Reorganized CHF - Dodoma region

Reorganized CHF - Dodoma, Morogoro and Shinyanga Regions

 

As the CHFs are conceptualized as a prepayment arrangement, they resemble many features of health insurance. Health Insurance schemes present many complex issues, so we used four subcategories to analyse the effectiveness of CHFs in the Dodoma region: Design, Enrolment, Servicing and Sustainability. (Design refers to product manufacturing; Enrolment refers to product sales in information provision and underwriting; Servicing refers to claims processing, and relationships with providers and policy holders; and Sustainability refers to the maintenance of long-term stability.) [suggested: For a detailed look at our analysis, see our Case study “Rethinking Community Health Funds” (link). Or consider linking to the article Transforming Community Health Funds in Tanzania into Viable Social Health Insurance Schemes: the Challenges Ahead in the Bulletin of Medicus Mundi Switzerland, no. 120, June 2011.]

 

The analysis identified significant opportunities to update the CHF design to better serve the population. The HPSS project has worked closely with the Dodoma Region and the district councils and administration to re-organize Community Health Funds (CHFs) and to develop a tailor-made IT system, the Insurance Management Information System (IMIS).


A broad range of activities have been undertaken so far in this process:

  • Development of the Insurance Management Information System (IMIS)
  • Development of the organisational set-up for the new CHF and the IMIS
  • Development of Business Processes for the new CHF
  • Development of the Communications Strategy
  • Trainings for the new CHF structure
  • Logistics and infrastructure support for the CHF


Based on the experiences from Dodoma, the same reformed approach to CHF is applied in Morogoro and Shinyanga as part of the second phase of the project.

 

Transformed CHFs


When started to think about how CHFs could be improved, it was important to hear what community members thought. In the focus group discussions, it was heard that the pre-payment design was appreciated. It allows people to pay for their health care costs when they have money and gives them peace of mind at other times in the year when funds are scarce. But community members also expressed some dissatisfaction with the current CHFs.
These findings were taken into account, and when combined with structural analysis, number of opportunities to improve CHFs were identified. The steps for transforming the CHFs speak to the four analysis areas of Design, Enrolment, Servicing and Sustainability:
 

Design Issues:

The most important step in this view was to establish professional CHF governance and administrative structures, which de-link the CHF management from health service providers. This would enable the CHF to focus on health insurance tasks, representing the interests of the insured members, and would enable the health care providers to concentrate on optimising the quality of care they provide. In order to arrive at such a re-organised CHF structure, the support of the NHIF was a key factor. For this purpose, NHIF needs a prolonged and specified mandate by the Government of Tanzania.
Other design issues addressed; concern the question of whether and how the benefit package may be enlarged and adjusted to better reflect the needs and priorities of the population. Concerning the funding of the benefit packages, apart from the premiums paid by the population, the question should to which extent contributions by the Central Government and the Local Government Authorities may be expected was discussed. Apart from question of social acceptability, cost considerations with actuarial pricing was included into determining premiums. Finally, building up a functioning Insurance Management Information System for routine analysis, member tracking, claims tracking, etc., is required in a professionalised organisational set-up.
 

Enrolment Issues:

For strengthening the enrolment mechanisms it is of paramount importance to safeguard the support of local government structures in a multi-sectoral approach, where village councils, ward development committees, and district / municipal councils all actively engage themselves. In a medium-term perspective exemptions from paying user fees should be replaced by issuing CHF cards to the poor, funded by the Local Government Authorities. In an effort to strengthen enrolment procedures, the employment of dedicated officers for enrolment and a redesign of enrolment and accessing regulations seem to be promising approaches. Obvious questions about  financial sustainability for financing such a structure should be analysed and addressed.
 

Servicing Issues:

In a medium term perspective, one needs to consider a shift of the mechanism through which health facilities are reimbursed by the CHF from the present wholesale transfer approach to an approach linking the payment of service providers to the quality and quantity of services provided. The procedures for fund flow to health facilities needs urgently to be improved, in order to improve the impact of CHF funds at health facility level. Such an enhancement of financial management mechanisms should go hand in hand with a strengthening of planning capacities at the HFGCs, and training on financial management for health facilities. Introducing individual ID cards and a portability of cards through a billing or allocation mechanism seem to be much needed reform steps to increase the value and convenience of CHFs for the policyholders.
 

Sustainability Issues:

Finally, the overarching concern has to be to reach a sustainable solution for the CHFs, both in terms of their organisational structure, and in terms of financial viability. These two aspects go hand in hand, as any sustainable organisational structure would require a sound basis of financing. Important steps in this direction seem to be the build-up of a professionally managed CHF structure, going along with the introduction of a trained cadre of insurance professionals. Reaching financial sustainability for such a structure requires a deeper analysis of the costs included on the one hand, and commitment of key players such as the Central Government (matching funds), Local Government Authorities (pro-poor funding of CHF cards for exempted population), and the NHIF (either through re-insurance or through a transition into an integrated “Single Payer” Mechanism in social health insurance).