Donor agencies frequently claim that they do not subscribe to any blue print approach to health care reform in developing countries. Can we conclude that it’s just coincidence then that such a similar model of health insurance is under consideration in a growing number of low-income countries, despite little evidence that it can deliver universal coverage in such settings? A recent paper by Ghanaian NGOs in partnership with Oxfam brought into question the apparent ‘success’ of health insurance in Ghana. Here I take a look at Tanzania – another example of how the health insurance approach struggles to reach the most vulnerable and insecure in society i.e. the 90% of citizens who work in the informal economy.
Like for so many countries, user fees and other cost-sharing methods were introduced in Tanzania in the 1990s as part of the World Bank and IMF Structural Adjustment Programme. Again as is common, official user fee exemptions are rarely implemented successfully in Tanzania. Maternal services are supposed to be free for example but 73% of women delivering in a government facility still pay.
About ten years ago two new insurance schemes were introduced, one for the formal sector and one for the informal. The WHO has cautioned that such a split between formal and informal can lead to a two tier system and if it achieves partial success can delay more fundamental reform to reach citizens at scale. With only 4% coverage for the informal sector and a far inferior benefits package this risk is now a reality in Tanzania .
The National Health Insurance Scheme (NHIS) for formal sector and government employees is funded by a 6% salary contribution split between employee and employer. The insured employee, their spouse and four children are entitled to a generous package of health care from government and accredited non-state providers. However, as 90% of the population work in the informal sector its contribution to universal coverage is very limited.
The community health fund (CHF), and more recently its urban equivalent, Tiba Kwa Kadi (Tika), was set up with assistance from the World Bank with the aim of reaching 60% of households by 2003. It is a voluntary pre-payment scheme with an annual membership fee of 5,000 – 10,000 Tanzanian Shillings (US$3-$6). Member contributions are matched by government at district level. Benefits are much less than the NHIS – expensive hospital care is not covered.
The WHO Alliance for Health Policy and Systems Research recently estimated that national coverage of the CHF was less than 4%. Official figures for the NHIF and CHF combined estimate population coverage to be only 15%. Evidence shows that non-members, or 75% of Tanzanian citizens, are less likely to seek medical care when they are ill and are more likely to rely on self-medication. There are also serious equity challenges to consider. CHF contributions do not vary with income and inability to pay annual premiums is a major barrier preventing the poorest from joining the scheme. In principle those unable to pay are entitled to an exemption but there are significant problems with the criteria used and enforcement. Furthermore, regional inequality is exacerbated as poorer districts with fewer members are less able to generate additional revenue through match funding.
After ten years, 15% coverage is disappointing at best. I haven’t seen much evidence of donor agencies sharing the Tanzania experience with other countries interested in pursuing a similar health financing route.
 This is lower than official estimates – for 2007 the MOHSW reported that uptake of CHF was lower than expected at just 10% of rural households (range 4-40%)