1. Creating access to quality care through an integrated community insurance, quality improvement and recognition Risha P, Marwa H, Yokoyana J, Ngirwamungu E, van den Hombergh J, Spieker N.

2. Supply/Demand Challenges to improving quality of services in resource constrained countries Demand side  Out-of-pocket expenses  Access to health care  Ownership/ empowerment to choose  Solidarity Supply side  Quality  Capability of clients to pay for services  Cost/ efficiency  Risk/ investment  Data  Standards for benchmarking

3. DeliveryDelivery Linking Financing to Quality Improvement FinancingFinancingDemandDemand Health insurance Ownership/ empowerment Solidarity SupplySupply Improve infrastructure Processes and Systems Cost/ efficiency Risk/ investment data planning and prioritizing Improve infrastructure Processes and Systems Cost/ efficiency Risk/ investment data planning and prioritizing PatientPatient Consumer satisfaction Willingness to pre-pay Higher Donor/governments (tax) Prepayment by users Prepayment by users Facility /Provider Quality standards & improvement solutions for resource restricted settings in combination with targeted financing create an opportunity to enter a virtuous cycle

4. Health Insurance Fund (HIF) - KNCU Health Plan  Dutch Government Funded Program implemented by PharmAccess to improve access to quality healthcare for low & middle income communities particularly the informal sector through risk pooling and health insurance  Focus countries are: Kenya, Nigeria, Tanzania with TA for Mozambique, Namibia  The core principle of HIF program is to work with organized community groups such as farmers, SACCOS  Since 2011, HIF has collaborated with KNCU, to establish the KNCU health plan, which aims at improving access to quality health care for coffee peasants in Kilimanjaro region

5. HIF-KNCU Health Plan: Implementation HIF provides TA to KNCU to establish its health insurance scheme through  Actuarial analysis to establish insurance package and premium  Marketing to enroll members and their households into insurance groups  Selection of medical providers  Provision of subsidy to members in a decreasing fashion over time  Support in the administration of the Health Plan HIF Works with the health facilities providers to improve quality through improving structure/assets and also processes and systems  Medical due diligence to identify key structural/asset quality gaps and financial support to address them  Organize mentoring visits by medical specialists to HCWs at the HF  In collaboration with SafeCare provide technical assistance to the facilities to improve quality of service in a stepwise manner with international accreditation as the goal

6. SafeCare Background and Principles SafeCare: Is a joint initiative between COHSASA, JCI and PharmAccess that was launched in 2011 with the objective of: improving quality of healthcare in resource constrained countries in a stepwise manner based on international standards

7. SafeCare Principles  Realistic standards for healthcare providers in resource restricted settings, that are recognized for Accreditation and are ISQua approved  A step-wise improvement process that guides facilities towards accreditation and allows for benchmarking.  Build the capacity within existing (national) programs to implement and measure healthcare quality improvement  Recognize achievements based on Patient Safety and Effectiveness of Care through formal certification

8. SafeCare Implementation strategy Graded recognition SafeCare standards + tools Accreditation COHSASA/JCI External evaluation Full standards compliance Local facilitation Certificate awarded Facilitation of QI is done by technical assistance partners (e.g. K- MEMS, APHFTA) Evaluation of QI is done by SafeCare 0 months 12 months

9. Identifying quality gaps: SafeCare assessment

11. Linking financing to QI: Accomplishments since 2011  More than 7000 lives enrolled with average monthly visit of 271: visits increased from 10 -50% in HF provides service for KNCU HP clients  Medical due diligence carried out to 20 HF, 12 of them Joining the HIF- SafeCare program  Refurbishments, equipments, medical supplies to the tune of 2 billion Tsh

12. Accomplishments since 2011 (ii) 11 trainings on medical and management for year 2012, average attendance of 21 HCW Quarterly visit by Medical specialist (physician & Pediatricians) to primary Health Facilities

13. Accomplishment: SafeCare 10 certified SafeCare surveyors Tanzania trained using ISQUa accredited curriculum 12 health facilities under KNCU health plan enrolled into SafeCare, all have undergone baseline assessment. 8 Facilities under the Plan have undergone external assessment with 1 facility scoring upper level 3, 4 facilities level 2 and 4 at level 1 Improvement plans in place addressing critical safety and effectiveness of care

14. Lessons learnt and next steps Linking financing to QI has shown to be a powerful driver to move QI towards accreditation.  Comparable results have been observed for private health facilities by MCF/APHFTA using a similar approach  Empowers clients to pay for quality services and make informed choice  Creates a system for objective benchmarking of services Next steps:  Expand the program to all 92 KNCU primary societies;  Link the facilities to affordable bank loans through our other program the Medical Credit Fund  Work with other stakeholders: MOHSW, APHFTA, NSSF, Marie Stopes, adopting similar approaches in implementation

15. 15 Thank you