COMMUNITY HEALTH FUND (INSURANCE) IN TANZANIA

1. COMMUNITY HEALTH FUND (INSURANCE) IN TANZANIA OUR EXPERIENCE IN THE LAST 12 YEARS Dr Faustine Njau Tanzania

2. CONTENT • BACKGROUND INFORMATION • EXPERIENCE OF THE SCHEME • OBJECTIVES • DESIGN FEATURES AND CHRONOLOGY 1999-2007 • STATUS • SUCCESS STORIES • CONSTRAINTS • OPPORTUNITIES • THREATS • NEXT STEPS

3. BACK GROUND INFO… • UNIVERSAL ACCESS IS CONTINGENT UPON UNIVERSAL AVAILABILITY OF THE BASIC HEALTH SERVICES • AVAILABILITY IS ALSO SUBJECT TO ADEQUATE FINANCING & HUMAN RESOUCE FOR HEALTH AND MANAGEMENT • THE CHALLENGES IN THE AFRICA REGION ON THIS SUBJECT IS “CHRONIC AND SEVERE” UNDER FINANCING OF HEALTH CARE

4. BACK GROUND INFO…2 • FROM COMMUNITY INVOLVEMENT AND PARTICIPATION TO COMMUNITY OWNERSHIPS, AND SHARE HOLDERS IN PRIMARY HEALTH SERVICES:- OWNERS/SHARE HOLDERS: • TAKE RESPONSIBILITY INCLUDING FINANCING. • OVER SEE THE MANAGEMENT OF ASSETS AND SERVICE DELIVERY. • THEY HAVE THE VOICE AND SAY TO THE DIRECTION OF THE QUANTITY AND QUALITY OF SERVICE DELIVERY.

5. BACK GROUND INFO…3 • ONE OF THE FUNDAMENTAL STRATEGY IS OWNERSHIP/SHARE HOLDING BY THE COMMUNITY : • Through complimentary financing of the Health Services • Boards and committees that have a voice and say, how the services are to be provided and managed.

6. COMMUNITY HEALTH FINANCINGTHE TANZANIAEXPERIENCE OBJECTIVES OF CHF SCHEME:- • To address the financing gap of the basic health care due to severe budget deficit. This is in the context of HIPC. • To compliment health care financing in Tanzania in a form of Cost-Sharing (between the community and the government) • To strengthen the ongoing health reforms. • To enhance Fiscal decentralization and ownership of the PHC – Services by the community. • To recognize community voice and mandate to be heard in the health service as financiers as well

7. THE DESIGN OF COMMUNITY HEALTH FINANCING SCHEME IN TANZANIA • Designed to fit into prepayment for health care in a form of cost-sharing andnot cost recovery • It is the same spirit of Bamako Initiatives. • Making Communities share holders/owners of PHC Facilities, and not charitable goods • From the notion of government facilities to that of community owned facilities. • It is community right to health, right to speak, right to ask for results and right to correct mismanagement of the facilities. This is community empowerment. • In line with the principle of Decentralization by Devolution beyond the District (LGAs) Headquarters.

8. PRACTICAL EXPERIENCE TO DATE • 1995 Design of the CHF Scheme • Some partners were lookers, could not believe the design will work (Concepts and Contextual differences). • 1996 -Pre-testing the design in one District (LGA) Igunga for 3 years. It worked. • Piloting 4 more districts and later 5 more. • 2001 – Total 10 districts (LGAs under the pilot) • Adjustment of the design from experience gained. • Payment methods in cash, payment in kind, payment through co-operatives members accepted etc. and is determined by community committees (each LGA, different amount depends on their ability and willingness to pay) • It is a voluntary scheme) • Need to standardize payment seen but not yet implemented.

9. EXPERIENCE TO DATE…2 • 2001 - Bill passed to establish CHF in all LGAs. • The bill require LGAs to make bylaws for establishing the fund. • There should be a Health Board at each LGA to over see amongst others Health Development issues and the running of CHF in the District. • Guidelines for CHF written and printed, available:- (a) Concept and Objective of CHF (b) Establishment CHF in a LGA – Mechanics. (c) Training Manual (d) Planning Guide on use of Health funds.

10. EXPERIENCE TO DATE…3 • STATUS: • Target 98 LGAs eligible for CHF establishment by 2004but:- • 74 LGAs have established CHF - by 2007 • All 98 Have established CHSB and committees to manage CHF 2007. • This scheme is good for Rural House Holds (setting) not good for Urban setting. • A design for Urban is on pretest in 4 urban areas from 2004. Instead of a HHs – contribution, in urban areas we need each individual to contribute and have own Health/Card to access basic health care from public run facilities.

