Social Health Insurance in Tanzania

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Social Health Insurance in Tanzania

• An overview

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Table 1 Tanzania Administrative and Health
System
Source Ministry of Health Health Statistics
Abstract 2002
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Health Financing Options in Tz

• These are such as
• National Health Insurance Fund (NHIF)
• National Social Security Fund (NSSF)
• Community Health Funds (CHF)
• Micro-health Insurance Schemes (MHIS)
• Other Funding sources include
• Government and Local Governments
• Basket Funding
• NGOs
• Private Financing
• Community Financing
• Donor Funding

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National Health Insurance Fund Aims

• To strengthen cost-sharing by providing an
  opportunity for the formal sector employees to
  contribute through their contributions to a Fund.
• To provide free choice of providers to Public
  servants who were formerly restricted to
  government health facilities.
• To enhance health equity among formal sector
  employees in the provision of health care
  services.
• To institute a permanent and reliable system for
  the provision of health services to formal sector
  employees.
• To improve accessibility and quality of health
  services by introducing competition among health
  care providers from Public, Faith-based, Non
  Government Organizations and Private Health
  Providers.
• To reduce the financing gap by supplementing the
  Government budgetary allocation to the health
  sector by contributions from formal sector
  employees.

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Description of the NHIF

• The (NHIF) was established in 1999 by a
  parliamentary Act No. 8 of 1999.
• The operations of the scheme commenced on the 1st
  July 2001,
• The benefits to Members started from October
  2001.
• The scheme is based on internationally accepted
  insurance principles,
• The scheme provides a wide range of short term
  benefits to her members.
• Currently, the NHIF serves for the Public service
  employees including their spouses and four
  children and/or legal dependants
• It is a compulsory scheme for public servants

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Structure of the NHIF

• Coverage
• 4.5 pf population.
• Contributions
• The NHIF is financed through contributions
  (employers contribute 3 and employees 3) of the
  basic salary of the employees
• Identification of Members
• Though identity cards.
• Benefit Package
• Currently the benefit package includes
  Registration fees, Basic diagnostic tests,
  Outpatient services including medications and
  investigations, In-patient care (fixed rate per
  day per level of health facility), Surgery,
  spectacles and other services

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Structure of the NHIFcontinued

• Areas of exemptions of coverage
• all public funded programs
• illegally/socially disapproved acts
• Accreditation of Health Facilities
• Hosp, H/C, Dispensaries and pharmacies/ ADDOs
• Provider Payment Mechanisms
• Fee-for-service is the main payment mechanisms
  that was adopted at the start of the operations
  of the Fund.
• Capitation in some

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Successes recorded by the NHIF

• Assurance of access to health services at all
  times
• Contribution to the Health Sector Development as
  a component in Health financing
• Attitude changes
• From free services to contributions
• From cash payments to use of Cards
• From laisser-faire to ownership by Members
• Use of Cards have reduced bribery tendencies
• Sustainable system outside the Government general
  taxation system
• Brings services closer to members (Zones)
• Its setting has been model to most interested
  countries

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Problems encountered by the NHIF

• General perception at early days (mainly
  negative)
• Some stakeholders are yet to fulfill their roles
• Drug shortages
• Absence of infrastructures eg part 1 pharmacies
  in most parts of the countries
• Emergence of fraudulent tendencies
• Problems related to the health system and
  infrastructure itself have negative impacts on
  the funds operations

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Challenges of the NHIF

• Limited scope of coverage
• Operates in un-regulated environment
• Low awareness by the public on how these
  different schemes operates
• Preference on cash payments vs card
• Absence of set basic package (by MoHSW)
• Non adherence by some health service providers on
  the standards set by MoH and the NHIF
• Fraud

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NSSF-Social Health Insurance Benefit (SHIB)

• SHIB is the 7th benefit to be implemented in the
  NSSF Act. Section 41 of the NSSF Act No. 28 of
  1997.
• Established so as to provide crucial support to
  the Governments efforts of increasing access to
  health care services to the poor majority in the
  country.

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SHIB- The Benefit Package

• Aimed at providing most of general healthcare
  services for beneficiaries
• Out-Patient Services
• Consultations
• Basic Specialized investigations
• Drugs under the National Essential Drug List
• Simple procedures (e.g. wound dressing)
• Referral to higher levels special hospitals

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SHIB- The Benefit Package

• In-Patient Services
• Accommodation
• Consultation with a Medical Officer or specialist
• Basic investigations(e.g. blood slide for mps,
  stool, etc)
• Specialized investigations
• Drugs under the National Essential Drug List
• Minor and Major Operations
• Blood transfusion
• Specialized procedures
• Medicines on discharge
• Referral to higher level specialized hospitals

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SHIB- Exclusions

• Diseases under special preventive programs and
  Public Health Care Services e.g.TB and Leprosy,
  Cancers, HIV/AIDS, Epidemics, Maternal and Child
  Health (MCH), Mental Illness, Sexually
  Transmitted Diseases (STDs), Any other disease
  that will be categorized in this domain.
• Self-inflicted diseases or injuries e.g. drug
  abuse, tobacco, alcohol, attempted suicide, and
  criminal abortion
• Luxurious like Cosmetic treatments with no
  medical indications e.g. plastic surgery

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SHIB-Limitations

• Emergency cases for principal beneficiaries
  traveling away-
• Outpatient - not more than 4 times/year
• Inpatient (48 hours) - not more than 2 times/year
• Hospitalisation a maximum of 42 days of
  inpatient care per beneficiary per year

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SHIB-Coverage and Eligibility

• the Scheme covers a member and dependants (one
  spouse and up to four children)
• three months of healthcare services after
  stoppage of contributions due to termination,
  falling in arrears of contribution and
  retirement
• qualifying members must have contributed for at
  least three months immediately before accessing
  the services and
• pensioners willing to contribute 6 of their
  monthly pension shall continue enjoying
  healthcare benefits.
• NB NSSF is considering inclusion of other
  persons who are not statutory members of the
  Scheme

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SHIB-Method of Payment

• Payment of providers is by Capitation method
• Reasons for Capitation
• Easy to administer
• Builds a self-monitoring system and
  accountability among the Stakeholders
• links members to a specific provider who is
  responsible for providing healthcare and
  record-keeping
• provides a predictable cash flow.

