Assessment of Strategic Healthcare Purchasing Arrangements and Functions Towards Universal Coverage in Tanzania

Document Type : Original Article

Authors

Ifakara Health Institute, Dar es Salaam, Tanzania

Abstract

Background 
Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania.

Methods 
We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data.

Results 
The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates.

Conclusion 
Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

Keywords


  1. Etiaba E, Onwujekwe O, Honda A, Ibe O, Uzochukwu B, Hanson K. Strategic purchasing for universal health coverage: examining the purchaser-provider relationship within a social health insurance scheme in Nigeria. BMJ Glob Health. 2018;3(5):e000917. doi:1136/bmjgh-2018-000917
  2. Ataguba JE, Ingabire MG. Universal health coverage: assessing service coverage and financial protection for all. Am J Public Health. 2016;106(10):1780-1781. doi:2105/ajph.2016.303375
  3. Mbau R, Kabia E, Honda A, Hanson K, Barasa E. Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. Int J Equity Health. 2020;19(1):19. doi:1186/s12939-019-1116-x
  4. Hanson K, Barasa E, Honda A, Panichkriangkrai W, Patcharanarumol W. Strategic purchasing: the neglected health financing function for pursuing universal health coverage in low-and middle-income countries comment on "what's needed to develop strategic purchasing in healthcare? Policy lessons from a realist review". Int J Health Policy Manag. 2019;8(8):501-504. doi:15171/ijhpm.2019.34
  5. Sieleunou I, Tamga DDM, Maabo Tankwa J, Aseh Munteh P, Longang Tchatchouang EV. Strategic health purchasing progress mapping in Cameroon: a scoping review. Health Syst Reform. 2021;7(1):e1909311. doi:1080/23288604.2021.1909311
  6. Klasa K, Greer SL, van Ginneken E. Strategic purchasing in practice: comparing ten European countries. Health Policy. 2018;122(5):457-472. doi:1016/j.healthpol.2018.01.014
  7. Bossert T, Chitah MB, Bowser D. Decentralization in Zambia: resource allocation and district performance. Health Policy Plan. 2003;18(4):357-369. doi:1093/heapol/czg044
  8. Maluka S, Chitama D, Dungumaro E, Masawe C, Rao K, Shroff Z. Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation. Int J Equity Health. 2018;17(1):118. doi:1186/s12939-018-0835-8
  9. Shayo EH, Senkoro KP, Momburi R, et al. Access and utilisation of healthcare services in rural Tanzania: a comparison of public and non-public facilities using quality, equity, and trust dimensions. Glob Public Health. 2016;11(4):407-422. doi:1080/17441692.2015.1132750
  10. Kapologwe NA, Meara JG, Kengia JT, et al. Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: a strategy towards achieving universal health coverage in Tanzania. BMC Health Serv Res. 2020;20(1):218. doi:1186/s12913-020-5057-2
  11. United Republic of Tanzania Ministry of Health and Social Welfare: Health Sector Strategic Plan July 2015 – June 2020 (HSSP IV) Reaching all Households with Quality Health: (HSSP IV) Reaching all Households with Quality Health Care. Dar es Salaam, Tanzania: URT; 2015.
  12. National Health Accounts for financial years 2013/14, 2014/15 and 2015/16: The United Republic of Tanzania, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania [press release]. 2019.
  13. United Republic of Tanzania, National Health Accounts 2020, Dodoma, Tanzania. 2020.
  14. Brinda EM, Andrés AR, Enemark U. Correlates of out-of-pocket and catastrophic health expenditures in Tanzania: results from a national household survey. BMC Int Health Hum Rights. 2014;14:5. doi:1186/1472-698x-14-5
  15. Ssewanyana S, Kasirye I. Estimating catastrophic health expenditures from household surveys: evidence from Living Standard Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) from sub-Saharan Africa. Appl Health Econ Health Policy. 2020;18(6):781-788. doi:1007/s40258-020-00609-1
  16. National Bureau of Statistics, Tanzania Mainland Poverty Assessment, Executive Summary. 2020. https://www.nbs.go.tz/nbs/takwimu/hbs/Tanzania_Mainland_Poverty_Assessment_Report.pdf.
  17. Wang H, Rosemberg N. Universal Health Coverage in Low-Income Countries: Tanzania’s Efforts to Overcome Barriers to Equitable Health Service Access. Washington, DC: World Bank; 2018.
  18. Mtei G, Makawia S, Ally M, Kuwawenaruwa A, Meheus F, Borghi J. Who pays and who benefits from health care? An assessment of equity in health care financing and benefit distribution in Tanzania. Health Policy Plan. 2012;27 Suppl 1:i23-34. doi:1093/heapol/czs018
  19. Haazen D. Making Health Financing Work for Poor People in Tanzania. World Bank Publications; 2012. doi:1596/978-0-8213-9473-1
  20. Mtei G, Mulligan JA, Palmer N, Kamuzora P, Ally M, Mills A. An Assessment of the Health Financing System in Tanzania: Implications for Equity and Social Health Insurance: Report on Shield Work Package 1. 2007. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=993421.
