CASE STUDIES
FOR
HEALTH POLICY AND
SYSTEMS ANALYSIS
CASE STUDY ON HEALTH SYSTEMS
FINANCING
Community Health Funds
The development of sustained African health policy and systems research and teaching capacity requires the
consolidation and strengthening of relevant research and educational programmes as well as the development
of stronger engagement between the policy and research communities. The Consortium for Health Policy and
Systems Analysis in Africa (CHEPSAA) will address both of these issues over the period 2011 - 2015. CHEPSAA’s
goal is to extend sustainable African capacity to produce and use high quality health policy and systems
research by harnessing synergies among a Consortium of African and European universities with relevant
expertise. This goal will be reached through CHEPSAA’s five work packages:
1.
2.
3.
4.
5.
assessing the capacity development needs of the African members and national policy networks;
supporting the development of African researchers and educators;
strengthening courses of relevance to health policy and systems research and analysis;
strengthening networking among the health policy and systems education, research and policy
communities and strengthening the process of getting research into policy and practice;
project management and knowledge management.
The CHEPSAA project is led by Lucy Gilson (Professor: University of Cape Town & London School of Hygiene and
Tropical Medicine).
PARTNERS
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Health Policy & Systems Programme, the Health Economics Unit, University of Cape Town, South Africa
School of Public Health, University of the Western Cape, South Africa
Centre for Health Policy, University of the Witwatersrand, South Africa
Institute of Development Studies, University of Dar es Salaam, Tanzania
School of Public Health, University of Ghana, Legon, Ghana
Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya
College of Medicine, University of Nigeria Enugu, Nigeria
London School of Hygiene & Tropical Medicine, United Kingdom
Nuffield Centre for International Health and Development, University of Leeds, United Kingdom
Karolinska Institutet, Sweden
Swiss Tropical and Public Health Institute, University of Basel, Switzerland
CHEPSAA WEBSITE
www.hpsa-africa.org
ACKNOWLEDGEMENTS
An acknowledgement is given to all CHEPSAA partners who contributed to the course development process.
SUGGESTED CITATION
CHEPSAA. (2014). Introduction to Complex Health Systems: Case Study materials. CHEPSAA (Consortium for Health
Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org
This document is an output from a project funded by the European
Commission (EC) FP7-Africa (Grant no. 265482). The views expressed
are not necessarily those of the EC.
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Health Systems Financing – The Case of Community Health Funds
Contents
The CHEPSAA Project ................................................................................ Error! Bookmark not defined.
Towards Universal Health Coverage via Community Health Funds ........................................................ 2
Facilitator’s Guide................................................................................................................................ 2
Issues Covered ................................................................................................................................. 2
Curriculum Prerequisites ................................................................................................................. 2
Session Time Needs ......................................................................................................................... 2
Case Study Summary ....................................................................................................................... 2
General Objective of Case Study ..................................................................................................... 3
Participants’ Learning Objectives .................................................................................................... 3
Facilitator’s Case Study Directions .................................................................................................. 3
Learning Assessment ....................................................................................................................... 4
Facilitator’s Resources......................................................................................................................... 5
Background to Community Health Funds ....................................................................................... 5
Facilitator’s Discussion Guide ............................................................ Error! Bookmark not defined.
Participants’ Resources: Handout 1 ................................................................................................... 6
The Case – Community Health Funds.................................................................................................. 6
Participants’ Resources: Handout 2 ................................................................................................... 9
Background for Participants ................................................................................................................ 9
Participants’ Resources: Handout 3 ...................................................... Error! Bookmark not defined.
Selected Readings and Sources ......................................................................................................... 14
Creative Commons License ................................................................................................................... 18
Health Policy & Systems Analysis
A Case Study for
Health Systems Financing
Towards Universal Health Coverage via Community Health Funds
Facilitator’s Guide
Issues Covered
This case study deals with Community Health Funds and tackles issues around:
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Politics & power
Stakeholder facilitation
Accountability & Trust
Access, quality and equity
Curriculum Prerequisites
The case study assumes participants have had a general introduction to health systems definitions, functions,
values, and frameworks including the WHO Health Systems Building Blocks. It also assumes an introduction to
health systems thinking for health systems strengthening. Participants should have been exposed to didactic
sessions on universal health coverage, governance, participation, trust, as well as politics and power including
the Gilson and Walt (1994) policy triangle.
