Strengthening of Claiming, Reimbursement and Use of Funds for the National Health Insurance Fund Experiences from the Pilot Region (Tanga) and Suggestions for Further Roll-out Gradeline Minja (HSRS MoHSW), Dr. Aifena Mramba (NHIF), Mechard Tiba

1
Strengthening of Claiming, Reimbursement and
Use of Funds for the National Health Insurance
FundExperiences from the Pilot Region (Tanga)
and Suggestions for Further Roll-out Gradeline
Minja (HSRS MoHSW), Dr. Aifena Mramba (NHIF),
Mechard Tiba (GTZ), Manfred Stoermer (Health
financing consultant)developed on behalf of
Tanzania German Programme to Support Health
(TGPSH /GTZ) November 29, 2007
2
Background

• NHIF contributions and reimbursements 2004/5
• Contributions collected 24.0 bn TSh
• Claims lodged 4.9 bn TSh
• Reimbursements paid 4.2 bn TSh (86)
• NHIF contributions and reimbursements 2005/6
• Contributions collected 31.7 bn TSh
• Claims lodged 5.4 bn TSh
• Reimbursements paid 4.9 bn TSh (91)

3
Overall Aim and Organisation of the Study

• Aim
• Strengthening the system of claims and
  reimbursement for the benefit of district health
  services
• Organisation of the Study (Four phases)
• I Situation analysis (January 2006)
• II Pilot implementation in Muheza district
  (April 2006)
• III Impact assessment (November 2006)
• IV Impact assessment of regional roll-out in
  Tanga Region and suggestions for national
  roll-out (November 2007)

4
Specific Objectives of this Study Phase

• Muheza and Lushoto districts Assessing the
  functioning of NHIF claiming/ reimbursement/ use
  of funds and measure its progress
• Assess the ongoing training on NHIF claiming and
  reimbursement in Tanga Municipality and evaluate
  its appropriateness
• Evaluate the activities carried out by the
  Regional NHIF coordinator Tanga and the District
  NHIF coordinators in terms of supervision and
  monitoring
• Follow up of implementation of recommendations
  for the peripheral and national level submitted
  during the pilot studies on NHIF support.
• Suggest way forward for national roll-out for
  facilitating improved claiming/reimbursement/use
  of NHIF funds

5
Methodology for present study (phase IV) Impact
assessment of regional roll-out in Tanga Region

• Document review
• Semi-structured interviews
• Field visits to Muheza and Lushoto Districts /
  Tanga Region
• Muheza and Lushoto districts interviews with DED,
  DMO, DHMT, District Treasurer / accountants,
  District NHIF Co-ordinator
• 2 dispensaries, 2health centres and 2 district
  hospitals visited, interviews with in-charges and
  members of health facility governing committees
• Tanga Region RMO, RHMT, Regional NHIF
  Co-ordinator, GTZ
• Participatory observation of a training workshop
  on NHIF claiming and reimbursement in Tanga
  Municipality

6
Roll-out in Tanga Region Training on NHIF
claiming and reimbursement

• July 2007
• Trainings in Handeni, Korogwe and Lushoto
  districts470 participants from 132 facilities
  in total 10 trainings on division level,
  facilitated by 6 trainers (4 NHIF, 2 RHMT)
• November 2007
• Trainings in Kilindi and Pangani districts and
  Tanga City270 participants from 86
  facilitiesin total 5 trainings on division
  level, facilitated by 4 trainers (2 NHIF, 2 RHMT)

7
Costs of the Training Workshops for Tanga Region
8

• Findings Development of Claims and
  Reimbursements in Tanga Region

9
Development of Claims and Reimbursements in
Muheza District (govt. health facilities)
10
Development of Claims and Reimbursements in
Muheza District (all health facilities)
11
Development of Claims and Reimbursements in
Lushoto District
12
Development of Claims in Tanga Region
13
Development of Reimbursements in Tanga Region
14
Reimbursement of NHIF Funds by Region from
2005/06 to 2006/07
15
Summary Development of Claiming and Reimbursement

• In general an upward trend can be observed both
  for claiming funds and for the reimbursements
• Reduction in reimbursements, and later also in
  claims, since Feb 2007 because of changing Govt.
  policy on Malaria treatment (use of ALU as first
  line drug), and corresponding change in price
  reimbursed for ALU drop from TSh 8500/ per
  treatment to TSh 500/

