1Mkwawa University College of Education, Iringa, Tanzania
2Institute of Development Studies, University of Dar es Salaam, Dar es Salaam, Tanzania
In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country’s level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania.
A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes.
There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts.
This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.
Azfar O, Kähkönen S, Lanyi A, Meagher P, Rutherford D. Decentralization, governance and public services the impact of institutional arrangements: a review of the literature. IRIS Center, University of Maryland, College Park; 1999.
Lagarde M, Palmer N. The impact of user fees on health services utilization in low-and middle-income countries: how strong is the evidence? Bull World Health Organ. 2008;86(11):839–848. doi:10.2471/BLT.07.049197
Manzi F. Experience of Exemptions and Waiver Mechanisms in Kilombero District. Satellite Workshop on Health Insurance, Dar es Salaam, MOHSW; 2005.
Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet. 2001;358(9284):833-836. doi:10.1016/s0140-6736(01)05975-x
James C, Hanson K, McPake B, et al. To retain or remove user fees?: reflections on the current debate in low- and middle-income countries. Appl Health Econ Health Policy. 2006;5(3):137-153.
Hsiao WC. Experience of community health financing in the Asian Region. In: Preker AS, Currin G, eds. Health Financing for Poor People: Resource Mobilization and Risk Sharing. Washington: World Bank; 2004: 119.
Dror DM, Preker AS. Introduction. In: Dror DM, Preker AS, eds. Social Reinsurance: A New Approach to Sustainable Community Health Financing. Washington: World Bank; 2002:627.
Shaw RP, Griffin CC. Financing Health Care in Sub-Saharan Africa Through User Fees and Insurance. Washington: World Bank; 1995.
Adebayo EF, Uthman OA, Wiysonge CS, et al. A systematic review of factors that affect uptake of community based health insurance in low-income and middle-income countries. BMC Health Serv Res 2015;15:543. doi:10.1186/s12913-015-1179-3
United Republic of Tanzania (URT). Community Health Fund Act, No 1 of 2001.
Maluka S, Bukagile, G. Implementation of community health fund in tanzania: why do some districts perform better than others? Int J Health Plan Manage. 2014;29:e368-e382. doi:10.1002/hpm.2226
Mtei G, Mulligan J. Community Health Fund in Tanzania: A Literature Review. Consortium for Research and Equitable health systems (CREHS) London School of Hygiene and Tropical Medicine; 2007.
Mubyazi, GM, Borghi J. Desirability, challenges and options for launching a community health fund scheme in Tanzania: interview based views from community members and health managers in Kagera region and review of lessons from other CHF implementing district. Afr J Health Econ. 2012.
Ekman B. Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan. 2004;19:249-270. doi:10.1093/heapol/czh031
Spaan E, Mathijssen J, Tromp N, McBain F, Have A, Baltussen R. The impact of health insurance in Africa and Asia: a systematic review. Bull World Health Organ. 2012;90:685-692. doi:10.2471/BLT.12.102301
Meng Q, Yuan B, Jia L, et al. Expanding health insurance coverage in vulnerable groups: a systematic review of options. Health Policy Plan. 2011;26:93-104. doi:10.1093/heapol/czq038
Acharya A, Masset Edoardo S, Taylor F, et al. The impact of health insurance schemes for the informal sector in low-and middle-income countries: a systematic review. World Bank Res Obs. 2013;28:236-266. doi:10.1093/wbro/lks009
Msuya JM, Jutting PJ, Asfaw A. Impacts of Community Health Insurance Schemes on Health Care Provision in Rural Tanzania. ZEF; 2004.
URT. The Budget Speech Estimate for the Ministry of Health and Social Welfare (MoHSW) for the Financial Year 2014/2015. Tanzania: Ministry of Health and Social Welfare; 2014.
Bonan J, Lemay-Boucher P, Tenikue, M. Household’s willingness to pay for Health Micro Insurance and its impact on actual take-up: results from a field experiment in Senegal. Working Paper No 15. 2013.
Quaye R. Balancing Public and Private Health Care Systems: The Sub-Saharan Experience. Maryland: University Press of America; 2010.
Asgary C, Willis K, Taghvaei AA, Rafeian P. Estimating rural Willingness to pay for health insurance. Eur J Health Econ. 2004;5:209-215.
Macha J, Kawawenaruwa A, Makawia S, Meti G, Borghi J. Determinants of community health fund membership in Tanzania: a mixed methods analysis. BMC Health Serv Res. 2014;14:538. doi:10.1186/s12913-014-0538-9.
Mwesiga LP. A Project on Enhancement of Community Participation in Community Health Insurance: A Case of Mwananyamara Ward [Thesis]. Tanzania: The Southern New Hamphire University at the Open University of Tanzania, 2007.
Stoammer M, Hanlon P, Tawa M, Macha J, Mosha D. Community Health Fund in Tanzania: Innovation Study. GIZ; 2012.
Kessy FL. Improving Health Service Through Community Participation in Health Governance Structure in Tanzania. J Rural Community Dev. 2014;9(2):14-31.
Adebayo EF, Uthman OA, Wiysonge CS, et al. A systematic review of factors that affect uptake of community based health insurance in low-income and middle-income countries. BMC Health Serv Res. 2015;15:543. doi:10.1186/s12913-015-1179-3
World Health Organization (WHO). Toward Better Leadership and Management in Health: Report on an International Consultation on Strengthening Leadership and Management in Low-income Countries. Accra, Ghana: WHO; 2007.
Asante A, Hall J. Analysis of Health Leadership and Management Capacity in Six Asia and Pacific Island Countries. Kensington: HRH Knowledge Hub, University of New South Wales, 2010.
Asante AA, Iljanto S, Rule J. Strengthening Health Management and Leadership at the District Level: What Can We Learn From High Performing Districts in the West Java Province of Indonesia? Sydney, Australia: Human Resources for Health KnowledgeHub; 2012.
Maluka S, Bukagire G. Community participation in the decentralised district health systems in tanzania: why do some health committees perform better than others? Int J Health Plann Manage. 2016;31(2):E86-E104. doi:10.1002/hpm.2299
Mubyazi GM, Kunda SJ, Kisinza WN, Nyoni J, Borg J. Feasibility of a community health fund in Tanzania: a qualitative analysis of policy prospects and local stakeholders’ experience-based views in Kagera region. Afr J Health Econ. 2014;AJE-2014-000:1-36.
Marberry SO. Innovations in Healthcare Design: Selected Presentations From the First Five Symposia on Healthcare Design. Canada: John Wiley and Sons, Inc; 1995.
Mayer RC, Gavin MB. Trust in Management and Performance: Who Minds the Shop while the Employees Watch the Boss? Acad Manage J.. 2005;8(5):874-888.
Bradley S, Kamwendo F, Masanja H, et al. District health managers’ perceptions of supervision in Malawi and Tanzania. Hum Resour Health. 2013;11:43. doi:10.1186/1478-4491-11-43.