Community Health Funds in Tanzania: a review of experience

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Community Health Funds in Tanzania a
review of experience

• Gemini Mtei
• Jo Mulligan
• Ifakara Health Research Development Centre
• Presentation to the CHF Best Practices Workshop
  31st January 2 February 2007
• Golden Tulip Hotel Dar es Salaam

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Outline

• Background
• Concept of the CHF
• CHF in Tanzania
• Findings
• Possible way forward

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Background

• IHRDC asked to conduct a desk review of CHF
  experience in Tanzania.
• Aim to
• provide a general overview of existing CHF
  relevant projects and initiatives in Tanzania
• summarise main issues raised
• create a base of information that will contribute
  to enhancing a common understanding of CHF
  challenges among the different stakeholders
• Methods comprised literature review and hand
  searching of documents and files held by CHF
  stakeholders.

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The Concept of CHF

• Definition Community health financing-
  households finance health care costs and being
  involved in the mgt and organization of the
  financing scheme health services (Carrin
  2003)
• Community - population in village, district or
  geographical area, social economic group or
  ethnic group
• CBHF - a result of problems with Tax financing
  and SHI
• Tax financing - small Tax base, big informal
  sector, dependence on donors, and dependence on
  International trade
• SHI- national consensus , income inequalities,
  managerial problems, poor infrastructure (roads,
  banks, telecommunication) to facilitate
  collections, re-imbursements and monitoring

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CHF in Tanzania

• Started in 1996 with pilot study in Igunga
  District
• Act enacted in 2001 CHF Act, 2001
• Designed to cover the informal sector esp. in
  rural areas
• Voluntary Membership household membership
• Same Contribution for each member household
• TIKKA in Urban and Peri-Urban settings (Town,
  Municipals, Cities)

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Objectives of CHF

• According to CHF Act of 2001, objectives are
• (i) to mobilize financial resources from the
  community
• (ii) provide quality and affordable health care
  services through sustainable financial mechanism
• (iii) improve health care services management in
  the communities

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• FINDINGS

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• This review examined the following issues
• Coverage and Enrolment
• Pro Poor Approaches (Equity issues)
• CHF management and accountability
• Provision and Use of Services

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CHF Coverage

• 69 Councils have launched CHF
• Other councils have delayed launching due to
• lack of commitment by some regional and district
  officials
• inadequate follow-up from the MOH
• lack of capital for initiation of the scheme
• lack of uniformity on premiums,
• unclear referral mechanisms, etc (MOH 2003a)

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Enrolment

• Enrolment has non-uniform pattern.
• Example Iramba (Mwendo,2001), Rungwe (Sheuya,
  2006) have an encouraging enrolment,
• while in Hanang (Musau,2004), Igunga and Singida
  rural (Shaw, 2002) enrolment has droped
• Hanang from 23 in 1999 to 2.2 in 2004
• Reasons include,
• low user fees,
• - high membership fee,
• low income,
• - introduction of NHIF,
• - perceived poor quality of public facilities,
• - limited coverage to referrals,
• - poor health staffs attitudes,
• - broad exemption policy, etc
• Shaw (2002), Mhina (2005), MOHSW (2006), Msuya
  (2004), Mwendo (2001), MOH (2003b)

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Pro-Poor Approaches

• Tanzania National Policies
• NHP Vision
• to improve health and well being of all
  Tanzanians with a focus on those most at risk and
  encourage the health system to be more responsive
  to the needs of the people
• NSGRP emphasizes on
• equity in the delivery of health and social
  services so as to improve access for children,
  women, the poor and other vulnerable groups
  especially in rural areas

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How does CHF helps the poor?