11. EXPERIENCE TO DATE…4 SUCCESS: In all LGAs implementing CHF:- • Essential drugs are available and hence, ↑↑services available. • Accessible more than previous – base on availability of supplies • Community ownerships is felt • 10 – 30% House Holds have memberships card in 74 LGAs. • 50% of patients are exempted (Nov. 2005 in some districts). • Exemptions and Waivers are working (March 2005) • Providers responsiveness to community demands. • Higher level of accountability (see External evaluation report for health sector in TZ 1999-2006)

12. EXPERIENCE TO DATE…3 SUCCESS: • Efficiency & Effectiveness has increased (supplies, equipment rehabilitation of facilities etc). • Quality of services improved • Management improved. • In All District Health Plans, there is activity to support CHF advocacy, and a code to pay for the poor households. • At the central level the MoHSW has introduce code to pay for waivers and exemptions pending, conclusion of service agreements.

13. EXPERIENCE TO DATE…3 CONSTRAINTS:- • The health sector is severely under funded, this gap feeling measure is not enough to deliver the basic package as yet. • Demand services at Referral levels to be paid from the CHF including Amenities (Boarding, food and transport during referral). • Management problems – human resources is a problem and more so even in the LGAs. • Weak advocacy at all levels, though very high political will.

14. Opportunities available OPPORTUNITIES : • The context is correct, people want to participate and not be treated as objects of charity (the poor have equal rights to participate in development) . • CHF is voluntary – hence demand driven – people want the government to roll over quickly more than we were prepared. • Partners are now ready to support the CHF Programme, GTZ, World Bank, SWISS, DANIDA, USAID, ECSA, Pharma access, France. • Exemptions and Waivers should be a honorable duty of Community Leadership and not the central govt. • Providers should be responsible for service provision not exemptions or waivers.

15. Opportunities Available…2 • Through the Boards and Committees, peoples voice start shaping providers behaviors. • Private participation, an opportunity to get service contracts LGAs, level and gets paid. • Quality improvement. • Window of enhancing accountability. • Fiscal decentralization – government contributions transferred directly to CHF accounts to be managed at local level beyond the district. • More transparent waivers and exemptions now in community committees and out of the government Technocrats and bureaucracy .

16. Opportunities available…3 • Stronger and better managed districts (LGAs) are providing technical support to other LGAs. • ECSA – Health Community Agenda for – TA. • It is a Global agenda for Health financing and Social Protection. • Improve management at all levels and incentives to providers and managers of health facilities. • Introduce budget item for waivers and exemptions at LGA levels as has been done at MOHSW • Round up (average cost) for care to be paid at one stop station at the H/Facility – This enhances cross – subsidization, removes confusion and uncertainties.

17. THREATS:1 • The wrong assumption that those who are poor are also sick. This is not the case at all !! • The assumption that “ABOLISH USER FEES” by the poor nations from all social services will increase access and equity !! (equity and access are a function of AVAILABILITY) • Poverty Reduction strategies - Some believe Health Care should be freely provided by the poor governments, regardless of past failures.

18. THREATS:2 • Continued stigmatizing the poor as objects of charity • Assumption that poverty is a permanent state (which is not ) • Increasing costs of health care and HIV/AIDS epidemic. It confounding to any health care initiatives, including community health funding NO MUCH FREEDOM TO MAKE OWN CHOICES:- • Donor Dependency – Government budgets in Tanzania 35-42%. • The sector is financed on budget with 10 USD, (2007/08) of which internal government funding is 65-58 %

19. THE NEXT STEPS • Scale up CHF country wide to all 132 LGAs, • Establish umbrella association of CHFs to allow cross subsidization and portability of the cards across Tanzania • Solicit international partnerships in financing the mgt and monitoring CHF including revenue targeting • The vision is that of social health insurance in intermediate adopt a mixed strategy for health financing • Operational Research and studies to improve the schemes • Link the CHF and the NHIF to synergize each other. • Advocate ALAT to take a proactive roll in community health financing

20. NEXT STEPS …2 • Request international support including that of WHO • CHF is a home grown scheme and is localized. No prescriptions from outside but we need people who can listen and support our scheme instead of imposing theirs on it. • We welcome other countries in the region to study our scheme and see how it is adaptable to their settings

21. THANK YOU FOR ATTENTION