Session Time Needs
The case It requires three sessions that could be conducted all in one day or in sessions spread over two to
three different days:
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Session 1. 30 minutes of facilitated initial contact time for introducing the case work;
Session 2. 3 hours of non-contact time for group work in small groups of ~ 5 participants each;
Session 3. 2-3 hours of feedback and facilitated discussion.
Tags: Systems Thinking, Community Health Funds, CHF, Financing, Community Based Insurance
Case Study Summary
This case study assists the participants to go beyond the rhetoric associated with highly advocated paradigms
based on convincing logic and theory to discover the difficulties when such paradigms are inserted, often
vertically, into real world health systems without due consideration of design and the behaviour of complex
adaptive health systems and the actors. The participants are given the case task (Handout 1) and given time to
role-play as representatives of the building blocks of the health system to examine the strengths and
weaknesses of the Voluntary Community Health Fund model as implemented. Later they are given a transcript
of a meeting between the Ministry of Health and a variety of stakeholders (Handout 2) and the results of a
health systems analysis of the performance of the Community Health Fund. The task of the participants is to
see how close they can anticipate the problems using systems thinking, and then to go farther to propose
modifications to the CHF model that might mitigate shortcomings or take advantage of synergies elsewhere in
the system.
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Health Systems Financing – The Case of Community Health Funds
General Objective of Case Study
To employ the Building Blocks of systems thinking to understand the system-wide effects of a health
financing scheme and use these to optimize a tailored response.
Participants’ Learning Objectives
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To develop a basic understanding of the concept of a Community Health Fund as a financing
mechanism, its structure, function, benefits and disadvantages, and its implications in universal health
care coverage;
To use a health systems thinking approach to understand reasons for their success or failure;
To propose possible solutions to existing problems with the program;
To draw conclusions about the interrelatedness and cyclical dependency of building blocks effects on
each other, linking the Finance building block with other relevant aspects of health systems
Facilitator’s Case Study Directions
1. Session 1. Provide each participant with a copy of the task (Handout 1) which describes the CHF as it
should operate or is expected to operate. Allow some time for them to read through and manage any
initial clarification questions. Time needed is about 30 minutes contact.
2. Session 2. Break the class into small groups of no more than five and allow them to discuss internally
and independently in their small groups. Have them role-play as representatives of the health system
building blocks and the public. Once they have identified the issues, provide Handout 2, which is the
transcript of a meeting between MOH CHF officials other stakeholders. They are then asked to use a
mind mapping software application to organize points in an eventually structured way (e.g. free open
source products like Xmind are useful)( http://www.xmind.net/download/win/ ). Total time about 3
hours.
3. Session 3. After participants have finished, initiate a plenary discussion session in which they formally
present back to you their deliberations, analyses and possible solutions.. The Faciliator takes the role
of the Permanent Secretary of the MoH. Facilitate a discussion in such a way to ensure that all
participants have developed an understanding of the reading and the issues covered. The Facilitator’s
Discussion Guide suggests themes and questions to help direct the discussion.
Caution!
The complexity of the issues described could give rise to a number of possible avenues for discussion. There
may arise a tendancy to focus specifically on only the financial aspects of CHF and the direct impacts associated
with it. If this happens, steer them back towards discussing CHF and health systems financing in light of the
system as a whole.
Health Policy & Systems Analysis
Learning Assessment
Assessment Directions
This Case Study Task asks participants to act as program planners for the Ministry of Health to apply Systems
Thinking to improve the national CHF scheme. The participants are asked to generate a MindMap directed to
the Minister of Health (the Facilitator) detailing the specifics of their findings and suggestions. The Facilitator is
to evaluate the participants with the following rubric during the presentation of the final Session (Session 3).
