Community Health Funds Community Health Funds in Tanzania: in Tanzania:

a review of experiencea review of experience

Gemini MteiGemini MteiJo MulliganJo Mulligan

Ifakara Health Research & Development CentreIfakara Health Research & Development Centre

Presentation to the CHF Best Practices Workshop Presentation to the CHF Best Practices Workshop 3131stst January – 2 February 2007 January – 2 February 2007

Golden Tulip Hotel Dar es SalaamGolden Tulip Hotel Dar es Salaam

OutlineOutline

Background Background Concept of the CHFConcept of the CHF CHF in TanzaniaCHF in Tanzania FindingsFindings Possible way forwardPossible way forward

BackgroundBackground

IHRDC asked to conduct a desk review of CHF experience in IHRDC asked to conduct a desk review of CHF experience in Tanzania.Tanzania.

Aim to:Aim to: provide provide a general overview of existing CHF relevant projects a general overview of existing CHF relevant projects

and initiatives in Tanzania;and initiatives in Tanzania;

summarise main issues raised;summarise main issues raised;

create a base of information that will contribute to enhancing a create a base of information that will contribute to enhancing a common understanding of CHF challenges among the common understanding of CHF challenges among the different stakeholdersdifferent stakeholders

Methods comprised literature review and hand searching of Methods comprised literature review and hand searching of documents and files held by CHF stakeholders.documents and files held by CHF stakeholders.

The Concept of CHFThe Concept of CHF

Definition: Definition: Community health financing- Community health financing- households financehouseholds finance health care health care costs and being costs and being involved in the mgtinvolved in the mgt and and organizationorganization

of the of the financing scheme & health services (Carrin financing scheme & health services (Carrin 2003) 2003)

• Community - population in village, district or geographical area, Community - population in village, district or geographical area, social economic group or ethnic groupsocial economic group or ethnic group

CBHF - a result of problems with Tax financing and SHI CBHF - a result of problems with Tax financing and SHI

Tax financing - small Tax base, big informal sector, dependence on Tax financing - small Tax base, big informal sector, dependence on donors, and dependence on International tradedonors, and dependence on International trade

SHI- national consensus , income inequalities, managerial problems, poor SHI- national consensus , income inequalities, managerial problems, poor infrastructure (roads, banks, telecommunication) to facilitate collections, infrastructure (roads, banks, telecommunication) to facilitate collections, re-imbursements and monitoring re-imbursements and monitoring

CHF in TanzaniaCHF in Tanzania

Started in 1996 with pilot study in Igunga DistrictStarted in 1996 with pilot study in Igunga District

• Act enacted in 2001 – CHF Act, 2001Act enacted in 2001 – CHF Act, 2001

Designed to cover the informal sector esp. in rural areasDesigned to cover the informal sector esp. in rural areas

Voluntary Membership – household membership Voluntary Membership – household membership • Same Contribution for each member Same Contribution for each member

householdhousehold

TIKKA in Urban and Peri-Urban settings (Town, Municipals, Cities)TIKKA in Urban and Peri-Urban settings (Town, Municipals, Cities)

Objectives of CHFObjectives of CHF According to CHF Act of 2001, objectives are;According to CHF Act of 2001, objectives are;

(i) to mobilize financial resources from the community(i) to mobilize financial resources from the community

(ii) provide quality and affordable health care services (ii) provide quality and affordable health care services through sustainable financial mechanismthrough sustainable financial mechanism

(iii) improve health care services management in the (iii) improve health care services management in the communitiescommunities

FINDINGSFINDINGS

This review examined the following issues;This review examined the following issues;

Coverage and Enrolment Coverage and Enrolment

Pro – Poor Approaches (Equity issues)Pro – Poor Approaches (Equity issues)

CHF management and accountabilityCHF management and accountability

Provision and Use of ServicesProvision and Use of Services

CHF Coverage CHF Coverage 69 Councils have launched CHF69 Councils have launched CHF

Other councils have delayed launching due toOther councils have delayed launching due to

lack of commitment by some regional and district lack of commitment by some regional and district officials; officials;

• inadequate follow-up from the MOH; inadequate follow-up from the MOH;

lack of capital for initiation of the scheme; lack of capital for initiation of the scheme;

• lack of uniformity on premiums, lack of uniformity on premiums,

unclear referral mechanisms, etc (MOH 2003a)unclear referral mechanisms, etc (MOH 2003a)

EnrolmentEnrolment Enrolment has non-uniform pattern.Enrolment has non-uniform pattern.