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Advantages of SHIB

• Relief to the employers
• Relief to the members
• Contribution to the Government towards better
  healthcare services in the country, to become the
  2nd largest healthcare provider after the
  Government

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Community Health Funds Background

• It is part of the health financing reforms that
  begun in 1990.
• Health care financing study undertaken between
  1990-1992 recommended introduction of cost
  sharing and National Health Insurance.
• Community Health Fund was conceived later to
  mitigate the shortfall of National Health
  Insurance coverage.

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Community Health Funds Background

• A decentralised voluntary health Insurance scheme
  operating at district level
• A govt initiative to target people from the
  formal and informal sector as well as the poor.
• A way of trying to cover basic health care
  services and to give access to those excluded by
  other schemes.

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Community Health Funds (CHF)Background

• Started on pilot basis in one district.
• The pilot was then extended to nine more
  districts after evaluation.
• Policy decision has now been reached to cover all
  districts.
• It is taken as one of the conditions to extend
  cost sharing in primary health care facilities.

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Community Health Funds The Concept

• Risk pooling among families in the informal
  sector.
• Households pay once a predetermined premium for
  the medication of the whole family per year.
• Payment is often made at the time of harvesting
  or when the season of income has arrived.
• Since the premiums are in the form of capitation,
  providers and contributors have the liberty to
  spend in preventive and promotive health
  services.
• Contributors have a choice of providers.
• Provides opportunity for providers to increase
  efficiency

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Community Health Funds (CHF)

• Why community financing?
• Improves efficiency and equity
• Allows sharing of risk (community-rating)
• Allows collection of resources
• Facilitates community participation (contribution
  to the general welfare of the community)

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Impact of community-based schemes

• Increase access
• Generate resources
• Improve equity
• Improved Access for members of Schemes
• Increased utilization of the members as compared
  to non-members
• Reduced out-of-pocket payment for members as
  compared to non-members

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Micro-health Insurance Schemes (MHIS)

• Are voluntary schemes set up and run by
  co-operatives, churches or local communities
• They provide access to basic health care services
  at a single provider taken under contract
• Cater for small sections of the population
• Are managed locally

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MHIS (2)

• Most are registered under societies Act, and
  Trustees Deed.
• Covers the informal sector or groups of common
  interest
• Benefit package and contributions are set and
  agreed by the respective members
• UMASIDA and VIBINDO - successful cases of Mutual
  Health Insurance
• Started in 1994, contribution Tsh 1,500/ to Tsh
  3000/ per month (operates in Dar es salaam,
  Kilimanjaro and Arusha)

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MHIS (3)

• The number of MHI are on increase from Churches
  and charitable organisations
• Based on Mutual and common interest, Most of
  these schemes covers the poor in the informal
  sector
• MHIS are subject to many organisational and
  managerial weaknesses due to their self-managing
  character (limited skills and capacities of those
  running the schemes).

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NGOs

• These subsidizes specific health programmes
• Usually operate at local levels
• Have their own sources of funds
• Usually have preference in the types of
  programmes or the health services they offer or
  conduct.

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Private Financing

• Comprise of Direct individual (out-of pocket)
  payments as well as private health insurance
  schemes
• To-date Tanzanian households provide the greatest
  proportion of health care financing
• Out-of-pocket payments are gradually becoming
  less popular in urban centres, as people are now
  enrolling in Insurance schemes.
• i.e. moving from cash payments to card payments
  (at the point of receiving health service)
• Cash payments are tricky modes especially for the
  poor

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Private Health Insurance

• Private health Insurance schemes are relatively
  recent modes of health care financing in Tz
• These are such as AAR, MEDEX and Strategis.
• Are Voluntary and cover mostly salaried workers
  on an individual basis or as employees of a
  registered employer.
• Benefit package is rated i.e each member has a
  specific benefit package depending on the premium
  he/she paid.
• Operates on an individual equivalency (no pooling
  of risks).
• There is adverse selection of risk
• Premiums are calculated according to the
  anticipated risk e.g. age, sex, risk
  exposure-medical family history, medical
  individual history etc
• In Tz PHI schemes mostly operate in urban areas
  and with private health providers.

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Community Financing

• These are informal contributions for the purpose
  of health
• Are solidarity funds and/or special arrangements
  made for health e.g. with individual companies,
  collections etc

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Donor Funding

• Are funds donated in kindness
• Are usually for specifically designed health
  projects/programmes
• Have a variety of contributions I.e both monetary
  and technical assistance
• Provides about the same proportion of funds for
  health as the GoT
• Recent trend by donors is channelling their funds
  into the global national budget (and not directly
  to health budget) hence impacts the health sector
  on how to secure an appreciable share of the
  funds from the government

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Basket Funding

• Health sector partners pool their funds
  contributed for health
• Funds come from several stakeholders in health
  i.e the Government, Local Government, NGOs and
  other development partners