1. Community Health Funds in Tanzania: a review of experience Gemini Mtei Jo Mulligan Ifakara Health Research & Development Centre Presentation to the CHF Best Practices Workshop 31 st January – 2 February 2007 Golden Tulip Hotel Dar es Salaam

2. Outline  Background  Concept of the CHF  CHF in Tanzania  Findings  Possible way forward

3. Background  IHRDC asked to conduct a desk review of CHF experience in Tanzania.  Aim to: provide a general overview of existing CHF relevant projects and initiatives in Tanzania; provide a general overview of existing CHF relevant projects and initiatives in Tanzania; summarise main issues raised; summarise main issues raised; create a base of information that will contribute to enhancing a common understanding of CHF challenges among the different stakeholders create a base of information that will contribute to enhancing a common understanding of CHF challenges among the different stakeholders  Methods comprised literature review and hand searching of documents and files held by CHF stakeholders.

4. The Concept of CHF Definition: Community health financing- households finance health care costs and being involved in the mgt and organization of the financing scheme & health services (Carrin 2003) Definition: Community health financing- households finance health care costs and being involved in the mgt and organization of the financing scheme & health services (Carrin 2003) Community - population in village, district or geographical area, social economic group or ethnic groupCommunity - population in village, district or geographical area, social economic group or ethnic group CBHF - a result of problems with Tax financing and SHI CBHF - a result of problems with Tax financing and SHI Tax financing - small Tax base, big informal sector, dependence on donors, and dependence on International trade Tax financing - small Tax base, big informal sector, dependence on donors, and dependence on International trade SHI- national consensus, income inequalities, managerial problems, poor infrastructure (roads, banks, telecommunication) to facilitate collections, re-imbursements and monitoring SHI- national consensus, income inequalities, managerial problems, poor infrastructure (roads, banks, telecommunication) to facilitate collections, re-imbursements and monitoring

5. CHF in Tanzania  Started in 1996 with pilot study in Igunga District Act enacted in 2001 – CHF Act, 2001Act enacted in 2001 – CHF Act, 2001  Designed to cover the informal sector esp. in rural areas  Voluntary Membership – household membership Same Contribution for each member householdSame Contribution for each member household  TIKKA in Urban and Peri-Urban settings (Town, Municipals, Cities)

6. Objectives of CHF  According to CHF Act of 2001, objectives are; (i) to mobilize financial resources from the community (ii) provide quality and affordable health care services through sustainable financial mechanism (iii) improve health care services management in the communities

7. FINDINGS

8. This review examined the following issues; Coverage and Enrolment Coverage and Enrolment Pro – Poor Approaches (Equity issues) Pro – Poor Approaches (Equity issues) CHF management and accountability CHF management and accountability Provision and Use of Services Provision and Use of Services

9. CHF Coverage  69 Councils have launched CHF  Other councils have delayed launching due to lack of commitment by some regional and district officials; lack of commitment by some regional and district officials; inadequate follow-up from the MOH;inadequate follow-up from the MOH; lack of capital for initiation of the scheme; lack of capital for initiation of the scheme; lack of uniformity on premiums,lack of uniformity on premiums, unclear referral mechanisms, etc (MOH 2003a) unclear referral mechanisms, etc (MOH 2003a)

10. Enrolment  Enrolment has non-uniform pattern. Example: Iramba (Mwendo,2001), Rungwe (Sheuya, 2006) have an encouraging enrolment, Example: Iramba (Mwendo,2001), Rungwe (Sheuya, 2006) have an encouraging enrolment, while in Hanang (Musau,2004), Igunga and Singida rural (Shaw, 2002) enrolment has droped Hanang from 23% in 1999 to 2.2% in 2004  Reasons include, -low user fees, -high membership fee, -low income, -introduction of NHIF, -perceived poor quality of public facilities, -limited coverage to referrals, -poor health staffs’ attitudes, -broad exemption policy, etc {Shaw (2002), Mhina (2005), MOHSW (2006), Msuya (2004), Mwendo (2001), MOH (2003b)} {Shaw (2002), Mhina (2005), MOHSW (2006), Msuya (2004), Mwendo (2001), MOH (2003b)}

11. Tanzania National Policies  NHP Vision “to improve health and well being of all Tanzanians with a focus on those most at risk and encourage the health system to be more responsive to the needs of the people”  NSGRP emphasizes on ‘equity in the delivery of health and social services so as to improve access for children, women, the poor and other vulnerable groups especially in rural areas’ Pro-Poor Approaches

12. How does CHF helps the poor?  CHF type schemes extend coverage to a large number of rural and low income populations that would otherwise be excluded (Preker, et al. 2002) and protect members by reducing the level of out of pocket payments (Ekman 2004)  Being a CHF member -improve access to formal health care providers and reduce the use of alternatives as self medication and traditional healers for the poor - reduces the risk of trading-off assets with health care seeking {Msuya et al. (2004)}