  21. National Health Insurance Fund (NHIF). Acturial Valuation Report as at June 2015. Dar es Salaam, Tanzania: NHIF; 2016.
  22. Lee B, Tarimo K, Dutta A. Tanzania’s Improved Community Health Fund: An Analysis of Scale-Up Plans and Design. 2018. http://www.healthpolicyplus.com/ns/pubs/10259-10469_TanzaniaiCHFScaleUpbrief.pdf. Accessed June 2019.
  23. Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC). Tanzania Health Financing Strategy 2015-2025 Path Towards Universal Health Coverage. Dar es Salaam, Tanzania; 2015.
  24. 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 Res Policy Syst. 2013;11:21. doi:1186/1478-4505-11-21
  25. National Health Insurance Fund (NHIF). The National Health Insurance Fund Act, 1999. Dar es Salaam, Tanzania: NHIF; 1999.
  26. National Social Security Fund (NSSF). The National Social Security Fund Act, 1997. Dar es Salaam, Tanzania: NSSF; 1997.
  27. Salari P, Di Giorgio L, Ilinca S, Chuma J. The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Glob Health. 2019;4(6):e001809. doi:1136/bmjgh-2019-001809
  28. Barasa EW, Maina T, Ravishankar N. Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. Int J Equity Health. 2017;16(1):31. doi:1186/s12939-017-0526-x
  29. Yin RK. Case Study Research: Design and Methods. Thousand Oaks, CA: SAGE Publications; 2003.
  30. Strategic Purchasing Africa Resource Centre (SPARC). Technical Partnership on Strategic Health Purchasing Progress Mapping. Cotonou, Benin: SPARC; 2020.
  31. Lee B, Tarimo K, Dutta A. Analysis of Cost Escalation at the National Health Insurance Fund in Tanzania. Washington, DC: Health Policy Plus (HP+); 2018. http://www.healthpolicyplus.com/ns/pubs/10271-10491_TZAnalysisofCostEscalation.pdf.
  32. White J, O’Hanlon B, Chee G, et al. Tanzania Private Sector Assessment. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates Inc; 2013.
  33. United Republic of Tanzania (URT). Community Health Fund Act, 2001. Dar es Salaam, Tanzania: URT; 2001.
  34. Wagenaar C, Marwa H, Irrgang E. iCHF: How a Public-Private Partnership Can Help Make Healthcare Work in Northern Tanzania. Amsterdam, The Netherlands: PharmAccess Group; 2016.
  35. Kapologwe N, Joachim C, Makawia S, Mtei G. Making Provider Payment Mechanisms More Strategic: Removing the Roadblocks to Implementation. https://resyst.lshtm.ac.uk/resources/making-provider-payment-mechanisms-more-strategic-removing-roadblocks-to-implementation. Published 2019.
  36. Kuwawenaruwa A, Borghi J. Health Insurance Cover is Increasing Among the Tanzanian Population but Wealthier Groups Are More Likely to Benefit. Vol 11. Dar es Salaam, Tanzania: Ifakara Health Institute; 2012.
  37. Piatti-Fünfkirchen M, Ally M. Tanzania Health Sector Public Expenditure Review 2020. Washington, DC: World Bank; 2020.
  38. Kazungu JS, Barasa EW, Obadha M, Chuma J. What characteristics of provider payment mechanisms influence health care providers' behaviour? A literature review. Int J Health Plann Manage. 2018;33(4):e892-e905. doi:1002/hpm.2565
  39. Liu X, Hotchkiss DR, Bose S. The impact of contracting-out on health system performance: a conceptual framework. Health Policy. 2007;82(2):200-211. doi:1016/j.healthpol.2006.09.012
  40. Aas IH. Incentives and financing methods. Health Policy. 1995;34(3):205-220. doi:1016/0168-8510(95)00759-8
  41. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press (US); 2017.
  42. Jegers M, Kesteloot K, De Graeve D, Gilles W. A typology for provider payment systems in health care. Health Policy. 2002;60(3):255-273. doi:1016/s0168-8510(01)00216-0
  43. The National Health Policy 2017. Tanzania: Ministry of Health; 2017.
  44. National Health Policy 2003. Dar es Salaam, Tanzania: Ministry of Health; 2003.
  45. Kalolo A, Radermacher R, Stoermer M, Meshack M, De Allegri M. Factors affecting adoption, implementation fidelity, and sustainability of the Redesigned Community Health Fund in Tanzania: a mixed methods protocol for process evaluation in the Dodoma region. Glob Health Action. 2015;8:29648. doi:3402/gha.v8.29648
  46. Wiedenmayer K, Mbwasi R, Mfuko W, et al. Jazia prime vendor system- a public-private partnership to improve medicine availability in Tanzania: from pilot to scale. J Pharm Policy Pract. 2019;12:4. doi:1186/s40545-019-0163-4
  47. Kuwawenaruwa A, Tediosi F, Obrist B, et al. The role of accountability in the performance of Jazia prime vendor system in Tanzania. J Pharm Policy Pract. 2020;13:25. doi:1186/s40545-020-00220-8
  48. Kuwawenaruwa A, Remme M, Mtei G, et al. Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania. Int J Health Plann Manage. 2019;34(1):e860-e874. doi:1002/hpm.2702
  49. Kapologwe NA, Kalolo A, Kibusi SM, et al. Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol. Health Res Policy Syst. 2019;17(1):11. doi:1186/s12961-018-0400-3

Articles in Press, Corrected Proof
Available Online from 16 July 2022
  • Receive Date: 14 April 2021
  • Revise Date: 06 July 2022
  • Accept Date: 13 July 2022
  • First Publish Date: 16 July 2022