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Social Health Insurance in Tanzania

An overview

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Table 1: Tanzania Administrative and Health System

Administrative level Public Health Facility Ownership of Facility

Public Voluntary Private

Level No. Facility type Number Number Number

Zone 6 Tertiary hospitals 4 - -

Region 21 Secondary hospitals 1 in each region

17 - -

District 121 Primary hospital 1 in each district

85 81 42

Division 372 Health centre 292 69 41

Ward 2000 Dispensary 2683 598 1099

Village 11000 Village health post 4000 - -

*Source: Ministry of Health; Health Statistics Abstract 2002

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Health Financing Options in TzThese 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 NHIF…continued

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 Government’s 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 employersRelief to the membersContribution 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