Example: Iramba (Mwendo,2001), Rungwe (Sheuya, 2006) have an encouraging Example: Iramba (Mwendo,2001), Rungwe (Sheuya, 2006) have an encouraging enrolment, enrolment,

while in Hanang (Musau,2004), Igunga and Singida rural (Shaw, 2002) while in Hanang (Musau,2004), Igunga and Singida rural (Shaw, 2002) enrolment has dropedenrolment has droped

Hanang from 23% in 1999 to 2.2% in 2004Hanang from 23% in 1999 to 2.2% in 2004 Reasons includeReasons include, ,

- low user fees, low user fees, -- high membership fee, high membership fee,

- low income, low income, -- introduction of NHIF, introduction of NHIF,

-- perceived poor quality of public facilities, perceived poor quality of public facilities, -- limited coverage to referrals,limited coverage to referrals,

-- poor health staffs’ attitudes, poor health staffs’ attitudes, -- broad exemption policy, etcbroad exemption policy, etc

{Shaw (2002), Mhina (2005), MOHSW (2006), Msuya (2004), Mwendo {Shaw (2002), Mhina (2005), MOHSW (2006), Msuya (2004), Mwendo (2001), MOH (2003b)}(2001), MOH (2003b)}

Tanzania National PoliciesTanzania National Policies

NHP VisionNHP Vision ““to improve health and well being of all Tanzanians with a to improve health and well being of all Tanzanians with a

focus on those most at risk and encourage the health system focus on those most at risk and encourage the health system to be more responsive to the needs of the people”to be more responsive to the needs of the people”

NSGRP emphasizes onNSGRP emphasizes on ‘‘equity in the delivery of health and social equity in the delivery of health and social

services so as to improve access for children, women, the services so as to improve access for children, women, the

poor and other vulnerable groups especially in rural areas’poor and other vulnerable groups especially in rural areas’

Pro-Poor ApproachesPro-Poor Approaches

How does CHF helps the poor?How does CHF helps the poor? CHF type schemes extendCHF type schemes extend

coverage to a large number of rural and low income coverage to a large number of rural and low income populations that would otherwise be excluded (Preker, et populations that would otherwise be excluded (Preker, et al. 2002al. 2002) )

andandprotect members by reducing the level of out of pocket protect members by reducing the level of out of pocket paymentspayments (Ekman 2004) (Ekman 2004)

Being a CHF member Being a CHF member

- improve access to formal health care providers and reduce improve access to formal health care providers and reduce the use of alternatives as self medication and traditional the use of alternatives as self medication and traditional healers for the poorhealers for the poor

- - reduces the risk of trading-off assets with health care seeking reduces the risk of trading-off assets with health care seeking {{Msuya et al. Msuya et al. (2004)}(2004)}

A:A: Exemption and WaiversExemption and WaiversApplies for those unable to pay the contribution feeApplies for those unable to pay the contribution fee

... ... District councils are expected to fully subsidize the CHF membership fees for District councils are expected to fully subsidize the CHF membership fees for those who those who have been exempted or waived...have been exempted or waived...

ChallengesChallenges source of funding, source of funding, identifying the poor, identifying the poor, general/blanket exemption, general/blanket exemption, Ensuring the awareness of existence of the policyEnsuring the awareness of existence of the policy

To overcome such challenges, some Councils (eg. Mwanga, Muheza) have managed To overcome such challenges, some Councils (eg. Mwanga, Muheza) have managed to identify the poorto identify the poor

• Criteria include, Criteria include, elders and widows with no one to take care off, elders and widows with no one to take care off,

• physically/mentally handicapped, physically/mentally handicapped, orphans, orphans,

• those with poor houses, etcthose with poor houses, etc

CHF Pro-Poor MechanismsCHF Pro-Poor Mechanisms

B:B: Cross subsidisationCross subsidisation CHF is cross subsidizing between the CHF is cross subsidizing between the

households households

Rich PoorRich Poor and and health illhealth ill

Need to find a way of having a mixture of Need to find a way of having a mixture of membershipmembership

i.e. not only the poor /ill joining the schemei.e. not only the poor /ill joining the scheme

Pro-Poor Mechanisms cont..Pro-Poor Mechanisms cont..

District council is the core of CHF activities.District council is the core of CHF activities.

District councils responsible for sensitization activitiesDistrict councils responsible for sensitization activities

Community members involved through their Community members involved through their representatives in the Council Health Services Boardrepresentatives in the Council Health Services Board

Management & AccountabilityManagement & Accountability

Observations:Observations:

In some councils, members are not aware of the performance/operation of In some councils, members are not aware of the performance/operation of their schemes (Chee, et al 2002, MOH 2003b)their schemes (Chee, et al 2002, MOH 2003b)

The CHSB and WHC members are not binded to be members of CHFThe CHSB and WHC members are not binded to be members of CHF

Risk of non-representation of CHF membersRisk of non-representation of CHF members

Mis-management of funds in some councilsMis-management of funds in some councils

no frequent auditing is conductedno frequent auditing is conducted

others do not use the collected contributionsothers do not use the collected contributions

Management of funds is left to facility workersManagement of funds is left to facility workers

Management & Accountability Cont..Management & Accountability Cont..