16

• Findings Accessing and Utilising Funds

17
Accessing and Utilising Funds

• Background
• Health facilities should be able to utilize the
  NHIF funds for improving their services
• NHIF reimburses funds on a health facility level,
  based on the claims of each health facility
• NHIF checks whether the claims adhere to the
  requirements and rejects some of them
• Accessibility
• Presently NHIF funds in Tanga Region are
  deposited on sub-treasury / regional level for
  hospitals, on the CHF account (sometimes also
  called cost sharing account) at district level
  for health centres and dispensaries

18
The Bottleneck of Accessing and Utilising Funds
Muheza District

• So far none of the first level health facilities
  (health centres, disp.) ever benefited from
  utilizing NHIF funds
• However, we were informed that the first ever
  utilisation of such funds is in progress a first
  requisitioning of drugs is under way
• Procedures are expected to take some weeks
• No records are kept on the amounts available for
  each individual health facility at the levels of
  DMO, the District Treasurer or the District NHIF
  Co-ordinator
• The health facilities do not know what is the
  amount available for them from NHIF funds.

19
The Positive Example of how to Access and Manage
Funds in Lushoto District (I)

• DMO keeps records on the balance of funds (NHIF,
  CHF, user fees) for each health facility (sub
  accounts with codes have been developed)
• District hospital buys drugs at MSD on behalf of
  first level health facilities and builds buffer
  stock at District Pharmacy
• District Pharmacy is provided with the balance of
  funds available for each health facility by the
  DMO

20
The Positive Example of how to Access and Manage
Funds in Lushoto District (II)

• Health facilities identify their demand of drugs
  and get approval from the health facility
  governing committee
• District Pharmacist is empowered by DMO to
  validate and authorize requests for drugs of the
  health facilities and dispense the drugs to them
  the same day (without further signature of DMO)
• Details of the requested and dispensed drugs are
  reported back to DMO by District Pharmacist
• DMO deducts the value of the dispensed drugs from
  the respective health facility sub-accounts and
  compensates the hospital

21
The Positive Example of how to Access and Manage
Funds in Lushoto District (III)

• Good general management practice
• DMO instructs all health facility in-charges to
  report to district capital by the 15th of each
  month, for handing in claim forms to NHIF
  co-ordinator, requisitioning and collecting
  drugs, and any other business
• In-charges who report later than 15th of the
  month have to report directly to the DMO and
  explain the delay
• Travelling costs to district capital are budgeted
  in the CCHP
• By-annual meetings are held with all health
  facility in-charges of the district

22
The Positive Example of how to Access and Manage
Funds in Tanga Municipality

• Each health centre keeps an own bank account,
  which at the same time serves as a bank account
  for the neighbouring dispensaries
• NHIF funds are deposited on the health facility
  bank accounts
• Each health facility is exactly aware of the
  balance of funds
• The in-charges and members of governing
  committees present at the training workshop in
  Tanga report unanimously of good experiences with
  keeping their own bank account

23
Financial Monitoring Tools

• During phases I-III of the study financial
  monitoring tools were developed for monitoring
  inflows, outflows and balance of funds (for NHIF,
  CHF and user fees) at the levels of DMO, District
  Treasurer and health facility
• These financial monitoring tools are not being
  utilised in the districts visited
• Lushoto set up an own financial monitoring
  system, Muheza has no financial monitoring in
  place
• It is still maintained by the team that financial
  monitoring of NHIF funds and communication of the
  balances available to health facilities is of
  utmost importance
• The financial monitoring tools should be
  mainstreamed and integrated in the routine
  financial administration system

24
Summary Accessing and Utilising Funds

• The lacking access to NHIF reimbursed funds for
  health facilities has to be seen as a major
  obstacle regarding improvement of the quality of
  health services, and regarding motivation of
  health staff to do the claiming
• The examples of Lushoto (sub-accounts and drug
  buffer stocks) and Tanga Municipality (own bank
  accounts) show that this problem can be overcome
  with good management practice
• Complicated financial administration procedures
  at district level and remoteness of the account
  keeping (sub-treasury at region for hospitals)
  create major costs in terms of expenditures and
  delays

