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

Abstract

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.

Figure 1

Overview of management structures from the district level down.

Figure 2

Overview of management structures from the central to district level before and after the reform.

Figure 3

Overview of CHF revenue and matching grant payments between 2008–2011 in USD. SOURCE: [31]; [32]; [33]. Note that data were not available on CHF membership in 2008, hence it was not possible to estimate CHF revenue, only matching grant disbursements. 1. Ministry of Health and Social Welfare, Health Sector Public Expenditure Review, 2009/10. 2011: Dar es Salaam, Tanzania. 2. Ministry of Health and Social Welfare, Health Sector Public Expenditure Review, 2010/11 Draft,. 2012: Dar es Salaam, Tanzania. 3. MOHSW, Matching grand disbursement records. 2008.

Figure 4

Overview of total district funds from NHIF reimbursements, CHF premiums and user fees in the two case study districts between 2008–2011 in thousand USD. NOTE TO TABLE: _R: RURAL; _U: URBAN Data Sources: Annual reports of revenue from the CHF coordinators in the respective districts. In the urban district, the CHF coordinator did not report on NHIF revenue. These data were obtained from the district NHIF coordinator.

Figure 5

Comparison of cost sharing revenue^b and expenditure for 2008–2011 in the rural district in thousand USD. SOURCE: [34], [35], [36].

Figure 6

Trends in health insurance coverage for the NHIF and CHFbetween 2008 and 2011. SOURCE: NHIF data [20]; CHF data (MoHSW, 2008, NHIF 2009–2011), using projection-based population.