PHA-Exchange> Tanzania community health financing (CHF)

[Aviva]

From: <grace_chee at abtassoc.com>


> Dear all,
I work with  the PHRplus project, and recently led an assessment of the CHF
in Hanang (Tanzania)
> district, which had introduced the CHF in 1998.  The findings from Hanang
> should be considered in this discussion, as they provide a somewhat
> different picture of the current situation.
>
> Hanang had been reported to be one of the high performing CHF districts,
> with enrollment rates of 30%.  In actuality, we found that this enrollment
> rate quoted at the central level could not be substantiated.  It is likely
> that the reported rate is based on cumulative enrollment, so that it
> represents the total number of households that were ever members.  Our
> research estimates that 2-3% of the households in the district were
> members in 2001.  This data calls into question the validity of the quoted
> membership rates for all of the CHF districts.  One of our key findings is
> that the current administration and management procedures do not allow
> accurate, ongoing self-monitoring of the CHF performance.
>
> In Hanang, the CHF does not act as an independent agent, but rather as a
> vehicle of the DHMT.  The level of community involvement is limited, and
> there was little understanding of how the CHF is managed.  The Ward Health
> Committees that are to play a role in managing the CHF are generally not
> functioning.  There were reports of facility In-charges calling CHF
> meetings to get approval to make some expenditure from CHF funds
> collected, and no members turning up.  In those cases, the District
> Medical Officer would approve the expenditure and release the funds.  In
> Hanang, from 1998-2000, the majority of the CHF funds (59%) were used to
> construct the district hospital (at the direction of district officials).
>
> Some of the broader design issues cannot be discussed without agreement
> and understanding of the goals of the CHF.  For example, many health
> officials in Tanzania argue that enrollment would increase if the CHF fee
> were lowered (in Hanang its Tsh 10,000).  Shaw’s paper argues that
> enrollment would increase if the user fee were increased.  While either of
> these changes may well lead to higher enrollment, the question to be
> answered is: what does this higher enrollment achieve?
>
> 1) Just increasing the pool of insured does not ensure a healthier pool of
> people to broaden the sharing of risks – given that the benefits package
> includes only outpatient care (which are generally low cost, somewhat
> predictable risks), most people have a good idea of their benefits from
> enrolling.  The people who enroll will still be the ones who expect that
> the value of services they use will be greater than the enrollment fee.
>
> 2) Higher enrollment also does not ensure financial benefit for the health
> system.  The data from Hanang showed that on average, each member
> household visited the HC/dispensary 32 times during an 11 month period
> studied.  Thus, for the Tsh 10,000 enrollment fee these HH received
> services “valued” at Tsh 32,000 – 48,000 (based on user fee rates at HC
> and dispensaries).  Given that the user fees only represent a small
> portion of the cost of services, the health system is “losing” more money
> for each member household that joins.  Even if we assume that there is
> excess capacity in the system in terms of “fixed cost” personnel (which is
> the case in some areas), the CHF membership fees are probably not
> sufficient to cover even the variable costs of drugs or lab tests.
>
> 3) Lastly, higher enrollment could arguably improve access to services.
> If this is achieved by raising user fees to increase enrollment, it
> probably does not serve to increase access for the poor because they would
> not be able to come up with the lump sum enrollment fee anyway.  It does
> provide extra incentive for the more well-off to join, in which case the
> matching subsidy is going to the more well off.  Lowering the CHF
> enrollment fee to increase enrollment may increase access for the poor,
> but at even greater expense to the health system.
>
> These findings and others have been shared with both officials in Hanang
> district and the CHF Coordinator’s office.  While the findings were
> generally accepted, and even substantiated with information from other
> districts, the solutions are less clear.  Our assessment did not seek to
> answer the question of whether to support the CHF, but how to improve
> implementation of the CHF.  To that end, we are supporting a series of
> activities aimed at improving performance, including increasing enrollment
> – with the agreement that high enrollment is not the primary goal.  I
> agree with one of Bill Hsiao’s comments, which is that the CHF (used to
> refer to the prepayment and user fee system) is viewed as just another
> source of funding.  Thus, the implementation changes we propose primarily
> seek to improve management and efficient use of these funds.
>
> I would urge people who are interested in the CHF to review the findings
> from Hanang – the paper is available at the following link:
> http://www.phrproject.com/publicat/tech/africa/te015_fin.pdf.
>
The CHF is to be implemented in all districts by
> 2003.