who is covered by health insurance schemes and which...

WhoiscoveredbyhealthinsuranceschemesandwhichservicesareusedinTanzania? 1

SHIELD Policy Brief TANZANIA

BackgroundThisbriefarisesfromtheSHIELD(StrategiesforHealthInsurance for Equity in Less Developed Countries)project, which was initiated in 2006 and ended in2010. The aim of SHIELD is to critically evaluateexisting inequities in health care in Ghana, SouthAfricaandTanzaniaandtheextent towhichchangesin health care financing mechanisms can addressequitychallenges.In Tanzania, there is growing commitment to theexpansion of health insurance to meet the goal ofproviding a universal health system. A universalhealthsystemisonethatprovidesfinancialprotectionfrom the costs of health care and access to neededhealth care for all Tanzanians. This policy briefoutlines the current health insurance schemes inTanzania, looks athow the schemes aredesigned intermsofcontributionsandbenefitsoffered,andhowcoverage is spread across different socioeconomicgroups. Finally, the brief indicates how healthinsuranceisimpactinguseofhealthcareservices,andmakes recommendations for improved tailoring ofinsurancetomeetthegoalofuniversalcoverage.Toassesshowhealthinsurancecovervariesbysocioeconomic status and how it impacts health careutilisation, researchers from the Ifakara HealthInstitute(IHI)collectedinformationonoutpatientandinpatienthealthcareutilizationandhealth insurancestatus from 2,234 households (12,201 individuals) in2008aspartoftheSHIELDproject.Households were interviewed in 3 urban councils(Morogoro, Ilala and Kinondoni) and 4 ruraldistricts(Mbulu, Singida, Kigoma and Kilosa). Researchersinterviewed 1,686 members of the National Health

Insurance Fund, 3,324 members of the CommunityHealth Fund1, 196 members of the Social HealthInsurance Benefit (SHIB) scheme, 173 members ofprivate health insurance schemes and 6,748 noninsuredindividuals.

Main features of health insuranceschemesinTanzaniaTable 1 outlines the five types of health insuranceschemesinTanzania.For the formal sector, the largest scheme is theNationalHealth Insurance Fund (NHIF). The schemewassetup in2001asamandatoryschemeforpublicservants and offers a wide benefit package. Thescheme is currently reachingout tomembersof theprivate formalsector. TheNHIF isadministeredbyan independent body answerable to theMinistry ofHealthandSocialWelfare.TheSocialHealthInsuranceBenefit (SHIB) scheme was formed in 2005 as anindependentbodywithin theNationalSocialSecurityFund (NSSF), which is one of the largest pensionfunds,andoffershealthinsurancetoNSSFmembers.

PolicyBriefSHIELDHealthFinancingReform

SHIELD: Strategies for Health Insurance for Equity in Less Developed Countries

Who is covered by health insurance schemes and which services are used in Tanzania?

This policy brief was prepared by Josephine Borghi and August Joachim. The authors are IHIresearchers,andtheresearchpresentedwasfundedbytheEuropeanCommission(SixthFrameworkProgramme; Specific Targeted Research Project no: 32289) and the International DevelopmentResearchCentre(IDRC).TheviewsexpressedarenotnecessarilythoseoftheEuropeanCommissionor the IDRC. Direct any questions about this brief to: [email protected]. The usual disclaimersapply.Compiledin2011

1Includingdistrictswhere thebenefitpackagewas limited toprimary careanddistrictswhichhadextended thebenefitpackage to cover some costs forreferralcare

CountingCHFmembershipcardsinadispensaryintheSingidadistrict



NSSFmemberscontribute10%oftheirgrosssalarytotheNSSF,which ismatchedby their employer,withtotalcontributionsequalling20%oftheirsalary. TheSHIB contribution is drawn from the overall NSSFcontribution to reimburse services used by SHIBschememembers. TobenefitfromtheSHIBscheme,individuals have to register with the scheme andcompleteanenrolment card,which canbeprovidedbytheiremployer.The private formal sector can also join a range ofprivate health insurance schemes (Strategis andAfricanAirRescue(AAR)areamongthelargestprivateinsuranceschemes).For the informal sector, theCommunityHealthFund(CHF)isthelargestschemeoperatinginruraldistricts.In2009 a similar schemebeganoperating in certainurban councils: the Tiba Kwa Kadi (TIKA). Untilrecently the CHF/TIKA was administered by theMinistry of Health and Social Welfare (MOHSW).Since 2009, the NHIF have taken over themanagement of the CHF/TIKA for a 3year period.Therearealsoarangeofsmallscalemicroinsuranceschemes (such as Chawana) operating across thecountryalthoughcoveragewithsuchschemesisverylowandfinancialsustainabilityaconcern(Jamuetal.,2009).