Assessment Criteria
The presentation should not last more than 15 minutes. The participant(s) are to be marked according to the
following rubric. Note that both the content criteria and the presentation criteria will be averaged thereafter
for a maximum total of 100 points.
Members of the other groups, as well as the facilitator, will allocate marks to their group according to the
following criteria:
Content Criteria
Extent to which proposed solutions affect facets of each Building Block and public are covered
Proper identification of relevant actors, implicated overarching issues, and sub issues
Exhaustiveness of potential unintended consequences addressed
Clarity and structure of proposed suggestions
Extent to which systems integration issues are delineated and discussed
Each building block is specifically and comprehensively addressed
Evidence of understanding the concept of Community Health Funds
Evidence of understanding of the key Health Systems concepts underpinning CHF
Total points for Content Criteria
Presentation Criteria
Clarity of delivery (visual and oral); MindMap is clear and organized
Coherence and clarity of content and ideas
Ability to respond to questions about the plan
Evidence of successful group work
Successfully completed within time allocation
Total points for Presentation Criteria
Points
allocation
20
15
10
10
10
5
5
5
80
Points allocation
5
5
5
2.5
2.5
20
Note: The observer groups’ and facilitator’s marks will be averaged to reach an overall total. Please note that
the highest and lowest grade allocated to a group by a student shall be disregarded in the averaging of marks.
Note on Setting up Group Work
As a facilitator, you can also ensure better group learning by:
 Designing well-structured and clear group tasks and assignments, and giving clear instructions,
including the objectives, learning goals, expectations, and time;
 Constructing groups or teams carefully, taking into account diversity (such as gender, culture,
language, education, etc.) styles, number of members (no more than 10; 4-6 is optimal for most tasks);
 Monitoring the group work to ensure everyone is on track;
 Build group work skills (such as in role play);
 Assessing and/or giving feedback on the group work.
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Health Systems Financing – The Case of Community Health Funds
Facilitator’s Resources
Background to Community Health Funds
Community Health Funds have been promoted vigorously in Africa by the World Bank and many bilateral
donors as alternative complementary financing mechanisms since 1995. Community Health Funds (CHF) are a
form of voluntary or compulsory health insurance intended to assist achieving universal health coverage of
essential health interventions. They are generally designed to collect annual premiums from individuals or
families that guarantee the family to exemptions from user fees and other costs for essential health services at
local government primary care health facilities. They are generally district scale membership schemes
(~250,000 members if the whole population subscribes). The poor are usually given membership with a
premium exemption. Funds collected are to be managed and used locally within the District, to provide the
necessary services and improve quality of existing services.
Community Health Funds are an example of a health system (financing) intervention that looks very appealing
in theory, but is fraught with challenges in practice. Many countries in Africa have adopted some form of CHF.
Evaluations of both pilot schemes and national scale implementations reveal major fault lines with this
approach to health insurance in Africa, yet donors continue to promote them.
In this case, participants are provided with a description of a Community Health Fund and its theoretical
advantages, and are challenged to imagine what the difficulties would be in actual implementation in an
African district health setting. They are encouraged to look at it through the framework of the WHO health
system building blocks of governance, financing, medicines and technologies, human resources, informatics,
service delivery and the community. In group work they role-play representatives of each of these
constituencies. They then feed these back in group work synergize across ideas.
Following this first discussion, they are provided with a transcript of a meeting between the Ministry of Health
and a CHF community and a CHF evaluation publication by Kamuzora and Gilson, 2007. A second plenary
discussion is held to see how close they came to anticipating the challenges of CHF.
Health Policy & Systems Analysis
Participants’ Resources: Handout 1
The Case – Community Health Funds
The Task
Read the case material provided on the following handouts below concerning the current situation of a
healthcare financing scheme, the Community Health Fund, of a rural district health system in Africa. Complete
the following tasks in yo
1. Case Summary
a. Case Study Events– Draw two separate flow diagrams illustrating the main drivers,
activities and events of the establishment of both Health Facility Governance Boards,
noting any unintended consequences of an event.
b. Case Study Context - Complete the context analysis form identifying the key features of
this particular case and how they have contributed to the situation.