13. A:Exemption and Waivers Applies for those unable to pay the contribution fee... District councils are expected to fully subsidize the CHF membership fees for those who have been exempted or waived...  Challenges source of funding, source of funding, identifying the poor, identifying the poor, general/blanket exemption, general/blanket exemption, Ensuring the awareness of existence of the policy Ensuring the awareness of existence of the policy  To overcome such challenges, some Councils (eg. Mwanga, Muheza) have managed to identify the poor Criteria include,Criteria include, elders and widows with no one to take care off, elders and widows with no one to take care off, physically/mentally handicapped,physically/mentally handicapped, orphans, orphans, those with poor houses, etcthose with poor houses, etc CHF Pro-Poor Mechanisms

14.  B:Cross subsidisation CHF is cross subsidizing between the households CHF is cross subsidizing between the households Rich Poor and health ill Need to find a way of having a mixture of membership Need to find a way of having a mixture of membership i.e. not only the poor /ill joining the scheme Pro-Poor Mechanisms cont..

15.  District council is the core of CHF activities.  District councils responsible for sensitization activities  Community members involved through their representatives in the Council Health Services Board Management & Accountability

16. Observations:  In some councils, members are not aware of the performance/operation of their schemes (Chee, et al 2002, MOH 2003b)  The CHSB and WHC members are not binded to be members of CHF Risk of non-representation of CHF members  Mis-management of funds in some councils no frequent auditing is conducted  others do not use the collected contributions  Management of funds is left to facility workers Management & Accountability Cont..

17. Provision and Use of Services  Some review/studies have shown improvement in provision and access Example: Purchase of microscope, drugs, etc (Shaw 2002) improvement in access to care for CHF members (Msuya, 2004, Musau 2004)  CHF covers primary care only (i.e. dispensary and health centers) exclude referral care  BUT some councils (eg. Hanang, Igunga, Mwanga, Rombo) have hospital level as part of benefit package

18.  Limitation in switching between providers if not after one year  Care is limited to facilities within members’ council  Limited private providers in rural areas not all NGOs/mission facilities are willingly to be accredited  Limited human resources Provision & Use Cont…

19. POSSIBLE IDEAS

20. On Enrolment Identifying contributing population and means of collecting the funds Identifying contributing population and means of collecting the funds Members involvement from the beginning. Willingness to pay studies might provide important insights of the community involved Members involvement from the beginning. Willingness to pay studies might provide important insights of the community involved Help in setting contributions and deciding on benefit package Help in setting contributions and deciding on benefit package More sensitization is required to make members aware (this is core) More sensitization is required to make members aware (this is core) Encourage group membership -as the case of Rungwe (sheuya, 2006)Encourage group membership -as the case of Rungwe (sheuya, 2006) Make use of the existing community group arrangement if anyMake use of the existing community group arrangement if any

21. On Management & Accountability Improve MOHSW role in management of CHF Improve MOHSW role in management of CHF Follow up on reports and arrange field supervisions Follow up on reports and arrange field supervisions Strengthen the CHF supervision section of the MOHSW and if possible open zonal offices Strengthen the CHF supervision section of the MOHSW and if possible open zonal offices Insist on Ward committees to report to the community members (through village meetings, etc) Insist on Ward committees to report to the community members (through village meetings, etc)

22. On Reaching the Poor Need to set guidelines of identifying the poor through experience of successful councils (eg Muheza) Need to set guidelines of identifying the poor through experience of successful councils (eg Muheza) Use the opportunity of Donors to fund the gaps in financing of poor (i.e pro-poor funding) Use the opportunity of Donors to fund the gaps in financing of poor (i.e pro-poor funding) Example:GTZ has been involved in Muheza and Rungwe. Others could follow the same Religious institutions could also be encouraged to fund the poor Religious institutions could also be encouraged to fund the poor Consider cross subsidizing the poor across councils Consider cross subsidizing the poor across councils (possibility of risk equalization fund?)

23. ISSUES FOR DISCUSSION

24.  Enrolment How to increase members and control drop-out? How to increase members and control drop-out? How to speed-up roll-out of the scheme? How to speed-up roll-out of the scheme?  Reaching the Poor How to improve Exemption/Waivers? How to improve Exemption/Waivers? How to identify the poor in the Communities (need for specified guideline?) How to identify the poor in the Communities (need for specified guideline?) Who should fund the gaps due Waivers/Exemptions? Who should fund the gaps due Waivers/Exemptions?  Management & Accountability How to ensure commitment of District Councils How to ensure commitment of District Councils What role should the MOHSW play What role should the MOHSW play How to assure representation of CHF members in CHSB and WHC? How to assure representation of CHF members in CHSB and WHC?  Provision and Use of Services How Possible it is to extend CHF coverage to referrals? How to motivate the private providers and religious facilities? Possibility of motivating rural health care staffs (although not CHF specific) Possibility of using facilities in neighbour councils  Sustainability of the Funds How to generate more funding? How to coupe with the fluctuations in rural individuals’ income?

25. THANK YOU FOR YOUR ATTENTION