HowmanypeoplearecoveredbyhealthinsuranceinTanzania?Health insurancecoverhasbeengradually increasingamongtheTanzanianpopulationsinceitsintroductionoveradecadeago(Figure1).Datacollectedaspartofthe SHIELD project from 2008 suggest that nationalcoveragewas around 9% in this year. More recentfiguresreleasedbytheNHIFsuggestthataround13%

of the national population are insured: 5.8% of thepopulationare insuredby theNHIF,6.6%bytheCHF(NHIF,2010)andanestimated1%areinsuredthroughtheremainingschemes(authorsestimation).Recent policy announcements indicate an intentionfrom the Minister of Health to increase thesecoverageratesto45%by2015(Figure1).

Which socioeconomic groups arecoveredbyhealthinsurance?There iswide variation inhealth insurance coverageby socioeconomic status. Health insurance cover ishigher among the rich: in 2008, 12% of the richestgroupswere insuredcompared to4%of thepoorestgroups. Richergroupswerecoveredbyawiderangeofhealth insuranceschemes,whereaspoorergroupswereonlycoveredbytheCHF(Figure2).

Figure1:Estimatedexpansioninhealthinsurancecoverovertime

InsuranceScheme Eligibility Contributionrate Benefitpackage

NationalHealthInsuranceFund(NHIF)

Mandatoryforpublicservantsandupto5dependents.Currentlyopeninguptoothermembersoftheformalsector

6%ofgrosssalary,splitbetweenemployerandemployee

Inpatient&outpatientcarefrompublicandaccreditedfaithbasedfacilities&privatefacilities&pharmacies

NationalSocialSecurityFund(SocialHealthInsuranceBenefitSHIB)

Mandatoryforprivateandparastatalemployeesandupto5dependents

Noearmarkedcontribution,reimbursementfundstakenfromNSSFcontributions

OutpatientandinpatientcareuptoTsh80,000atselectedfacilities.Membershavetosignupinordertoreceivebenefits

PrivateInsuranceSchemes(StrategisandAAR)

Voluntary,oftentiedtoemploymentindividualcover

Variousdependingonbenefits

Variouspackagestypicallyincludingoutpatientandinpatientcare

CommunityHealthFund(CHF)

Voluntary,foracoupleandchildrenunder18yearslivinginruraldistricts

BetweenTsh5,00020,000peryear/household

Primarylevelpublicfacilities.Limitedreferralcareinsomedistricts

Chawana,asexampleofmicroscheme

Marketvendors Tsh50/person/day PrivateoutpatientcareplustransportforreferralanduptoTsh10,000referralcosts

Table1:InsuranceschemesinTanzania



Whichhealthcareservicesareused?Health care use varies across insured and uninsuredgroups. Outpatient utilisation rates for schemestargeting the formal sector (private insurance, theNHIFandtheSHIBscheme)aregenerallyhigherthanthose of CHF/TIKAmembers (Figure 3). Apart fromtwoagegroups (0to4yearsandover50years), theuninsured have much lower rates of outpatientutilisation than other groups. Utilisation rates arelikely to be higher for uninsured groups who areeither very young or very old because exemptionpoliciesinpublicfacilitiespromotefreecareforthesegroups.

Inadditiontoincreasingtheuseofservicesamongitsmembers,health insurancealsoaffectswherepeoplego to seek outpatient care. For example, insuredindividualsaregenerallylesslikelytoseekcareatdrugshopsthantheuninsured(Figure4). However,therearedifferencesacrossinsuranceschemes: CHFmembersaremuchmore likelytousepublic

primary health facilities and less likely to go tofaithbasedhealthprovidersthantheuninsuredinruralareas

NHIFmembers inurbanareas (NHIFU)aremorelikelytouseprivateprovidersandpublichospitals,whereas those in rural areas (NHIF R) aremorelikely to go to public primary and faithbasedfacilities.

SHIBandprivateinsuranceschememembers(notshown inFigure4)aremore likely touseprivateproviders.