2. Hardware & Software
a. Identify the hardware and software issues and elements which are most important in
shaping this case, using guidance from Aragon’s framework below, and
b. Explain how they are linked and interact.
Understanding organisa ons
Hardware:
Organisa onal
hierarchy
HR establishment
Tangible so ware:
Management
knowledge and
skills
Intangible so ware:
capabili es to commit and
engage; adapt & self-renew;
balance diversity and coherence
Technology
Formal
management
processes
Finance
Values & Informal
rules
norms
Rela on- Commships
unica on
adapted from Aragon, 2010
3. Stakeholder Analysis
Identify the key actors in both Villages in the case and, situating them at the time of the
introduction of the HFGCs, map these in Diagram 1 according to their levels of commitment and
power to impact on successful implementation of the change. Draw lines between agents who
have a close relationship with each other (e.g. through flow of money or information, lines of
command or support). Consider how their position on the map changed over time, and be
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Health Systems Financing – The Case of Community Health Funds
prepared to explain this, as well as agents’ mindsets and levels of power, and how agents are
related to each other
4. Leading and Managing Change
Imagine you are working at the district level, in a position to lead and influence policy change. As
this leader, think about how you can increase buy-in for the change, and thus achieve more
successful implementation. Using the concepts and frameworks above and in the session 7
lecture on ‘Leadership of change in Health Systems’, design 3 strategies to increase other agents’
buy-in. These could include small wins. In developing strategies also think of the ideas raised in
the Duncan Green video.
Prepare to present and discuss in plenary with your facilitator, the most important behaviors
associated with success or failure of the boards and how actors, content, and processes have
worked to influence these and the local health system as a whole. Discuss what this means for
anchoring stronger community ownership and accountability.
Health Policy & Systems Analysis
Participants’ Resources: Handout 1
The Case – Community Health Funds
You are a public health professional in an African country. The Ministry of Health (MoH) has just assigned you
to a taskforce designed to assess a problem with the current healthcare financing situation. Part of your terms
of reference is to develop a proposal for improving coverage of their Community Health Financing (CHF)
program.
Community Health Funds in this country were piloted between 1995 and 2000, and then rolled out nation-wide
in 2000. They were promoted vigorously by the World Bank and many bilateral donors as alternative
complementary financing mechanism. Community Health Funds (CHF) is a voluntary health insurance scheme
intended to assist achieving universal health coverage of essential health interventions. It collects annual
premiums from individuals or families that guarantee the family to exemptions from user fees and other costs
for essential health services at local government primary care health facilities. There is a separate scheme in
each district. Potential membership is about ~250,000 if the whole population subscribes. The poor are
usually given membership with a premium exemption. Funds collected are to be managed and used locally
within the District, to provide the necessary services and improve quality of existing services. After 15 years of
implementation, coverage (membership) of the CHF in most districts is low (less than 20%) and communities
remain frustrated with access and quality of their basic health services.
Step 1. In a briefing from the Ministry of Health, you have been told that the CHF programme is a success but
that there is a desire to improve participation in the scheme. You are provided with documents that describe
the CHF and how it should operate. Now your Task Force has a chance to meet on its own. Assign among
yourselves roles such that you have a representative speaking for each of the six building blocks, and the
public, and look at the CHF design through those eyes. Ask how the design would affect you and your
constituency in the system. Identify any advantages, disadvantages, problems or opportunities that you might
anticipate. Record these as positives or negatives for each building block, and indicate whether they are major
or minor concerns.
Step 2. To get familiar with the issues, the new task force decides to attend an imminent meeting between
Ministry officials and national, district, ward, and village officials from around the country, focused on
discussing, debating and understanding the CHF’s shortcomings. Handout 2 contains a transcript of the
discussions at this meeting. Read this transcript.
