3Table 1: Tanzania Administrative and Health System Administrative levelPublic Health FacilityOwnership of FacilityPublicVoluntaryPrivateLevelNo.Facility typeNumberZone6Tertiary hospitals4-Region21Secondary hospitals 1 in each region17District121Primary hospital 1 in each district858142Division372Health centre2926941Ward2000Dispensary26835981099Village11000Village health post4000*Source: Ministry of Health; Health Statistics Abstract 2002
8Health Financing Options in Tz These 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 GovernmentsBasket FundingNGOsPrivate FinancingCommunity Financing*Donor Funding
9National 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.
10Description 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 dependantsIt is a compulsory scheme for public servants
11Structure 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 employeesIdentification 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
12Structure of the NHIF …continued Areas of exemptions of coverage:all public funded programsillegally/socially disapproved actsAccreditation of Health Facilities:Hosp, H/C, Dispensaries and pharmacies/ ADDOsProvider 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
13Successes recorded by the NHIF Assurance of access to health services at all timesContribution to the Health Sector Development as a component in Health financingAttitude changes:From free services to contributionsFrom cash payments to use of CardsFrom laisser-faire to ownership by MembersUse of Cards have reduced bribery tendenciesSustainable system outside the Government general taxation systemBrings services closer to members (Zones)Its setting has been model to most interested countries
14Problems encountered by the NHIF General perception at early days (mainly negative)Some stakeholders are yet to fulfill their rolesDrug shortagesAbsence of infrastructures eg part 1 pharmacies in most parts of the countriesEmergence of fraudulent tendenciesProblems related to the health system and infrastructure itself have negative impacts on the funds’ operations
15Challenges of the NHIF Limited scope of coverage Operates in un-regulated environmentLow awareness by the public on how these different schemes operatesPreference on cash payments vs cardAbsence of set basic package (by MoHSW)Non adherence by some health service providers on the standards set by MoH and the NHIFFraud
16NSSF-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.
17SHIB- The Benefit Package Aimed at providing most of general healthcare services for beneficiariesOut-Patient ServicesConsultationsBasic & Specialized investigationsDrugs under the National Essential Drug ListSimple procedures (e.g. wound dressing)Referral to higher levels & special hospitals
18SHIB- The Benefit Package In-Patient ServicesAccommodationConsultation with a Medical Officer or specialistBasic investigations(e.g. blood slide for mps, stool, etc)Specialized investigationsDrugs under the National Essential Drug ListMinor and Major OperationsBlood transfusionSpecialized proceduresMedicines on dischargeReferral to higher level & specialized hospitals
19SHIB- ExclusionsDiseases 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 abortionLuxurious like Cosmetic treatments with no medical indications e.g. plastic surgery
20SHIB-LimitationsEmergency cases – for principal beneficiaries traveling away:-Outpatient - not more than 4 times/yearInpatient (48 hours) - not more than 2 times/yearHospitalisation – a maximum of 42 days of inpatient care per beneficiary per year
21SHIB-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; andpensioners 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
22SHIB-Method of Payment Payment of providers is by Capitation methodReasons for CapitationEasy to administer;Builds a self-monitoring system and accountability among the Stakeholderslinks members to a specific provider who is responsible for providing healthcare and record-keeping;provides a predictable cash flow.
23Advantages of SHIB Relief to the employers Relief to the members Contribution to the Government towards better healthcare services in the country, to become the 2nd largest healthcare provider after the Government
24Community Health Funds …Background It is part of the health financing reforms that begun in 1990.Health care financing study undertaken between recommended introduction of cost sharing and National Health Insurance.Community Health Fund was conceived later to mitigate the shortfall of National Health Insurance coverage.
25Community Health Funds …Background A decentralised voluntary health Insurance scheme operating at district levelA 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.
26Community 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.
27Community 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
28Community Health Funds (CHF) Why community financing?Improves efficiency and equityAllows sharing of risk (community-rating)Allows collection of resourcesFacilitates community participation (contribution to the general welfare of the community)
29Impact of community-based schemes Increase accessGenerate resourcesImprove equityImproved Access for members of SchemesIncreased utilization of the members as compared to non-membersReduced out-of-pocket payment for members as compared to non-members
30Micro-health Insurance Schemes (MHIS) Are voluntary schemes set up and run by co-operatives, churches or local communitiesThey provide access to basic health care services at a single provider taken under contractCater for small sections of the populationAre managed locally
31MHIS (2) Most are registered under societies Act, and Trustees Deed. Covers the informal sector or groups of common interestBenefit package and contributions are set and agreed by the respective membersUMASIDA and VIBINDO - successful cases of Mutual Health InsuranceStarted in 1994, contribution Tsh 1,500/= to Tsh 3000/= per month (operates in Dar es salaam, Kilimanjaro and Arusha)
32MHIS (3)The number of MHI are on increase from Churches and charitable organisationsBased on Mutual and common interest, Most of these schemes covers the poor in the informal sectorMHIS are subject to many organisational and managerial weaknesses due to their self-managing character (limited skills and capacities of those running the schemes).
33NGOs These subsidizes specific health programmes Usually operate at local levelsHave their own sources of fundsUsually have preference in the types of programmes or the health services they offer or conduct.
34Private FinancingComprise of Direct individual (out-of pocket) payments as well as private health insurance schemesTo-date Tanzanian households provide the greatest proportion of health care financingOut-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
35Private Health Insurance Private health Insurance schemes are relatively recent modes of health care financing in TzThese 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 riskPremiums are calculated according to the anticipated risk e.g. age, sex, risk exposure-medical family history, medical individual history etcIn Tz PHI schemes mostly operate in urban areas and with private health providers.
36Community FinancingThese are informal contributions for the purpose of healthAre solidarity funds and/or special arrangements made for health e.g. with individual companies, collections etc
37Donor Funding Are funds donated in kindness Are usually for specifically designed health projects/programmesHave a variety of contributions I.e both monetary and technical assistanceProvides about the same proportion of funds for health as the GoTRecent 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
38Basket FundingHealth sector partners pool their funds contributed for healthFunds come from several stakeholders in health i.e the Government, Local Government, NGOs and other development partners