NHIF Phase One report - DOC

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					Final report

Review of claims status for the National Health
Insurance Fund

Phase One




                                  May 2006

                                  AD Kiwara
                                  Gradeline Minja
                                  Manfred Störmer
                                  Ulrika Enemark
Table of Contents

i. Acknowledgements ................................................................................................................... i
ii. Abbreviations .......................................................................................................................... ii
iii. Executive summary ................................................................................................................ ii

1.      Introduction.......................................................................................................................... 1

2.      Methodology ........................................................................................................................ 1

3.     Context ................................................................................................................................ 2
     3.1.  Health sector reforms and the NHIF .............................................................................. 2
     3.2.  Other insurance initiatives in Tanzania .......................................................................... 3

4.     Importance of NHIF as a source of funding ........................................................................... 4
     4.1.  Observations ............................................................................................................... 5
     4.2.  Recommendations ....................................................................................................... 8

5.     Accreditation ........................................................................................................................ 9
     5.1.   Background ................................................................................................................. 9
     5.2.   Observations ............................................................................................................. 10
     5.3.   Recommendations ..................................................................................................... 12

6.     Registration/deregistration of beneficiaries .......................................................................... 13
     6.1.   Background ............................................................................................................... 13
     6.2.   Observations ............................................................................................................. 15
     6.3.   Recommendations ..................................................................................................... 16

7.     The claiming system .......................................................................................................... 17
     7.1.   Background ............................................................................................................... 17
     7.2.   Observations ............................................................................................................. 17
     7.3.   Recommendations ..................................................................................................... 19

8.     Reimbursement and use of funds ....................................................................................... 20
     8.1.  Background ............................................................................................................... 20
     8.2.  Observations ............................................................................................................. 22
     8.3.  Recommendations ..................................................................................................... 23

9.     Benefit package and quality of care received....................................................................... 24
     9.1.  Background ............................................................................................................... 24
     9.2.  Observations ............................................................................................................. 24
     9.3.  Recommendations ..................................................................................................... 25

10.    Key recommendations ................................................................................................... 26
  10.1. Summary of key recommendations ............................................................................. 26
  10.2. Table of key recommendations ................................................................................... 29

11.         Phase two implementation ............................................................................................. 31

References ............................................................................................................................... 33
i. Acknowledgements

This report is the result of the first phase of the Review of the NHIF that is undertaken at the
request of the Ministry of Health, Dar es Salaam. The review is organised by the MOH, in
collaboration with Danida and GTZ and funded by MOH/Danida HSPS.

The team for the first phase consisted of A.D. Kiwara, Institute for Development Studies, University
of Dar es Salaam, Gradeline Minja, Health Economist, Health Sector Reform Secretariat, Ministry
of Health, Manfred Störmer, M.A. Public Administration, External Consultant and Ulrika Enemark,
Health Economist, External consultant. The team bears collective responsibility for the findings and
opinions expressed in this report. They cannot be attributed to the team members’ organisations,
their sponsors or to the Ministry of Health.

The team wishes to express its sincere gratitude to all those who facilitated its work: the many
health facility staff, government and aid agency staff, in Dar es Salaam, Tanga and Mwanza
regions and the districts, who were willing to share with us their time, insights and experiences.
The Team is thankful to the Health Sector Reform Secretariat/MOH, GTZ and Danida HSPS for
providing office space and logistics support, which has grossly facilitated the work of the team.