25

• Findings Appropriateness of the Training
  Workshops

26
Participants for the training

• Representatives from all health facilities from
  Bombo Regional Hospital, District hospitals,
  health centres and dispensaries in Tanga
  Municipal Council, Kilindi and Pangani districts
  respectively.
• At Bombo Hospital participants from each
  department
• Health centres maximum of four people,
  dispensaries in-charges
• Ward Executive Officers from the participating
  districts
• Chairpersons of the Facility Governing
  Committees.
• Representative from Workers from Tanzania Local
  Government Workers Union TALGWU).
• Representatives of NHIF members from the
  Education department (District Education Officers
  for Kilindi and Pangani districts, primary school
  teachers)
• Comment the selection of participants is
  appropriate

27
Objectives of the workshop

• Reduce the number of rejected claims by training
  the providers on how to fill the NHIF cards and
  provide clarification on problem areas.
• Provide information on recent changes in NHIF
  operations, i.e. benefit package, prices,
  approved drugs
• Clarify the roles of the NHIF Coordinator
• Provide information about NHIF Quality control
  analysis and payment procedures.
• Strengthen the financial monitoring of NHIF
  reimbursements at facility level to enable follow
  up by in-charge or health facility governing
  committee if information on reimbursements
  corresponding to claims is not received
• Enable health facility in-charges and health
  facility governing committees to take on an
  active role in monitoring total revenues
  collected, spent and available and how to access
  such accumulated funds.

28
Curriculum applied / Contents of the Workshop

• The workshop adequately addressed the NHIF
  procedures for filling membership forms, claiming
  and reimbursement and informed on recent changes
  in NHIF benefit package and role of the NHIF
  Coordinator
• The question of how the new health financing
  schemes fit into the context of health sector
  reform was discussed too briefly
• The issue of how to access and utilise funds is
  not captured in the workshop programme

29
Trainers / Facilitators

• Two facilitators one from NHIF HQ in Dar es
  Salaam and the other one from the Regional Health
  Secretariat.
• With exception of the health Sector reform topic,
  all the sessions were provided by the NHIF
  facilitator.
• The facilitators used active participation
  methods throughout the training session. However,
  in order to make the sessions more lively, the
  trainers should change more frequently.
• The trainers were very knowledgeable on the
  subjects of claiming and reimbursement procedures
  of NHIF.
• The training on health sector reform was too
  brief and did not adequately explain the
  objectives of the new financing schemes

30
Training Methodology

• Training methodology was mainly lecturing, with
  question and answer sessions
• Exercises were asking the participants to
  identify mistakes in wrongly filled forms and
  comment on good forms
• However no active group work where participants
  are asked to fill in forms themselves
• All forms used by NHIF are presently in English
  language. For easy understanding a Kiswahili or
  bilingual version would be helpful

31
Training Materials

• Forms for NHIF operations were used. Some lack
  detailed information to assist the person who is
  filling them

• Information on the procedure to follow when a
  member requires changing the name of his / her
  beneficiaries, or putting additional person as a
  beneficiary.
• Procedure to take when a membership card is lost.
• The amount to be paid as a penalty on requests
  for another membership card if the previous one
  is lost. The current charge is TShs. 20,000/ but
  this is not written anywhere.
• Retrieval of cards when the membership ceases.

32
Summary Main Findings on the Appropriateness of
the Training Workshops

• Participants are appropriately selected
• Contents should be extended to include accessing
  of funds
• Curriculum should be developed with definition of
  key contents
• Facilitators are appropriately chosen, but should
  take turns in taking over training sessions
• Training methodology should be supplemented with
  some activating exercises / group work

33

• Findings Regional and District NHIF
  Co-ordinators

34
Regional and District NHIF Co-ordinators (I)

• NHIF co-ordinators are in place in all districts
  of Tanga Region except Tanga Municipality.
• The District NHIF Co-ordinators do collect the
  claim forms and pass them on for payments.
• They distribute payment advice letters from NHIF
  to the health care providers
• They supervise and screen claim forms to ensure
  that they are properly filled.
• The follow up of health facilities which do not
  submit claims in time, however, seems to be weak
  in Muheza and stronger in Lushoto
• They collect operational problems related to NHIF
  implementation and discuss with CHMT members and
  NHIF zonal office

35
Regional and District NHIF Co-ordinators (II)

• It was noted that supportive supervision takes
  place in Lushoto with regard to NHIF operations
  by CHMT members as part of regular supervisory
  visits to all governmental health facilities.
  However, this was not very clear for Muheza.
• They facilitate that health facilities get
  feedback on amounts claimed and paid. The balance
  of funds available for the health facilities is
  only communicated in Lushoto and Tanga
  Municipality, not in Muheza
• They disseminate information on changes in
  package, prices, procedures etc. of the NHIF to
  the health facilities
• NHIF co-ordinators presently do not assist in
  follow up of members with missing NHIF
  beneficiary cards. Such members are presently not
  registered at health facility level and reported
  to the NHIF co-ordinators