Using the discussion transcript, brainstorm among the members of your group, using mind mapping (
http://www.xmind.net/download/win/ ) to identify the actors concerned and organize the major issues and
sub-issues that are identified. For each issue, problem or obstacle encountered suggest how the actors that you
previously listed interact with or influence each sub-issue and in what capacity. Drawing on this information,
prepare a presentation with your group suggesting possible ideas, suggestions, or counter-propositions to
develop a plan to aid the MoH in its endeavor. As you and your group work through your thoughts, bear in
mind again the associated building blocks and approach possible solutions from a systems-based and systemwide perspective. Consider how each suggestion would affect relevant behaviours in each building block.
Step 3. Feedback your findings in plenary to the Ministry of Health (your facilitator) using the generated
mindmap as part of your presentation, and engage in a discussion concerning your conclusions.
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Health Systems Financing – The Case of Community Health Funds
Participants’ Resources: Handout 2
Background for Participants
The following is a record of a community meeting:
MoH Official
“As many of you know, there have been some problems that we have identified with the implementation of
the Community Health Funds. Today I would like to speak about a few of them. I believe these problems fall
into a handful of categories, and unfortunately many of them originate at the bottom-level, among the
community members.”
There were murmurs in protest among the audience. He continued…
“I believe if we work together, especially at the community level, that many of these issues may be resolved,
and that CHF will not only be more functional, but benefit everyone greatly, as it is intended to.
“Firstly, and in my opinion most importantly, is the lack of payment of membership contributions. This seems
to be a major issue when we do the uptake in the middle of the year. Many members of the community are
“seemingly” unable to pay as they say that the co-payments are too high. But they have been designed to be
low enough so that the community collectively can certainly pay them.”
One community member put up his hand up, and spoke.
“Excuse me sir, but the co-payments are too high. I have 6 mouths to feed, not including my parents. And I
heard of other people receiving a lower rate than I received! There seems to be a strong lack of uniformity in
the premiums that are offered to different people, and that’s unfair. I feel that the people that need this kind
of coverage the most are those that are often left out, like our family.
Another community member stood up.
“I am told that I won’t get my money back if I don’t use the services. So why should we pay for services that we
don’t use? I don’t understand this idea of paying before I get sick.”
The MoH official raised his eyebrow when he heard this. Another community member raised her voice.
“For us, it is not that we cannot afford to pay the premiums. We find it unfair to be forced to pay for low
quality healthcare, as if that’s our only option. It’s the employees at the health facility, sometimes they’re not
even there, and then also there is the lack of equipment and medicines, unclean conditions, the way I am
treated there even! They discriminate against CHF members. I don’t want to pay into a system until I know the
care I will get will be good, and worth what money I can give. And I understand that we cannot be referred to
another, better facility under this scheme? Surely we should have a choice.
A man towards the front then spoke.
“For our family, it is that we are worried that our payments into the scheme will not be properly used, for our
benefit. How do we know that a large part of our money isn’t going into the wrong pocket? There is corruption
among us, how do we know that we have put our trust in the right people? I don’t trust the CHF managers. I
think we are better off paying at the time we get sick, and taking that risk, as opposed to losing our money
altogether.”
Health Policy & Systems Analysis
Another individual chimed in:
“I don’t want to have to pay for other people from my community! They should be able to take care of
themselves; I have enough problems taking care of my own.”
The MoH officiall waited patiently until the community members had finished, and then continued with his
concerns.
“In any case, it is not just the lack of membership contributions. Those people that need it most, as you said sir,
he nodded his head towards the community member that spoke earlier, they are not receiving care coverage,
but they don’t even bother signing up. We have exemptions for many people if they qualify, so it is the
community’s fault if they do not take advantage of these benefits.
“And yes, I agree with the woman, that the health care facility quality is a problem, but it always has been.”
The woman raised her voice again.
“Sir, do you contribute to a CHF fund? She looked around the room. Do any of you District, Ward, or even
Village officials pay into a CHF fund? What about the business men in the room?”
The MoH official cleared his throat and replied.
“Well, no. For the officials, I admit that there is no need to be a part of a CHF.”
Many of the various government officials nodded in agreement. He continued.
“We have government-subsidized health care coverage that is offered to public servants.”