                                                                                                     i
ii. Abbreviations
 ADDO             Acredited Drugs Dispensing Outlet
 AMO              Assistant Medical Officer
 CCHP             Comprehensive Council Health Plan
 CHF              Community Health Fund
 CHMT             Council Health Management Team
 CSSC              Christian Social Services Commission
 Danida           Danish International Development Assistance
 DDH              District Designated Hospital
 DH               District Hospital
 DMO              District Medical Officer
 FY               Fiscal Year
 GOT              Government of Tanzania
 GTZ              Gesellschaft für Technische Zusammenarbeit (German Technical
                  Co-operation
 HFGC             Health Facilities Governing Committees
 HSF              Health Service Fund
 JRF              Joint Rehabilitation Fund
 KfW              Kreditanstalt für Wiederaufbau (Bank for Reconstruction and
                  Development, Germany)
 LGA              Local Government Administration
 MD               Medical Doctor
 MOH              Ministry of Health
 MSD              Medical Store Department
 MTEF             Medium Term Expenditure Framework
 MTHUA            Mfumo wa Takwimu wa Uendeshaji wa Hudumaza Afya
 NHIF             National Health Insurance Fund
 OC               Other Charges
 OPD              Out Patient Department
 PE               Personnel Emolument
 PER              Public Expenditure Review
 PHN              Public Health Nurse
 PHC              Primary Health Care
 PORALG           Presidents Office for Regional Administration and Local
                  Government
 RMO              Regional Medical Officer
 TFDA             Tanzania Food and Drug Authority
 TSh              Tanzania Schilling
 USD              United States of America Dollars
     TFDA




Exchange rate (May 1, 2006):
1 EURO = 1594 TSh
1 USD = 1262 TSh




                                                                                 ii
iii. Executive summary

Introduction
The National Health Insurance Scheme for formal sector employees started operations in 2001.
Although public servants are spread across the country, the experience to date is that services,
especially at the health centre and dispensary level, are insufficiently used and that the NHIF is not
optimally used as revenue source for the health facility.

Methodology
The review is carried out in two phases. Phase one included a situation analysis with
recommendations for practical implementation. The objective of phase two is to assist health
facilities in selected districts to address weaknesses identified by implementing the
recommendations. Based on the experiences, recommendations will be made regarding wider
implementation.

For phase one the team interacted with offices in Dar es Salaam and made field visits to Tanga
and Mwanza Region, visiting 7 districts. The team reviewed documents and data supplied by
institutions and facilities visited.

Findings & main recommendations
The NHIF is collecting a significant amount in contribution from its members. Although on the
increase, the actual reimbursement for services rendered to members or their dependants remains
relatively low. This is a cause of concern.

The level of reimbursements made depends on the extent to which beneficiaries have cards, the
extent to which accredited facilities are available and provide services of such quality that they are
utilised, the extent to which such facilities correctly fill and submit claims and the extent to which
reimbursements flow to the health facilities and are used for improvement of services. The team
found that there were problems in all these areas.

While there are still improvements to be made in the claiming process, the team found that
generally attention has been given to claims processing. There is, however, a need for clarification
of procedures and practices in certain areas and a need for strengthening monitoring and follow up
on submission of claims. Non-use of services by members constitutes another problem both
relating to a technical problem with availability of beneficiary cards as well as to a problem with the
quality of services available in accredited facilities resulting in bypassing of lower level facilities and
preference for private providers.

With regard to the institutional set up to support the improvements in the functioning of the claims
and reimbursement system with a view to increasing expenditures and use of funds at facility level
the team recommends that

       The process of decentralisation in NHIF to zonal office continues and that these offices are
        adequately staffed and equipped.

       A focal person for NHIF is appointed by the DMO at district level. The responsibilities of the
        focal person should include
            o supporting health facilities in timely and correct processing of claims,
            o ensuring short introduction of new in-charges to the claiming process
            o assisting in follow up of members with missing NHIF beneficiary cards.




                                                                                                         iii
           In the longer term it could be considered to have a more general health financing focal
           person.

      The health facility governing committees are empowered through training and tools in
       relation to
           o the financial monitoring, i.e. in monitoring revenues collected, claims submitted and
               reimbursed, expenditures and balance available
           o decision-making on the use of revenues collected in the facility including the NHIF
               reimbursements (also in the context of achieving minimum quality standards)
           o planning and budgeting.
           This would of course be relevant also for other sources of financing.

      NHIF reimbursements are treated as other revenues collected at facility level in terms of
       where funds are deposited and procedures for accessing the funds in order to avoid parallel
       systems. Preferably such funds should be kept in a “cost sharing” account at district level.
       Clear guidelines on where to deposit funds and which rules for accessing funds that apply
       should be issued and effectively disseminated by MOH/PMORALG.


