1. Knowledge sharing workshop on social protection for vulnerable Groups ILO STEP/SFP Programmes October 15 th,16 th &17 th 2007 Bangkok, Thailand By Ansgar Mushi ILO. Dar-Es-Salaam & Sr. Rita Toutant TNCHF Dar-Es-Salaam

2. General overview Tanzania has a population of about 36.5 million people. The population working in formal employment is roughly one million, out of which 950,000 persons are covered by formal social security schemes. This is about 5% per cent of the active labour force of 17.5 million people. There are seven major formal institutions providing social security in Tanzania. Only 2 of them offering health benefits. Most of employees are covered under employers arrangements

3. Description of Social security system of Tanzania Labour Force Population distribution in social security system of Tanzania (approximately 16 Millions) Peasantry Agriculture employees and other Informal Sector employees account for about 93.3% Public sector and other formal sector employees account of about 6.5% of the total employees Public mandatory social security/ protection arrangements (Institutions are NSSF, PPF, ZSSF, LAPF, PSPF, GEPF, GPS (Treasury department), NHIF and Employment contract incentives) FORMAL SECTOR 6.4% of total labour force in the country INFORMAL SECTOR 93.5% of the total labour force in the country Private schemes which are not community based. The coverage is insignificant

4. Social Security system focuses on Long-term benefits Pensions Survivors Death and related costs No Unemployment and other short term benefits Health and Maternity benefits are covered by employers largely linked with employment contracts.

5. Health Financing Mechanisms National Health Insurance Fund – covering about 200,000 members, National Social Security Fund (NSSF) covering about 361,000 members Community Health Funds in different districts (about 68 districts out of 210 are now operating the scheme with an average of 4% of the district population covered) Community Based Health Funds (CBHIF) the coverage is limited to small organized groups e.g. small traders, religious groups and health providers initiatives. (TNCHF represents this small groups) Employers agreements Cost Sharing and government waiver and exemption policy Out of pocket

6. Number of Health Facilities by Ownership and Status FacilityAgency Govt.ParastatalPrivate not for Profit /Relig ious PrivateTotal Hospitals878 37219 Health Centers3311010139481 Dispensaries30381457637334679 Total34561639578095379 Source: Annual Health Statistical Abstract, April 2006

7. Figure 2: Distribution of Health Facilities in Tanzania by Ownership Source: Annual Health Statistics Abstract, April 2006

8. Central question is effective access to essential life saving health services for all

9. Challenges facing the health system Poor quality of care Inadequate information to health consumers Poor access by the very poor to health care Skilled Staff to Health facilities available Distribution of health Care facilities Policy implementation Massive drainage of Health staff from the voluntary sector to government system (Rural Urban Problems)

10. Key obstacles to effective access by the very poor Real costs of treatment (formal, informal, additional charges) Time and distance, and unaffordable transport costs Refusal of treatment by health workers if people are unable to pay Inflexible modes of payment Poor governance and accountability mechanisms.

11. Coping Mechanisms …and further impoverishment Delayed and inadequate treatment, or none at all Sale of critical assets (their land, animals, crops, labour … ) Reduced food intake Take children out of school Child Labour Borrow money

12. Health Sector Reforms Introduced in the 90s in response to worsening situation Financial sustainability is a key component of the reforms

13. Health care financing reforms Health care financing reforms include:  Donor support through budget support  User fees  Community Health Fund  National Insurance Fund

14. Other health care financing initiatives Micro health insurance schemes for the informal sector Private/ individual arrangements Family & community-based support systems

15. Challenges facing CHF and CBHIF in promoting equity Low membership rates, despite low premiums – not sustainable Members often the better-off households Government subsidy not benefiting the poorest households Weak governance system – weakness in financial management, accountability and transparency Poor administrative procedures and planning at district level

16. Why low enrolment? Inability of poorest households to pay an annual premium Ineffective exemption system for those too poor to pay – exclusionary Lack of information to members and non- members on benefits of CHF Better off households not convinced of need to insure themselves Quality of care – variable – mixed reports

17. Efforts to Increase enrolment TNCHF support to small schemes and some pilot CHF funds with support of GTZ and CIDR mainly in three regions in Tanzania Government through ministry of Health is advocating through media and local government institutions

18. Key question’s - CHF Can exemptions work? Who are the poorest of the poor?  Tanzania Network of Community Health Funds – invites development partners, private sector, NGOs, and individuals to contribute towards purchasing CHF cards for the poor – Can this work?

19. Thank You