36
Summary Main Findings on the Role of Regional /
District NHIF Co-ordinators

• The establishment of Regional / District NHIF
  Co-ordinators is very helpful for improving NHIF
  claiming / reimbursement
• They fulfil most of the roles expected from them
• Some improvements could still be made in regard
  to follow up of health facilities not submitting
  claims and follow up of members without ID cards
• A merging of the roles of NHIF co-ordinator and
  CHF co-ordinator into a Health financing
  co-ordinator would be desirable, but needs
  re-adjusting of the workloads

37

• Recommendations

38
Recommendations Making NHIF Funds Accessible to
Health Facilities (I)

• 1. Developing a guideline on where to deposit
  NHIF funds Recommended in a district level
  cost sharing account together with CHF and user
  fee fundsSuggested responsible level Health
  Financing Committee to take up the issue and
  co-ordinate with responsible units in MoHSW,
  PMORALG and MoF

39
Recommendations Making NHIF Funds Accessible to
Health Facilities (III)

• 2. Develop financial monitoring tools for
  tracking the funds at the level of each
  individual health facility (for NHIF, CHF, user
  fees) and integrate them in the routine district
  accounting system (Epicor)Recommended consider
  allowing health facilities to open own bank
  accountsotherwise at least sub-accounts for the
  district level account should be
  createdconsider how DMOs could be followed up
  on whether they provide the health facilities
  with their respective financial break-down
  Suggested responsible level MoHSW / RHMT for
  guiding, instructing and following up the DMOs
  DMOs for informing health facilities

40
Recommendations Making NHIF Funds Accessible to
Health Facilities (II)

• 3. Training of DMOs in accessing and utilisation
  of funds and in avoiding shortages in drugs and
  supplies
• Recommended informing and instructing DMOs in
  how to build up a buffer stock of drugs from
  which health facilities can easily draw their
  requirements obliging them to report reasons in
  case of failure and stock-outs Suggested
  responsible level MoHSW/RHMT and PMORALG

41
Recommendations Roll-out of Training Workshops
on NHIF funding (I)

• 4. Restructure the training workshops on NHIF
  funding
• Develop a curriculum / guideline for the
  trainings to be applied countrywide, which should
  contain e.g
• training session on how to access and utilise the
  funds training on how the health facilities can
  monitor the balance of funds from NHIF, CHF and
  user fees available to them
• practical exercise where participants fill in
  forms themselves
• invite DMO / DHMT to exactly explain how the
  health facilities can access their funds e.g. for
  drug supplies, and how buffer stocks for drugs
  will be maintained at district level

42
Recommendations Roll-out of Training Workshops
on NHIF funding (II)

• 5. Conduct training of trainers
• Consider conducting ToT to the zonal training
  centres in order to speed up the roll-out
• Begin the roll-out on the presently poorly
  performing regions (annual reimbursements below
  TSh 200 M)- Coast- Kigoma- Lindi- Mtwara-
  Shinyanga- Singida- Tabora- Rukwa

43
Recommendations Empowering of NHIF co-ordinators

• 6. Consider formally establishing the post of a
  Health Financing Co-ordinator to deal with all
  the health financing issues in the district
  (incl. NHIF, CHF, user fees) After establishing
  such a position consider reallocating the
  workload
• 7. Whenever a new employee joins the district
  health services he/she should first undergo an
  orientation with the Health Financing
  Co-ordinator for some days before proceeding to
  the work station

44
Recommendations Strengthening communication
between MoHSW and NHIF

• 8. Consider appointing a focal person in MoHSW
  responsible for health care financing aspects at
  the national level

45
Way Forward

• NHIF together with MoHSW should prepare a
  roll-out plan for implementation of all above
  mentioned recommendations, pointing out time
  frame, resources and responsibilities
• Estimated costs of roll-out for the 8 poorest
  performing regions in the countryapprox. 8 x
  TSh 75 M TSh 600 M ( approx. 500.000 USD)(to
  be calculated in detail per district)

46

• Ahsanteni Sana
• Kwa kunisikiliza