With regard to improving beneficiaries’ access to quality health services, the team recommends
that NHIF:

      Develop accreditation guidelines clearly defining the “minimum standards” required by a
       health facility in order to be accredited. National accreditation criteria presently being
       developed by CSSC, MOH, NHIF with consultation of TBS should not only spell out the
       recommended standards, but also clearly define the minimum standards below which no
       health facility can be granted accreditation.

      Review the quality of each government facility with the objective to identify which facilities
       do not fully fulfil the criteria stipulated in the Ministry of Health Standard Facility Guidelines.
       The facilities that do not meet the criteria should be given a transitional accreditation of 2-3
       years against a “Health Facility Development Plan” which would spell out how to improve
       the situation over that period. This plan could also be used as a tool for the Health Facility
       Governing Committee for mobilisation of funds as well as for prioritisation of use of
       revenues generated at facility level. The plan should be integrated into the CCHP.

      Explore the possibilities for extending accreditation to more pharmacies and drug outlets,
       particularly in the rural areas (e.g. the ADDO – system, depending on the findings of
       ongoing consultancy missions on ADDO).

In order to ensure that all eligible beneficiaries have cards the team recommends that

      A survey of eligible members and their membership card status is undertaken at district
       level in order to assess the magnitude of the problem and to address the problem of
       missing cards.

      A routine system for, in future, capturing eligible members without cards is set up.

      Clear guidelines for replacement of missing cards is disseminated to members and
       providers.




                                                                                                         iv
      In the short to medium term, the issue of retrieval of cards from members that become
       ineligible, due to retirement or change in job situation etc., is resolved. A starting point
       would be an options analysis taking into account costs and practicalities of alternative
       options.

Basically, the claiming and reimbursement system set up is sound, but there is lack of clarity on
some details and acceptable ways of claiming. Further, monitoring of submission and
reimbursement needs to be strengthened. In addition to strengthening the monitoring role of the
health facility governing committees mentioned above the team recommends that

      NHIF based on experience with areas that have caused confusion provide clear guidelines
       and effectively disseminate these, including such areas as
          o procedures for paying additional inpatient days exceeding the stipulated limits, if
              required
          o procedures for replacement of lost or missing membership cards
          o new treatment regimes that are reimbursable

      NHIF improve routine procedures
          o Give notification to health facilities through the DMO (copy to RMO) when health
              facilities have not claimed within 60 days
          o Regularly check that the address used for communication and payment to facilities
              are correct
          o Regularly update directory of all accredited health facilities
          o Undertake annual review of price list
          o Improve feedback letter from NHIF to DMO to provide reasons for rejection of
              claims not just by claim number, but also by facility.


Phase two implementation
Finally, the team proposes to test the feasibility of some of the recommendations with a view to
make recommendations for wider implementation based on the experiences with implementation in
selected districts. For selected districts the objectives of phase two are to:

           1.   Increase the number of NHIF members in the district with cards
           2.   Reduce the rate of claims being rejected
           3.   Increase the number of health facilities submitting their claims
           4.   Increase the awareness of the financial status of the facilities and ways of using
                balance funds.

The proposed activities to be implemented to address these objectives are:

           1. Development of a job description for an NHIF focal point, selection and training of
              focal persons.
           2. Undertaking a census of eligible NHIF members and their card-holding status.
           3. Development of routine reporting on NHIF members without cards.
           4. Development of simple financial monitoring tools.
           5. Training of health facility governing committees and health staff in principles of the
              NHIF, claims rules and regulations, financial monitoring as well as division of roles.




                                                                                                       v
1. Introduction

In the early 1990s, the MOH started exploring possibilities for the development of health insurance
as a long-term health care financing mechanism for Tanzania. One of the outcomes was the
decision to establish a mandatory National Health Insurance Scheme for formal sector employees
starting with the government sector. The scheme started operations in 2001.

Although public servants are spread across the country, the experience to date is that services,
especially at the health center and dispensary level, are insufficiently used and that the NHIF is not
optimally used as revenue source for the health facility. Among the reasons indicated are
    - facilities accredited have problems in claiming payment
    - the revenues from services provided to NHIF members are not easily accessible and
       therefore not used by health facilities.

