’
THE CBEH - KILIMANJARO TEAM
EVALUATION SEMINAR
HANOI – May, 2010
1
Towards Universal Health
Insurance in Tanzania
‘‘Operational experiences of Health
Insurance Regulations from different
countries and their practical
applicability in Tanzania’’
2
Why the topic

A move towards SHI is a core element of the
government’s HF policy: NHIF is a best example

Fits with the current debate in the region and global



WB, WHO: 2005 Assembly called for all HS to move to
Universal coverage ‘‘access to adequate health care for all at
an affordable price’’
ABUJA Declaration, MGD (Link health and poverty): Half
poverty by 2015
ILO/GTZ: Social Health Protection
3
More examples
 In
most developing countries
providing affordable health care is high
on the development agenda, given the
large numbers of people lacking
sufficient financial means to access
health services
4
while
 In
most developed the agenda is
towards guaranteeing the accessibility
of healthcare despite the increasing
costs, financial constraints of public
budgets and economic considerations
5
Methodology: Tools
Multiple
 Desk review

Interviews - More than 14 (Annex)

FDG - 14 Participants (Experts)
6
Limitations/Challenges

Restrict to four countries only :





Germany
Ghana
Philippines
Israel
Focus on limited parameters




Administration
Financing
Coverage
Benefit
7
Tanzania at Glance
8
Profile in Brief
Demography
Population-40 est with Average growth rate
Rural - 70%, Urban 30%
Economy
GDP - 4,754.46 billion
LFS – Formals - 25%, Informal - 75%
Per Capita around 444-500 USD (on average -annually)
Health
LFE - 51/52 M/F
Fertility Rate - Total 5.6
Per Capita - 11 USD (far from WHO - 34%)
Infant - 58 while Under 5 Mortality R - 91
9
THE HEALTH
STRUCTURE
IN BRIEF
10
11
12
13
14
FINANCING
WHO PAYS WHAT???
15
QUICK PICTURE
16
Regulatory Framework
Mix: Public/Private/Other
Compulsory
 National Health Insurance Fund (NHIF)
 National Social Security Fund (NSSF)
Voluntary
 Community Health Funds (CHF)*
 Micro-health Insurance Schemes (MHIS)
Other Funding sources include:
 Government and Local Governments
 Basket Funding
 NGOs
 Private Financing
17
Social Health Insurance
in Tanzania
An overview
18
INDICATORS

Varies in each Scheme: Depending on the Law
Administration
 Financing
 Coverage
 Benefit
 Please see Report for further details

19
Major/Related Health Policy








The National Health Policy: 2003
The National Poverty Eradication Strategy
The Vision 2025
National Strategy for Growth and Reduction of
Poverty (NSGRP)
Guiding Health Insurance Regulations
The Social Security Regulatory Act
The Insurance Act (2009)
Health Insurance Scheme Acts
20
The Selected Countries in Brief

Germany


Due to its impeccable experiences on social health
Insurance yet, very complex systems which covers
almost 90 per cent of the entire
Israel

Provided some of the interesting features with
regard to equity and benefit packages as well as
political commitment
21
Continues…

Ghana


It provides a comparable grounds with Tanzania, and it has
adopted an ingenious approach by incorporating existing
community financing schemes in extending healthcare
coverage
Philippines

As a middle income country provide a good basis for
comparable and applicable regulations due to the rich
experience on social health insurance and strategies used to
reach the informal sector through social health Insurance
22
GERMANY…..




Incremental development of SHI since 1883
Laws focused on how voluntary SKF (benefit,
coverage and fund management) by then local
government had the mandate to even make
membership compulsory
1854 - Compulsory national wide-miners
(milestone for categorical coverage )
By 1910 - 37%; 1950 – 70% while by 2000 88%
 Years
in total more than 100???
23
INDICATORS

Administration : The Joint Federal Commission, Social
code Book, 5.2.1.2



Make all laws (Social Code Book)
National Health Fund: Responsible for SKF
Financing

Mix (tax, contributions based on wages (cap 43,000 Euro per
year, employee 8% gross wage, employer 7% = 540 Euro per
month = by 2009 new flat rate contribution was to be set Sick F will continue to collect but put to a new national
health fund which allocate fund to SF (Double cost or ?)
24
Germany cont..

