Transcript COMMUNITY HEALTH FUND (INSURANCE) IN TANZNIA

COMMUNITY HEALTH FUND
(INSURANCE) IN TANZANIA
OUR EXPERIENCE IN THE LAST 12 YEARS
Dr Faustine Njau
Tanzania
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CONTENT
• BACKGROUND INFORMATION
• EXPERIENCE OF THE SCHEME
– OBJECTIVES
– DESIGN FEATURES AND CHRONOLOGY
1999-2007
– STATUS
– SUCCESS STORIES
– CONSTRAINTS
– OPPORTUNITIES
• THREATS
• NEXT STEPS
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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
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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
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SERVICE DELIVERY.
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.
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COMMUNITY HEALTH FINANCING
THE TANZANIA EXPERIENCE
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
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heard in the health service as financiers as well
THE DESIGN OF COMMUNITY HEALTH
FINANCING SCHEME IN TANZANIA
• Designed to fit into prepayment for health care in a
form of cost-sharing and not 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.
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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.8
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)
(b)
(c)
(d)
Concept and Objective of CHF
Establishment CHF in a LGA – Mechanics.
Training Manual
Planning Guide on use of Health funds.
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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
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run facilities.
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)
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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,
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conclusion of service agreements.
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
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political will.
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.
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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 .
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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
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uncertainties.
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.
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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 %
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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
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health financing
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
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to their settings
THANK YOU FOR
ATTENTION
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