AFRO-NETS> Tanzania community health financing (CHF)

[Claudio Schuftan <aviva@netnam.vn>]

Tanzania community health financing (CHF)
-----------------------------------------
From: <grace_chee@abtassoc.com>


Dear all,

I work with the PHRplus project, and recently led an assessment of 
the Community Health Financing (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 differ-
ent picture of the current situation.

Hanang had been reported to be one of the high performing CHF dis-
tricts, with enrollment rates of 30%. In actuality, we found that 
this enrollment rate quoted at the central level could not be sub-
stantiated. It is likely that the reported rate is based on cumula-
tive 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 admini-
stration 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 lim-
ited, 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 re-
lease the funds. In Hanang, from 1998-2000, the majority of the CHF 
funds (59%) were used to construct the district hospital (at the di-
rection of district officials).

Some of the broader design issues cannot be discussed without agree-
ment 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 ar-
gues 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 bene-
fits 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 mem-
ber household visited the HC/dispensary 32 times during an 11 month 
period studied. Thus, for the Tsh 10,000 enrollment fee these HH re-
ceived services ?valued? at Tsh 32,000 ­ 48,000 (based on user fee 
rates at HC and dispensaries). Given that the user fees only repre-
sent 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 ser-
vices. If this is achieved by raising user fees to increase enroll-
ment, it probably does not serve to increase access for the poor be-
cause 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 in-
crease 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 in-
creasing 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 find-
ings 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.

--
To send a message to AFRO-NETS, write to: afro-nets@usa.healthnet.org
To subscribe or unsubscribe, write to: majordomo@usa.healthnet.org
in the body of the message type: subscribe afro-nets OR unsubscribe afro-nets
To contact a person, send a message to: afro-nets-help@usa.healthnet.org
Information and archives: http://www.afronets.org