• CHF type schemes extend
• coverage to a large number of rural and low
  income populations that would otherwise be
  excluded (Preker, et al. 2002)
• and
• protect members by reducing the level of out of
  pocket payments (Ekman 2004)
• Being a CHF member
• improve access to formal health care providers
  and reduce the use of alternatives as self
  medication and traditional healers for the poor
• - reduces the risk of trading-off assets with
  health care seeking Msuya et al. (2004)

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CHF Pro-Poor Mechanisms

• A Exemption and Waivers
• Applies for those unable to pay the contribution
  fee
• ... District councils are expected to fully
  subsidize the CHF membership fees for those who
  have been exempted or waived...
• Challenges
• source of funding,
• identifying the poor,
• general/blanket exemption,
• Ensuring the awareness of existence of the policy
• To overcome such challenges, some Councils (eg.
  Mwanga, Muheza) have managed to identify the poor
• Criteria include,
• elders and widows with no one to take care off,
• physically/mentally handicapped,
• orphans,
• those with poor houses, etc

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Pro-Poor Mechanisms cont..

• B Cross subsidisation
• CHF is cross subsidizing between the households
• Rich Poor and health
  ill
• Need to find a way of having a mixture of
  membership
• i.e. not only the poor /ill joining the scheme

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Management Accountability

• District council is the core of CHF activities.
• District councils responsible for sensitization
  activities
• Community members involved through their
  representatives in the Council Health Services
  Board

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Management Accountability Cont..

• Observations
• In some councils, members are not aware of the
  performance/operation of their schemes (Chee, et
  al 2002, MOH 2003b)
• The CHSB and WHC members are not binded to be
  members of CHF
• Risk of non-representation of CHF members
• Mis-management of funds in some councils
• no frequent auditing is conducted
• others do not use the collected contributions
• Management of funds is left to facility workers

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Provision and Use of Services

• Some review/studies have shown improvement in
  provision and access
• Example
• Purchase of microscope, drugs, etc (Shaw 2002)
• improvement in access to care for CHF members
  (Msuya, 2004, Musau 2004)
• CHF covers primary care only (i.e. dispensary and
  health centers) exclude referral care
• BUT some councils (eg. Hanang, Igunga, Mwanga,
  Rombo) have hospital level as part of benefit
  package

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Provision Use Cont

• Limitation in switching between providers if not
  after one year
• Care is limited to facilities within members
  council
• Limited private providers in rural areas
• not all NGOs/mission facilities are willingly to
  be accredited
• Limited human resources

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• POSSIBLE IDEAS

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• On Enrolment
• Identifying contributing population and means of
  collecting the funds
• Members involvement from the beginning.
  Willingness to pay studies might provide
  important insights of the community involved
• Help in setting contributions and deciding on
  benefit package
• More sensitization is required to make members
  aware (this is core)
• Encourage group membership -as the case of Rungwe
  (sheuya, 2006)
• Make use of the existing community group
  arrangement if any

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• On Management Accountability
• Improve MOHSW role in management of CHF
• Follow up on reports and arrange field
  supervisions
• Strengthen the CHF supervision section of the
  MOHSW and if possible open zonal offices
• Insist on Ward committees to report to the
  community members (through village meetings, etc)

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• On Reaching the Poor
• Need to set guidelines of identifying the poor
  through experience of successful councils (eg
  Muheza)
• Use the opportunity of Donors to fund the gaps in
  financing of poor (i.e pro-poor funding)
• Example GTZ has been involved in Muheza and
  Rungwe. Others could follow the same
• Religious institutions could also be encouraged
  to fund the poor
• Consider cross subsidizing the poor across
  councils
• (possibility of risk equalization fund?)

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• ISSUES FOR DISCUSSION

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• Enrolment
• How to increase members and control drop-out?
• How to speed-up roll-out of the scheme?
• Reaching the Poor
• How to improve Exemption/Waivers?
• How to identify the poor in the Communities (need
  for specified guideline?)
• Who should fund the gaps due Waivers/Exemptions?
• Management Accountability
• How to ensure commitment of District Councils
• What role should the MOHSW play

• Provision and Use of Services
• How Possible it is to extend CHF coverage to
  referrals?
• How to motivate the private providers and
  religious facilities?
• Possibility of motivating rural health care
  staffs (although not CHF specific)
• Possibility of using facilities in neighbour
  councils
• Sustainability of the Funds
• How to generate more funding?
• How to coupe with the fluctuations in rural
  individuals income?

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• THANK YOU
• FOR
• YOUR ATTENTION