who expected that benefits between schemes would be harmonised.

The reform was unable to institute changes to the CHF design or district management structures because it has so far been unable to change CHF legislation which also limits facility capacity to use CHF revenue. Further, revenue generated is currently insufficient to offset treatment and administration costs, and the reform did not improve the revenue to cost ratio. Administrative costs are also likely to have increased as a result of the reform.

Conclusion

Informal sector schemes can benefit from merger with formal sector schemes through improved data systems, supervision, and management support. However, effects will be maximised if legal frameworks can be harmonised early on and a reduction in administrative costs is not guaranteed.

【 授权许可】

   
2013 Borghi et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

【 参考文献 】

• [1]McIntyre D, Garshong B, Mtei G, Meheus F, Thiede M, Akazili J, Ally M, Aikins M, Mulligan JA, Goudge J: Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania. Bull World Health Organ 2008, 86(11):871-876.
• [2]Macha J, Harris B, Garshong B, Ataguba J, Akazili J, Joakim A, Borghi J: Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa. Health Policy Plan 2012, 27:i46-i54.
• [3]Mtei GJ, Mulligan M, Ally N, Palmer A: Mills: An Assessment of the Health Financing System in Tanzania. Dar es Salaam: Ifakara Health Institute; 2007.
• [4]Obermann K, Jowett MR, Alcantara MO, Banzon EP, Bodart C: Social health insurance in a developing country: the case of the Philippines. Soc Sci Med 2006, 62(12):3177-3185.
• [5]International Social Security Association: Dynamic Social Security for Africa: Extending social protection for development. Social Policy Highlight 07 2008. http://www.issa.int/Resources/Social-Policy-Highlight/Dynamic-Social-Security-for-Africa-Extending-social-protection-for-development webcite
• [6]Mathauer I, Schmidt JO, Wenyaa M: Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand. Int J Health Plann Manage 2008, 23(1):51-68.
• [7]Dekker AH: Mind the gap: suggestions for bridging the divide between formal and informal social security. Law, Democ Devel 2008, 12(1):117-131.
• [8]Jacobs B, Bigdeli M, van Pelt M, Ir P, Salze C, Criel B: Bridging community-based health insurance and social protection for health care – a step in the direction of universal coverage? Trop Med Int Health 2008, 13(2):140-143.
• [9]Kwon S, Lu JR, Kwon S, Bayarsaikhan D: Social health insurance experience in South Korea. Comparative Desk-Review of Social Health Insurance Experiences in Japan, Korea, Taiwan and Mongolia 2005. [EQUITAP Working Paper #20] http://www.equitap.org/publications/docs/EquitapWP20.pdf webcite
• [10]International Social Security Association: Pursuing universal health-care provision in Lao People’s Democratic Republic. Social Security Observer 07 2009, 2009:2009. http://www.issa.int/News-Events/News2/Pursuing-universal-health-care-provision-in-Lao-People-s-Democratic-Republic/(language)/eng-GB webcite
• [11]International Labour Organization: Social Health Protection: An ILO Strategy towards Universal Access to Health Care: A Consultation. Geneva: International Labour Office; 2008.
• [12]Hanvoravongchai P, Hsiao WC: Achieving universal coverage with social health insurance. In Social Health Insurance for Developing Nations. Edited by Hsiao WC, Shaw RP. Washington D.C: World Bank; 2007.
• [13]Schieber G, Baeza C, Kress D, Maier M: Financing health systems in the 21st century. In Disease Control Priorities in Developing Countries. 2nd edition. Edited by Jamison DT. New York: Oxford University; 2006:225-242.
• [14]Spratt K: Policy Implementation Barriers Analysis: Conceptual Framework and Pilot Test in Three Countries. Washington D.C: Futures Group, Health Policy Initiative Task Order 1; 2009.
• [15]Powell-Jackson T, Morrison J, Tiwari S, Neupane B, Costello AM: The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal. BMC Health Serv Res 2009, 9:97. BioMed Central Full Text