The business man spoke up.
“Honestly, I don’t need to pay into a system. If I or someone in my family gets sick, we cover the costs at the
time of illness. The rates at the hospital are certainly low enough for us to afford.”
The woman then stated:
“Then how do we expect the fund to be sustainable, if all the wealthy people, whose funds are essential
contributions, do not participate at all?”
The MoH official nodded his head without responding to the question. He continued:
“ Another major problem is that roll-out of the scheme was slow, across all councils. I am very aware of this. A
large factor that contributed to this slow roll-out, as the woman suggested, was the question of the schemes
being comprehensive enough, and if they would be able cover referrals beyond district facilities. This is one
question that we are currently exploring.
“Membership to CH is still low in some districts and falling in those districts where it was initially relatively high.
In addition to the enrolment issue, there is also the problem of reaching the poor, as has already been
enumerated. However there is, very importantly, the issue of sustainability. If enrolment continues to be low,
then there is a decreased trend in revenue as a result of this. If people drop out, this again threatens the
sustainability. It is the community members that control this. If full participation at the community level is
given, then the fund will be functional. This is why I say, many of CHF’s current and potential problems lie on
the shoulders of the members themselves.”
After the MoH official had finished, a prominent community member took to the platform to voice his concerns.
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Health Systems Financing – The Case of Community Health Funds
“Sir, I fear that many of the problems that you and the others listed can be attributed to the shortcomings of
one major actor: the District Officer (DO/DM).
“You stated that low enrolment was one of the major obstacles in ensuring that this program succeeds. Let us
examine some of the given reasons for this fact. Someone mentioned that the villagers’ ability to pay the
premiums was limited, as the membership contributions are too high. However I would like to argue that they
are actually not too high. That a great many of us can, and indeed could, afford them. I am not wealthy, no
certainly not, I am hardly an average earner, but in truth I could afford this fee. The truly poor and vulnerable,
they are even exempt from paying this fee, since 1999! So no, no, it is not the amount that is charged, it is
when it is charged. Why are fees taken up in the middle of the year, when our crops are nowhere near fruition
and we have not yet seen a return on our investment? Why not just after harvest season, when we would have
the funds to contribute to the pot?
“And while we are talking about exemption, let us continue down this road. You say that the poor are not
signing up to be a part of the fund. Have you considered that they tried, yet perhaps that they may not have
succeeded? I have seen it with my own eyes, a poor family will submit their request for exemption to the ward,
which will thereafter send the request to the district manager. However, they will either receive a negative
response (with plenty of time having lapsed in between), or no response altogether! The district discourages
exemption proposals from the communities in this way; there is no response or feedback from them. It is
demoralizing and it doesn’t elicit any desire from the people to want to be a part of this scheme. Furthermore,
the district managers seem to completely ignore the guidelines which outline the exemption criteria for the
poor and vulnerable. It is…”
There was an outburst as a handful of district managers in the room outwardly voiced their dissent…
“It is the responsibility of the village government to set exemption criteria, not mine!”
“Nothing is clear to guide the exemption process!”
“Exemptions are too difficult to implement!”
“Too many ask for exemptions! If too many are exempt, the system is unsustainable!”
“The central government is not doing its job properly! Why did they not address the viability of the CHF in the
first place?”
Heads nodded vigorously in agreement. The man waited patiently for things to settle down again before
continuing.
“I will not elaborate any further, other than to say that the national government gives specific guidelines to the
district managers as far as exemption criteria are concerned.
“Then you go on to say that the communities are reluctant to join because they are wary of the health care
quality they would receive. Yet you point no fingers nor propose any ideas as to why this may be. I do certainly
believe that the quality of health care delivery is a multifaceted and important issue, and cannot just be
simplified into one argument, or based on one or two factors. However, it is wilful ignorance to ignore the role
that certain influential people play in further exacerbating the already shaky system.
“I sometimes feel that the district managers are essentially working towards the detriment of these health
facilities. They are not involved with the health facility in their charge; they do not ensure the supervision of
health staff to support delivery of quality services.”