The MOH (with support of DANIDA and GTZ) therefore decided to commission a review of the
NHIF with a focus on the status of claims and with a focus on practical recommendations for
implementation that will contribute to the development and consolidation of an effective system of
claims and reimbursement.

The review was planned to be carried out in two phases. Phase one includes a situation analysis of
problems and possible solutions with recommendations for implementation. The objectives of
phase one are to visualise the relative importance of NHIF funding in the context of other sources
at various levels of the health system and to analyse the reasons for the low level of claims
submitted, the flow of reimbursement to providers and the use of reimbursements, cf. Annex 1.

Based on the findings and recommendations, the objective of phase two is to assist health facilities
in targeted areas to address problems/ weaknesses identified in the situation analysis by
implementing the recommendations in selected districts and facilities. Based on the experience
expansion to the rest of the country could be considered.



2. Methodology

The Terms of Reference were initially discussed at a meeting with the Health Sector Reform
Secretariat. Clarification was sought on the issue of government health facilities not being fully
accredited, which the team had been asked to look into, while in the mean time the team had found
that a blanket accreditation had been given to all government health facilities. It was agreed that
this question was therefore relevant only for the private sector.

The assessments of the team is based on the review of documents supplied by MOH and NHIF
and data collected from institutions and facilities visited as well as on results of semi-structured
interviews in health facilities and institutions visited.

In line with the TORs the team undertook field visits in Tanga Region and selected districts in the
Lake Zone, i.e. in Mwanza Region. Statistics from NHIF on the performance in terms of claims
submission suggested that this was an appropriate choice. Tanga Region was the worst
performing of all regions, whereas the Lake Zone regions were among the best performing, cf.
Annex 2. Among the Lake Zone regions Kagera was the worst performing, but there was not so




                                                                                                       1
much difference to Mwanza. Further the NHIF Zone office for the Lake Zone is located in Mwanza.
For logistics reasons it was therefore decided to carry out the field visits in Mwanza Region.

The team has visited only a limited number of districts (7) within two regions and a limited number
of health facilities (24). Further, the attempt to cover facilities at various levels of service provision,
various types of ownership (government, faith-based, and private for profit) and location (rural,
urban) naturally implies that observations within each category are few and cannot necessarily be
generalised. Although the review therefore remains to a large extent qualitative by nature, the
recurrence of problems and issues encountered across various types of providers as well as
evidence from other parts of Tanzania suggests that the findings are not specific to Tanga and
Mwanza regions.

In the identification and analysis of potential barriers and alleviating mechanisms, the team has
taken point of departure in a framework for division of roles and responsibilities in which the NHIF
is essentially a purchaser of health services from a range of suppliers that include MOH and
private providers (faith-based or for profit). Further, the assessment at the district and facility level
is based on a conceptual distinction between the executive side, consisting of facility management
teams, DMO, RMO and MOH, and the legislative side, consisting of facility governing committees
and health boards.

The team collected some financial information in order to assess the relative importance of NHIF
funding compared to other source of funding at various levels of care. Financial information is,
however, not easily and consistently available, as also recognised in numerous studies (PER
Updates 2001-05).

The importance of the contribution from NHIF to overall funding of expenditures at district and
facility level, i.e. the claims reimbursed down to facility level, is determined by
    - the availability of accredited facilities offering reasonable quality services
    - the number of members who are registered and can access the services
    - the number of members who wants to access the services offered
    - the number of claims filled correctly and submitted for reimbursement
    - the timely reimbursement flowing to the health facilities used for quality improvement
Consequently, the team has attempted to identify and analyse for each of these determinants, the
underlying factors that could negatively or positively affect the level of claims reimbursement
available for use at facility level.

Based on the situation analysis a proposal was made for implementation of selected
recommendations in one district. The need for a follow-up assessment at a later stage will be
assessed in phase 2.


3. Context

The establishment and operations of the NHIF should be seen in the context of a series of health
sector reforms and a range of insurance initiatives in the health sector. This context is briefly laid
out in this chapter.