Provision and Use of ServicesProvision and Use of Services Some review/studies have shown improvement Some review/studies have shown improvement

in provision and accessin provision and access

Example:Example:

Purchase of microscope, drugs, etc (Shaw 2002) Purchase of microscope, drugs, etc (Shaw 2002)

improvement in access to care for CHF members improvement in access to care for CHF members (Msuya, 2004, Musau 2004)(Msuya, 2004, Musau 2004)

CHF covers primary care only (i.e. dispensary CHF covers primary care only (i.e. dispensary and health centers) exclude referral careand health centers) exclude referral care

BUT BUT some councils (eg. Hanang, Igunga, Mwanga, some councils (eg. Hanang, Igunga, Mwanga, Rombo) have hospital level as part of benefit packageRombo) have hospital level as part of benefit package

Limitation in switching between providers if not Limitation in switching between providers if not after one yearafter one year

Care is limited to facilities within members’ Care is limited to facilities within members’ councilcouncil

Limited private providers in rural areas Limited private providers in rural areas

not all NGOs/mission facilities are willingly to be accreditednot all NGOs/mission facilities are willingly to be accredited

Limited human resourcesLimited human resources

Provision & Use Cont…Provision & Use Cont…

POSSIBLE IDEASPOSSIBLE IDEAS

On EnrolmentOn Enrolment Identifying contributing population and means of collecting the Identifying contributing population and means of collecting the

fundsfunds

Members involvement from the beginning. Willingness to pay Members involvement from the beginning. Willingness to pay studies might provide important insights of the community studies might provide important insights of the community involvedinvolved

Help in setting contributions and deciding on benefit Help in setting contributions and deciding on benefit packagepackage

More sensitization is required to make members aware More sensitization is required to make members aware (this is (this is core)core)

• Encourage group membership -as the case of Rungwe Encourage group membership -as the case of Rungwe (sheuya, 2006)(sheuya, 2006)

• Make use of the existing community group arrangement if Make use of the existing community group arrangement if anyany

On Management & AccountabilityOn Management & Accountability

Improve MOHSW role in management of CHFImprove MOHSW role in management of CHF

Follow up on reports and arrange field supervisionsFollow up on reports and arrange field supervisions

Strengthen the CHF supervision section of the MOHSW Strengthen the CHF supervision section of the MOHSW and if possible open zonal officesand if possible open zonal offices

Insist on Ward committees to report to the Insist on Ward committees to report to the community members (through village community members (through village meetings, etc)meetings, etc)

On Reaching the PoorOn Reaching the Poor

Need to set guidelines of identifying the poor through experience Need to set guidelines of identifying the poor through experience of successful councils (eg Muheza)of successful councils (eg Muheza)

Use the opportunity of Donors to fund the gaps in financing of Use the opportunity of Donors to fund the gaps in financing of poor (poor (i.e pro-poor fundingi.e pro-poor funding))

Example:Example: GTZ has been involved in Muheza and GTZ has been involved in Muheza and Rungwe. Others could Rungwe. Others could

follow the samefollow the same

Religious institutions could also be encouraged to fund the poorReligious institutions could also be encouraged to fund the poor

Consider cross subsidizing the poor across councils Consider cross subsidizing the poor across councils

((possibility of risk equalization fund?)possibility of risk equalization fund?)

ISSUES FOR DISCUSSIONISSUES FOR DISCUSSION

EnrolmentEnrolment How to increase members and control How to increase members and control

drop-out?drop-out?

How to speed-up roll-out of the How to speed-up roll-out of the scheme?scheme?

Reaching the PoorReaching the Poor

How to improve Exemption/Waivers?How to improve Exemption/Waivers?

How to identify the poor in the How to identify the poor in the Communities Communities ((need for specified need for specified guideline?)guideline?)

Who should fund the gaps due Who should fund the gaps due Waivers/Exemptions?Waivers/Exemptions?

Management & AccountabilityManagement & Accountability

How to ensure commitment of District How to ensure commitment of District CouncilsCouncils

What role should the MOHSW playWhat role should the MOHSW play

How to assure representation of CHF How to assure representation of CHF members in CHSB and WHC?members in CHSB and WHC?

Provision and Use of ServicesProvision and Use of Services

How Possible it is to extend CHF How Possible it is to extend CHF coverage to referrals?coverage to referrals?

How to motivate the private providers How to motivate the private providers and religious facilities?and religious facilities?

Possibility of motivating rural health Possibility of motivating rural health care staffs care staffs (although not CHF specific)(although not CHF specific)

Possibility of using facilities in Possibility of using facilities in neighbour councilsneighbour councils

Sustainability of the FundsSustainability of the Funds

How to generate more funding?How to generate more funding?

How to coupe with the fluctuations in How to coupe with the fluctuations in rural individuals’ income?rural individuals’ income?

THANK YOU THANK YOU

FOR FOR

YOUR ATTENTIONYOUR ATTENTION