SOURCE:SHIELDHouseholdSurveyData2008

12%oftherichestgroupsareinsuredcomparedto4%ofthepoorestgroups

Figure2:Healthinsurancecover,byincomegroup

Figure3:Outpatientutilisationrates,byagegroupandtypeofhealthinsurancescheme

SOURCE:SHIELDHouseholdSurveyData2008 Figure4:ImpactofInsuranceonwherepeoplegoforoutpatientcare

NOTE:NHIFR=NHIFmembersinruralareas;NHIFU=NHIFmembersinurbanareas;UninsR=uninsuredpopulationinruralareas;UninsU=uninsuredpopulationinurbanareasSOURCE:SHIELDHouseholdSurveyData2008

Prop

ortio

nofpeo

plewho

areinsured

0%

20%

40%

60%

80%

100%

CHF NHIFR UninsR NHIFU UninsU

PublicHospital PublicPrimary FBO Private Drugshop



VisittheSHIELDwebsite:http://web.uct.ac.za/depts/heu/SHIELD/about/about.htmContacttheSHIELDScientificCoordinator:ProfessorDiMcIntyre([email protected])

ConclusionsHealth insurancecover isgradually increasingamongtheTanzanianpopulationsinceitsintroductionoveradecade ago. However,wealthier groupsworking intheformalsectoraremore likelytobenefitfromthisdevelopment than poorer groups. The diversity ofschemes, in termsof contribution ratesandbenefitsoffered, means that the effect of insurance isinconsistent,bothintermsoftheamountandnatureofservicesreceivedbymembers.Whatisclearisthatinsurance is generally increasing the intensity ofoutpatientcareuseandalsoinfluencingwherepeoplegoforsuchcare,divertingpeoplefrom informaldrug

shopstoformalcare. CHFmembersaremore likelyto use public primary care, than their noninsuredrural counterparts, consistent with their benefitpackage.Despiteequalcontributions,NHIFmembersinurbanareasuseamuchwiderrangeofoutpatientcarethanthoseinruralareas.

PolicyimplicationsThe findings from this researchhave implications forhealthpolicyinTanzania: Dataontheuseofhealthcareservicesarehighly

valuable for resource planning and insurancescheme management as this helps to identifypossible system abuse, and alert providers tosystemoverload. Itwould thereforebeuseful toaddress the lackofpubliclyavailabledataof thisnature.

Increasing theavailabilityofaffordable insuranceoptions for poorer groups and ensuring greaterconsistency in the benefits offered acrossschemes would help to improve health systemequity.

The inequity inserviceavailabilitybetweenurbanandruralareasshouldalsobetaken intoaccountwhensettingpremiumsforschemes,andparallelefforts should be made to increase providerchoiceforthoselivinginruralareas.

SHIELDpartners20062010SouthAfrica: HealthEconomicsUnit,

UniversityofCapeTown CentreforHealthPolicy,

UniversityoftheWitwatersrand

Ghana HealthResearchUnit,

GhanaHealthServiceTanzania IfakaraHealthInstitute

London LondonSchoolofHygiene

andTropicalMedicineNetherlands KoninklijkInstituutvoorde

TropenSweden MedicalManagement

Centre

Acknowledgements Wewouldliketothankthefollowingindividualsfortheir

valuablecontributionsandsupportinundertakingtheresearch:theCHFandNHIFcoordinatorsofSingida,Mbulu,KigomaandKilosadistrictsandthehealthfacilityinchargesofthefacilitieswhereweundertookdatacollection,andallofthehouseholdswhogaveuptheirtimeforinterview.

SHIELDreportsareavailablefrom:

http://web.uct.ac.za/depts/heu/SHIELD/reports/reports.htm

ThispolicybriefformspartoftheresearchcompletedfortheSHIELD(StrategiesforHealthInsuranceforEquityinLessDevelopedCountries)project.SHIELDaimstocriticallyevaluateexistinginequitiesinhealthsystemsandtoexaminetheextenttowhichmechanismstoprovidefinancial

protectioncanaddresstheseinequitiesinGhana,SAandTanzania.

SHIELD: Strategies for Health Insurance for Equity in Less Developed Countries

SHIELDisamultipartnerproject

Box 1

Alackofpublicallyavailabledataontheuseofhealthcareservices:

ApartfromthedatageneratedbySHIELD,thereisnootherpublicallyavailablenationaldataonuseofhealthcareservicesformembersofdifferenthealthinsuranceschemesandfortheuninsured.SuchdataarenotroutinelycompiledfortheCHFortheSHIB.WhilesuchdataareavailableforNHIFmembers,thefiguresarenotdisaggregatedbyagegrouporbyincome.Itwasnotpossibletoassessdataavailabilityamongprivateinsuranceschemes.

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