3.1. Health sector reforms and the NHIF
Up until the early 1990s health care services in Tanzania were mainly tax financed. Out of pocket
payments were an option for those who chose to use the private for profit facilities. In mid 1990’s,
however, health sector reforms were introduced in Tanzania.




                                                                                                              2
Health care financing was one of the four major areas addressed by the health care reforms.
Within health care financing the following reforms were instituted by the government.

       Establishment of the National Health Insurance Fund
       Establishment of Cost-sharing arrangements in public hospitals through user fees
       Introduction of community Health Funds (CHF)
       Introduction of Drug Revolving Fund
       Introduction of an indent system to replace gradually the “kit system”
       Giving powers including financial oversight to the local councils and communities and
        supervision of the health facilities in their locality through the establishment of the District
        health management committees and hospital, health center and dispensary health
        management teams;
       The private for profit sector was re-enacted

The National Health Insurance Fund was established approximately five years after initiation of
health sector reforms in Tanzania by Act of Parliament No. 8 of 1999. The Fund started operations
on July 1st, 2001.

3.2. Other insurance initiatives in Tanzania
The aim of introducing user fees was to generate revenue to pay for health services and ensure
that the available resources are used efficiently. In July 1993, the Government introduced a cost
sharing scheme as a mechanism to reduce the existing funding gap. Cost sharing was introduced
in the referral, and regional hospitals and later in district hospitals. In the councils which have
introduced Community Health Fund (CHF), cost sharing has been introduced in the health centres
and dispensaries.

Community Health Fund
Community Health Fund is a voluntary prepayment scheme which was introduced in Tanzania
after it had been pretested at Igunga district in 1996, and later extended to other nine districts in
the mainland 1. The CHF modality was finally expanded to other districts throughout the country.
Currently, there are 68 councils with CHF in Tanzania.

CHF premiums are set according to the community’s ability and willingness to pay. The CHF
members are issued a card and are able to access primary care services up to district level. At the
introduction of CHF, user fees are introduced and charged to non-CHF-members in order to
stimulate enrolment in CHF.

Under CHF, the Community institutes a mechanism to identify members of the community who are
unable to pay. The respective council pays for the contributions for the exempted households that
are issued membership cards. The Government provides a matching grant to membership fee
collections to ensure sustainability of the fund.

The funds are deposited in a CHF Account and managed by the Council Health Board. The
community can use the generated funds to increase access to regular supplies of health services,
drugs and medical supplies.




1
 The ten district where CHF was pre-tested were; Igunga, Nzega, Singida Rural, Hanang, Songea Rural and
Urban, Mbinga, Rungwe, Kilosa, and Same.



                                                                                                        3
Micro –Insurance schemes
There are several Micro-Insurance schemes which are run by churches, informal groups and
associations. Examples of such schemes include UMASIDA and VIBINDO 2 which are registered
under the Societies Act.

The objectives of the informal Micro Health Insurance schemes are;
    To strengthen the informal sector communities, enabling them to take decisions on their
       health through ownership.
    To seek an alternative health financing mechanism that will provide better access to health
       services and improved quality of care.
    To enhance the quality of health care services offered to the scheme at affordable prices.
    To promote comprehensive care for the scheme members through a contract signed with
       health care providers.
    To negotiate discounts in order to reduce the cost of medical care to the schemes

Private Health Insurance schemes.
The number of private health insurance schemes has been increasing. The commonly known
private insurance schemes include MEDEX (T) Ltd3, AAR4, Health Insurance and Strategies
Insurance.

Social Health insurance Benefit (SHIB)
SHIB is the 7th benefit under National Social Security Fund Act no. 28 of 1997. So far, the SHIB
has, however, not been implemented and members have not yet enjoyed benefits regarding health
care. The Scheme covers employees in the private sector, non-pensionable government and
parastatal employees, and self employed persons. Non-pensionable government employees are at
the same time members of the NHIF as NHIF covers all government employees, pensionable and
non-pensionable. Recently, the implementation of SHIB has been discussed. If that happens, the
issue of membership of non-pensionable government staff will have to be resolved.