• [16]Kamuzora P, Gilson L: Factors influencing implementation of the Community Health Fund in Tanzania. Health Policy Plan 2007, 22(2):95-102.
• [17]Birt CA, Gunning-Schepers L, Hayes A, Laraine J: How should public health policy be developed? A case study in European Public Health. J Public Health Med 2007, 19(3):262-267.
• [18]United Republic of Tanzania, Integrated Labour Force Survey: 2006, National Bureau of Statistics and Ministry of Planning. Dar es Salaam, Tanzania: Economy and Empowerment; 2007.
• [19]United Republic of Tanzania: Community Health Fund: Operations Guidelines. Dar es Salaam: MoHSW; 2001.
• [20]Msambichaka LA, Humba EBD: A Historical Development of the National Health Insurance Fund of Tanzania: From Resistance to Radiance. Dar es Salaam: Semuka International Ltd; 2011.
• [21]Borghi J, Mtei G, Ally M: Modelling the implications of moving towards universal coverage in Tanzania. Health Policy Plan 2012, (Suppl 1):i88-i100.
• [22]Borghi JA, Makawia S, Kuwawenaruwa A: Community health insurance: a financially sustainable approach to universal coverage in Africa? Insights from Tanzania. In 2nd Global Symposium on Health Research. Beijing, China; 2012. Unpublished
• [23]United Republic of Tanzania: Health Sector Strategic Plan III: “Partnerships for Delivering the MDGs” July 2009 – June 2015. Dar es Salaam: MoHSW; 2008.
• [24]Mtei G, Mulligan J: Community Health Funds in Tanzania: A Literature Review. Dar es Salaam: Ifakara Health Institute; 2007.
• [25]Community Health Fund: Best Practices Workshop Report. Dar es Salaam: MoHSW; 2007.
• [26]COWI: EPOS: Joint External Evaluation of the Health Sector in Tanzania: Final Report. Dar es Salaam: MoHSW; 2007.
• [27]Lankers C, Mgonela K, Mtei G, Mushi A: Suggestions towards a Framework for the Future Development of Health Insurance in Tanzania. Dar es Salaam: MoHSW; 2008.
• [28]Gilson L, Erasmus E, Borghi J, Macha J, Kamuzora P, Mtei G: Using stakeholder analysis to support moves towards universal coverage: lessons from the SHIELD project. Health Policy Plan 2012, 27(Suppl. 1):i64-i76.
• [29]Mdee H: Challenges and Opportunities of Community based Health Funds (CBHF) in the Emerging Social Health Insurance Policy Environment in East Africa (An Overview of the Tanzania Community Health Fund and National Health Insurance Fund) in 7th Community Health Financing Association of East Africa (CHeFAEA) Regional Conference. Uganda: Entebbe; 2009.
• [30]NHIF: Action Plan for CHF Operations. Dar es Salaam: NHIF; 2009.
• [31]Kessy F: Technical Review of Council Health Service Boards and Health Facility Committees in Tanzania. MoHSW: Dar es Salaam; 2008.
• [32]United Republic of Tanzania: Health Sector Public Expenditure Review Update 2008. Dar es Salaam: MoHSW; 2009.
• [33]United Republic of Tanzania: Health Sector Public Expenditure Review, 2010/11 Draft. Dar es Salaam: MoHSW; 2012.
• [34]Tantau J: Annual Community Health Fund Progress Report. Singida: MoHSW; 2009.
• [35]Tantau J: Annual Community Health Fund Progress Report. Singida: MoHSW; 2010.
• [36]Tantau J: Annual Community Health Fund Progress Report. Singida: MoHSW; 2011.
• [37]NHIF: Revival Plan of Action for the Community Health Fund (2011/2012). Dar es Salaam: NHIF; 2011.
• [38]United Republic of Tanzania: Health Sector Public Expenditure Review 2009/2010. Dar es Salaam: MoHSW; 2011.
• [39]Carrin G, Waelkens MP, Criel B: Community-based health insurance in developing countries: a study of its contribution to the performance of health financing systems. Trop Med Int Health 2005, 10(8):799-811.
• [40]Coheur A, Jacquier C, Schmitt-Diabaté VSJ: Linkages between statutory social security schemes and community-based social protection mechanisms: A promising new approach. In Technical Commission on Medical Care and Sickness Insurance Technical Commission on Mutual Benefit Societies. Moscow: World Social Security Forum; 2007.