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Health Insurance for Rural Population – the Re-Organisation of Community Health Funds in Tanzania.

Author(s) Manfred Stoermer1, Manoris Meshack2, Ralf Radermacher3, Fiona Chilunda4, Yann Gelister5
Affiliation(s) 1Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2Health Promotion and System Strengthening Project, Swiss Tropical and Public Health Institute, Dodoma, Tanzania, 3Micro Insurance Academy, Micro Insurance Academy, Bonn, Germany, 4Health Promotion and System Strengthening Project, Swiss Tropical and Public Health Institute, Dodoma,Tanzania, 5Micro Insurance Academy, Micro Insurance Academy, Bonn, Germany.
Country - ies of focus Tanzania
Relevant to the conference tracks Advocacy and Communication
Summary Community Health Funds (CHF) in Tanzania face problems in design, enrolment, servicing, and sustainability. Since 2011 the Swiss Government funded “Health Promotion and System Strengthening Project”, HPSS, has undertaken a re-design of the CHF in the 7 districts of Dodoma Region. The “CHF Iliyoboreshwa” (improved CHF) displays a purchaser-provider split, a strong Insurance Management Information System (IMIS), active enrolment at village level, portability of membership, and cross-district reimbursement. After one year of operation (August 2013), the “new CHF” has enrolled 408,000 persons, equivalent to 20% of the population, which is well above the national average of 7.9% of the previous CHF system.
What challenges does your project address and why is it of importance? Community Health Funds (CHF) in Tanzania aims at building a risk pooling mechanism for rural populations and informal sector communities. Implementing the “Health Promotion and System Strengthening” (HPSS) project, the Swiss Tropical and Public Health Institute (Swiss TPH) and their partner organisation Micro Insurance Academy (MIA) carried out an analysis which revealed structural problems with respect to design, enrolment, servicing, and sustainability. On request of the Ministry of Health and Social Welfare (MoHSW) the Swiss Agency for Development and Cooperation (SDC) supports the development of structural changes for CHF within the HPSS project.
CHF design problems arise from the a lack of separation between purchaser and provider roles, the CHF being operated by the District Medical Office. CHF coordinators work part-time, and benefit packages are inappropriate. The lack of a data management system results in data being not readily available for monitoring purposes, re-enrolment, or claiming of “matching funds”. Passive enrolment at health facilities is a weak enrolment mechanism. Problems of servicing include the missing linkage between provision of health care and reimbursement. Funds are spent at a district level regardless of the services provided by health facilities.
How have you addressed these challenges? Do you see a solution? The HPSS project has systematically addressed the problems identified by developing a re-organised Community Health Fund, the “CHF Iliyoboreshwa” (“Improved CHF). This model is being implemented in the 7 district and municipal councils of Dodoma Region since 2012.
The core of the re-design is the new Insurance Management Information System (IMIS) which provides the Community Health Funds with a comprehensive solution for data management, including membership enrolment through mobile phone technology, contribution management, claims processing and payment, as well as member feedback collection.
The IT system allows online and offline operation. Each family member is now getting their own CHF card, when it used to be one card per family, and this individual card allows easier access to health services. One of the major problems up to now has been the limitation of access to only one health facility in the home place of members. With the new system this limitation is overcome. The new CHF card can be used in any public health facility across the districts of Dodoma Region, including hospitals. Each health facility attached to the CHF network received a smart phone which is readily available in Tanzania and is able to connect to the data base to instantly download member photos from the IT system for easy identification of the member.
The same mobile phones are also used to enrol people into the CHF by taking their photo and uploading them to the IMIS database. This also works in rural areas with limited internet access through backup provisions for offline data management. Enrolment Officers are now placed at the community level to enrol members in a quick and easy procedure using the CHF phone. The new system also allows health facilities a fast and simple processing of the claims they submit after treating CHF patients. This is expected to strengthen the financial capacities of the health services. The new CHF system, once further tested and proven to be effective in Dodoma Region, is designed in a way that it can easily be rolled out nationwide, with the central server already being in place. The investment into developing the CHF Iliyoboreshwa is therefore hoped to benefit not only Dodoma Region, but the whole population of Tanzania.
How do you know whether you have made a difference? The re-organized CHF is a scheme operated fully by the Local Government Authorities themselves. The CHF offices are in place, and all cadres involved in the system have been trained. More than 600 Enrolment Officers have been identified by the communities and are enrolling CHF members against a moderate commission.
At the end of August 2013, after barely one year of operation, the “CHF Iliyoboreshwa” (together with remaining “old members” of the previous system”) had enrolled 68,027 households out of 347,265 households in Dodoma Region. Approximately 400,000 persons are now covered with health insurance, out of a population of 2,000,000. After not even a year of operation, the new health insurance system already reaches a coverage of approximately 20%, far above the national average of 7.9% with the “previous” CHF system, with some districts standing out with as much as 33%. This is a remarkable success already, and enrolment figures are still increasing.
Further, the members of the re-organized CHF now have access to each of the 250 health facilities being presently associated to the CHF network. Access to hospital level health care has become possible for the CHF members, even outside their home district. Cross-district reimbursement of claims directly to health facilities has been introduced, and for the first time health facilities start seeing tangible benefits for treating CHF members.
Have you or the project mobilized others and if so, who, why and how? The development of the reformed CHF “CHF Iliyoboreshwa” has been undertaken in close coordination and cooperation with the Government of Tanzania both at national as well as at regional and district / municipal level, and important stakeholders have been involved. The development of the “Insurance Management Information System” (IMIS), for instance, has been accompanied by a technical advisory group composed of the MoHSW, the Prime Minister's Office, Regional Administration and Local Government (PMO-RALG), and the National Health Insurance Fund (NHIF). The project activities are governed by a Regional Advisory Board chaired by the Regional Administrative Secretary (RAS), with the highest level representation of the district and municipal councils. The reforms are very actively pursued by the district and municipal councils responsible for the CHF structures, while the HPSS project limits itself to the provision of technical advice and expertise.
When your donor funding runs out how will your idea continue to live? The health insurance structures developed with support of the HPSS project are fully integrated in the structures of the Local Government Authorities. A “CHF Board” answerable to the district / municipal council oversees the operations of the CHF Iliyoboreshwa. The CHF office is staffed by personnel fully paid by the district / municipal council. The central CHF server will shortly be transferred to the premises of the Prime Minister's Office, Regional Administration and Local Government (PMO-RALG), who will take charge of operating the IT system on behalf of the district / municipal councils, as they do with other software (e.g. accounting software EPICOR). The central server is technically fully prepared to add on any further district and municipality in Tanzania depending on the decisions of the government. A decision on possible roll-out of the CHF Iliyoboreshwa is presently being discussed in the Ministry of Health and Social Welfare and in the “Interministerial Steering Committee” for the preparation of the new health financing strategy.

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