A man interjected from across the room.
Health Policy & Systems Analysis
“You are just saying these things because you don’t like the manager of your district. You cannot fully lay the
blame on one person or group of people.”
Another individual stood up immediately towards the back of the hall.
“While I do not agree with everything this man says, some of the things he is saying are true. The services do
not reach the targeted people. There is no effective monitoring; the leaders do not go out of their offices to see
what is happening at the health center.”
The original community member continued, seemingly unphased.
“A medical facility can only be as good as its staff, space, and medical supplies. That said, why have repeated
requests to procure drugs and medical equipment been turned down by the DM, or delayed at best? If we
cannot get the supplies we need to have a well-running facility that offers quality care, and the same individual
that is in charge of approving medicine and diagnostic equipment is also the same person that is discouraging
the CHF through their basic actions and attitudes, then who is to blame?”
A member of one of the Ward Councils spoke at this point.
“It is true, I too am tired of the District Board’s inaction. I am a Ward committee member, and we have been
extremely dissatisfied with the CHF Board’s procedures for approving the Ward budgets because many of our
requests do not get approved or it takes the Board a long time to approve them. We members unanimously
recommended that the Ward CHF Chairperson and Secretary go to the district headquarters to seek
explanation regarding the problems surrounding approval procedures for the ward budgets from the district
CHF Board Chairperson and Secretary.
“This in turn, bleeds into another problem: that the DMs do not allocate a budget at all for the CHF
administration activities, which is what happened last semester, and we could not even spend the CHF money
that had been accumulating in the bank! This meant that the funds available to districts for supervision or
general management were not used to support CHF administration activities, which resulted in disastrous
consequences in care quality. For example, a community health service board (CHSB) in charge of approving
requests for drug and medical supplies, as well as health facility rehabilitation, could only hold irregular
meetings, while in another district their CHSB stopped meeting altogether due to lack of transport and per
diem funds to keep the boards going. These boards are essential to health care quality at the facility level.”
A District Manager sitting close to the woman took his turn.
“In response to that, I would just like to say that our district, and I believe all districts in general, don’t even
have enough funds to begin with for CHF administration. I see it this way: CHF is just one set of district activities
amid the many other commitments that we have; an additional and separate activity from our daily business.
CHF is like an NGO. It’s not a council program, as the CHF Board is seen as a supra-body, operating above the
council. It is like an independent project operating on its own funds.”
The Ward Council member retorted:
“The CHF funds can be used for quality improvement, so you are greatly mistaken.”
Another voice broke out:
“And what about corruption? We don’t trust them, the CHF managers! The Ward Council, they allow their CHF
managers and the HF staff to misuse our funds.”
A man towards the front declared:
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Health Systems Financing – The Case of Community Health Funds
And whose responsibility is it to supervise the ward-level CHF managers and the health facility staff? It is the
“DM. And they don’t do that. There is a serious lack of transparency in financial matters which has left
everyone in the community with a big confidence gap. They don’t disclose expenditure information of the
locally raised CHF funds; they don’t tell us how the money has been used. We [the community] never know
what is happening. No financial report has ever been given to us. So we don’t understand.”
Another man affirmed.
“As been mentioned before, there are large discrepancies in our village members’ understanding of CHF; the
knowledge gap is great. In our village for example, we have people that do not see the rationale of insuring
against health risks, of paying for a service before they get sick; they just don’t understand the concept. They
don’t know about the benefits, and again, there is the whole exemption issue-they just don’t even know that
they can qualify to be exempt, or that exemptions even exist. And that is the greatest shame, as the poor and
vulnerable are one of the main target populations for this scheme.”
The same woman who had spoken earlier rose her voice again.
“Again, who is responsible for this? The DMs, who don’t seem to have tried all avenues to address this
problem. I understand that the DMs did not arrange to educate the communities before introducing and
launching CHF, which is quite counterintuitive if you ask me.”
The DMs again spoke up in their defense:
“We did not do so because we had such little time for preparing these activities. As far as I can remember,
preparations in the community started in May and the district launched CHF on the first of June. There was
political motivation to this too; there was so much pressure from above, and it came so swiftly! A considerable
amount came from the ruling party as it was enshrined in its election manifesto.”