Benefit


Preventive, mental, in-out patient, prescription
drugs, rehabilitation, long-term care (separately mandatory)
Coverage

Compulsory - 48 Euro per year,75%, above opt out,
Shi - 88%, 10 private less than 1 no insurance - By
2009 - Mandatory
25
ISRAEL




Political commitment even before independence
1911 Health Insurance for agricultural workers in collective
settlement
1995(NHI) by 80s more than 80% was insured
The nature and the achievement of the health care system in
Israel stem, to a large extent, from its foundation in organized
social arrangements as well as a general consensus that society as
a whole is responsible for the health of its citizens. This guiding
principle has been reflected in the structure of health services in
Israel, combining state activities with those of the voluntary
health plans (non-profit mutual organizations).

More than 84 yrs
26
Israel continues..

Administration




National Insurance Institute funds – Collect
MOH-Supervise
Four non-profit health plans operate in Israel; Clalit, Maccabi, Meuhedet
and Leumit.
Financing: Contributions/Tax –Progressive

Individuals pay 3.1% on wages up to half of the average national wage
and 4.8% on income beyond that level

Coverage

Benefit hospital care, community-based health care,
pharmaceuticals
27
UNLIKE GERMANY…

Israel does not have a well-developed culture of
government regulation in the health sector.
Instead, government has relied primarily on
budgetary controls, offers of subsidies and moral
and political suasion to influence
nongovernmental providers.
28
Philippines

Phase 1 Covering the formally employed sector


August 4, 1969 Philippines Medical Care Act approved 1972
Philippine Medicare Commission formed, start of mandatory
enrolment of employees in the formal sector and 1991 Local
Government Code introduced; dealing with service Delivery,
enrolment of indigents
Phase 2 Shifting toward universal coverage

1995 Phil Health created to implement Republic Act
78751999 Department of Health launches the Health Sector
Reform Agenda October 1999 Launch of indigent program
29
Philippines….

Administration


Phil-Health responsible for managing and
Developing the NHIP
Financing

The premiums are set at 2.5% of employees’ salaries
divided equally between employers and employees.
A salary cap is set at P25, 000 per month that means
contribution do not increase when earning reach this
level or beyond
30
Ghana

Ghana passed the National Health Insurance
Act (NHIA) in 2003, and it became operational
in March 2004. The scheme is operated as a
decentralized national health insurance system
encompassing district mutual health and private
schemes in all 110 districts
31
Ghana …

Administration


The National Health Insurance Council govern the
insurance scheme and reports to the president
through the minister of health.
Financing

Employers/Employees
32
Ghana….

Benefit


The central government sets the minimum benefits package,
licenses and regulates the health insurance schemes, certifies
the providers, and collects a national health insurance levy
and uses it to subsidize premiums for the poor.
Coverage

Aim: achieving insurance coverage of 30 to 40% of the
population by 2010 and 50 to 60% by 2015 – 20.
33
Ghana….

Benefit


According to Obamann et al. (2005) the benefits under the
NHIP are principally, but not exclusively, related to inpatient
care. Under PhilHealth’s implementing rules and regulations,
the scope of benefits is determined in terms of; inpatient
hospital care, room and board charges, fees of health care
professionals
Coverage

Membership is on compulsory for all government and non
government employees.

More than 30 years
34
SUM - UP Lessons
The state has been responsible
 for supervising, licensing and overall planning
of health services
 Subsidized some of the voluntary health plans
and other bodies, as well as directly providing
some services not offered by the health plans,
 Flexibility: Portability/switching of
 regulate competition among health plans
 Long time and Phases
35
Towards Universal Coverage:
Applying Lessons

Good Governance
 Harmonization

of all regulations and Policies
Quality Service
 May
need new agent to own or control
facilities

Political commitment
 Translated
into implementation
36
Towards Universal Coverage:
Applying Lessons…
Clear measurable Objectives
 Pragmatic strategies


Looking at each sector and design schemes
accordingly)
Invest in Human capital
 Research


Data and Improving Technology
37
FINDINGS PART II:
INTERVIEWS/FGD
What do you think is solution for universal coverage of
health insurance in Tanzania: 67% to structure and
utilize the existing structure of HI
8%
we need structure of HI that will
involve all public servants,
informal and formal sectors.
8%
we need to involves all health
insurances stakeholders
To have a regulator that will
oversee the implimentation of HI
17%
67%
we need mandatory health
insurances
38
Is there a fiscal solutions?


Some facts:
Formal Sector (25%) (About 12 %)
Public
 Private (NHIF/NSSF/Voluntary)


Informal Sector (75%)
Irregular Income( 65)
 Poor and Senior citizen (old age, retirees) -10 %

39
The need for coordinated
regulation…
100% of all interviewed stakeholders
show their concern on the need to
have an elaborated health insurance
regulation
in
order
to
improve/harmonizing the existing
structure and enhance the move
towards Universal Coverage
Possibilities
Formal choose – NHIF/NSSF
 Informal

 CHF/TIKA
–Matching Funds/Contributions
 CHF
- Under NHIF ( Card to all members,
mobility of services up to District)
 What to do
Advocacy
 Training
 Research

41
…more to consider
 Poor
and Old
 Subsidies
through CHF/NHIF ( Is it
sustainable? With budget deficit?)
 Tax
 Corporate
(earmarked for this group)
 Environmental Taxes (Excise tax/Alcohol,
Cigarettes etc)
42
Advantages and challenges
Scheme type
Advantages
Challenges
Public or
national health
service
Only system that guarantees 100% population
coverage
Progressive revenue collection
National budget offers wide resource base
Administrative simplicity (lowest admin costs)
Funding variable and may be
limited by budget/MoF
Limited provider competition or
choice
Quality issues
Social health
insurance
Mobilizes additional resources from employers
Earmarked funding insulates revenue from annual
budget round
Usually progressive
Transparency/visibility of system enhances
legitimacy/population support as well as quality
care
May not achieve 100% coverage
due to link to work and premiums
Taxes usually capped, so less
progressive
Payroll contributions may
adversely affect employment
More complex management
systems
Private
voluntary
schemes
Financial protection to those who can afford
and offer tailored HI products
Increases sources of funding for sector
Can increase competition for quality and efficiency
May reinforce inequities in access
Cannot provide 100% coverage
May result in ‘wasteful’ expenses
eg marketing, extra admin costs
43
Advantages and challenges (2)
Scheme type
Advantages
Challenges
CBHI and
MHOs
Targets population groups usually outside public
social protection schemes
May help equity by closing social protection gap
with formal sector
Facilitate donor and Govt support /subsidies
Assist Govt and donors to better target subsidies
and extend protection to informal sector
Develop tools and techniques used by NHIS
Small risk pools result in low revenue
and limited benefits
Limited financial protection due to
small revenue base and benefit
package
Cannot cover poorest without unless
subsidized
Limited ability to affect care delivery
NHIS/NHIF
Same as CBHI/MHOs above plus:
Ability to cover much larger population due to
bigger risk pool and revenue base
Offers much more attractive benefits
Addresses equity shortcomings of CBHI
Design may not be optimal esp if
driven mainly by politics
Revenue bases still fragile, thus
sustainability still in question
Tendencies towards bureaucratization
and centralization
Cost escalation an issue
Reaching the very poor still a
challenge
44
Way forward - Conclusion
Forming
Storming
Norming
Performing
45
Presenters
•Zubeda Chande – Country
•Members
•Innocent Mauki –
•Happiness Katuma –
•Victima Munishi –
Team Coordinator
46