A ward official chimed in with support:
“CHF came to us all like a fire brigade. The program is good but implementation is beset with problems.”
The woman interjected:
“And yet still. No time was invested even after the fact of implementation in mobilizing communities, or at
least, these activities were rare. There were hardly any visits by the DM to the communities. How do you feel
that this affected enrolment?”
He turned his head where the DMs were sitting. One reluctantly stated:
“Sensitization of communities was low in the beginning year, we went to all wards and achieved a 4%
membership rate, but I think this has dropped because we did not go back to the wards to create more
awareness.”
…
After some prolonged discussion and debate, a woman spoke to close the discussion.
“There is a general lack of information about the fundamental operations of the CHF. There is little knowledge
about the fund itself. How is the fund going to help us if it is not known to people? We are unaware of existing
schemes and unaware of exemptions. But it is not just that we are unaware; we are also misinformed about it
its function. Many fail to understand the concept of insuring against health risks, and the benefits of doing so. I
believe the solution to success lies within this problem.”
Health Policy & Systems Analysis
Participants’ Resources: Handout 3
Contextual feature
Micro context
organisational
climate & culture
other policies
organisational
capacity
interpersonal factors
Macro context
social & political
pressures &
interests
historical & sociocultural context
economic conditions
& policy
international
context
environmental
factors
Specific issues relevant to this experience
(remember not all issues might be relevant
to this case)
Impact of these issues on actors (name these) and the case, and
implications for policy implementation
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Health Systems Financing – The Case of Community Health Funds
Handout 4
Handout 5: Unpacking agent behavioural drivers and power
AGENT
Mindsets, values and interests
What are the core elements of the
agent’s ‘mindset’ (beliefs, values
driving behaviour in general?)
Given the elements identified
in column 1, is actor’s response
to the change likely to be
committed, compliant,
indifferent, resistant, or
hostile?
Forms and level of power to influence implementation
What forms of power can the agent
mobilise to support his/her actions
around the new policies?
What power limits does the actor face
in taking action around the new
policies?
Health Policy & Systems Analysis
Handout 5
Agent Map
Diagram 1: Agent map
Low <<---------------------Power------------------->>.High
Locate your actors on this map of support and opposition for change, taking account of their power level
Very committed << compliant << indifferent >> resistant >> hostile
Commitment
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Health Systems Financing – The Case of Community Health Funds
Selected Readings and Sources
1.
Borghi J, Maluka S, Kuwawenaruwa A, et al. Promoting universal financial protection: a case study of
new management of community health insurance in Tanzania. Health Research Policy and Systems
2013;11:21
2.
Derriennic, Yann, Katherine Wolf, and Paul Kiwanuka-Mukiibi. February 2005. An Assessment of
Commmunity-Based Health Financing Activities in Uganda. USAID. Bethesda, MD: The Partners for
Health Reformplus Project, Abt Associates Inc.
3.
Dong H, Kouyate B, Cairns J, Mugisha F, Sauerborn R: Willingness-to-pay for community-based
insurance in Burkina Faso. Health Econ 2003, 12:849-862.
4.
Kamuzora, P. and Gilson, L. Factors influencing implementation of the Community Health Fund in
Tanzania. Health Policy Plan 22(2), 95-102. 2007.
5.
Kessy F. 2008. Technical Review of Council Health Service Boards and Health Facility Committees in
Tanzania. Report prepared for the MOHSW with financial support from DANIDA and SDC.
6.
Maluka SO. 2013. Why are pro-poor exemption policies in Tanzania better implemented in some
districts than in others? Int J Equity Health 12: 80.
7.
McIntyre D, Thiede M, Dahlgren G, Whitehead M. 2006. What are the economic consequences for
households of illness and of paying for health care in low- and middle-income country contexts? Soc
Sci Med 62: 858–865
Health Policy & Systems Analysis
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Health Systems Financing – The Case of Community Health Funds