The scheme will be financed out of the contributions of 20% of gross salary from both employer
and employees for National Social Security Fund (NSSF). Members will be able to access both
inpatient and outpatient care in addition to other social benefits offered by the scheme.



4. Importance of NHIF as a source of funding

When the NHIF was introduced it was, amongst other, envisaged that it would improve the
revenues from cost sharing in government facilities by providing a channel for formal sector
employees to contribute to the financing of health care services. At the same time it was envisaged
that it would provide an environment for the growth of the private health care sector. It was also
seen as a mechanism for enhancing equity in health among formal sector employees by increasing
access to private facilities and through channelling increased funding to rural facilities to increase
access to quality services. As a spin-off other users would also benefit from increased quality.




2
    VIBINDO Society is an umbrella organization of informal sector operators based in the Dar Es Salaam.
3
    MEDEX is an abbreviation for Medical Express.
4
    AAR is an abbreviation for Against All Risk



                                                                                                           4
4.1. Observations
National level
Membership of NHIF is compulsory for all public sector employees. The total contribution per
employee amounts to 6% of gross salary, equally shared by the employer and the employee. This
is not an insignificant amount. According to the PER2004, the budget for the government’s
contributions for FY04 amounted to 6.6 bn TSh, corresponding to 8% of Other Charges or 4.5 % of
recurrent expenditures or 3.4 % of total sector expenditure (PER Update 2004). The actual transfer
was even higher, with NHIF contributions amounting to 4.8% of total on-budget expenditures (PER
Update 2005).

Such a contribution for health is, however, an illusion, if the funds are just accumulating and not
used to purchase health services. In principle, the funds (net of administrative costs and
maintenance of necessary reserves) are available for financing health services and it is as such
appropriate to include it in the estimated government budget allocation available for health services
at the aggregated level. However, only the amount actually spent for purchasing health services
should be included in the actual expenditures. Furthermore, there is a risk of double counting the
total resources used on health services, if funds are first counted on transfer to NHIF, then after
transfer to districts are included in the cost sharing envelope which is added to health care
expenditures.

The reimbursements made by NHIF give an indication of the maximum contribution to the funding
of the actual expenditures. It can, however, only provide a maximum estimate as the
reimbursements made from NHIF are not necessarily spent at point of destination in the same
year. The total contributions (employers and employees in all sectors) amounted to 24 bn TSh in
2004/5 with only 4.9 bn TSh worth of claims being lodged, of which only 86% were reimbursed.

Table 1. NHIF reimbursements compared to total health sector expenditures 2001-04
                                                 Actual expenditures        Budget
                                                 2001/02 2002/03 2003/04 2004/05
NHIF claims reimbursements paid (mill TSh)           247.4    1345.9 3808.4   4204.6
Total recurrent health expenditures (mill TSh)    111860     137610 162750 230920
Total health expenditures, domestic funds           95330    110770 150020 184930
NHIF reimbursement to total recurrent health exp    0.22%     0.98%  2.34%    1.82%
NHIF reimbursement to total domestic health
exp.                                                0.26%     1.22%  2.54%    2.27%
Note: Total recurrent excluding AGO spending on NHIF.
Source PER Update 2005 Table 4 and Table 7; NHIF Facts and Figures June 2005.

District level
The major source of funding for the districts is the government block grants and council health
basket funds. Other important sources are the central level budget allocations for drugs and
supplies, donor direct project funding and to lesser extent council own funds. Supplementary to
these main sources are the different mechanisms at facility level for generating funds from users or
the community5:
 - Health Services Fund (HSF), which covers contributions from user fees at government
    hospitals
 - Community Health Fund (CHF), a community based prepayment scheme for primary care

5
  There is a confusion of terminology: Some take cost sharing to include all these sources, while others use
the term cost sharing only for the hospital user fees implemented under the initial cost sharing policy. Some
countries use the term Internally Generated Funds to cover various mechanisms for revenue generation at
facility level.



                                                                                                                5
-    National Health Insurance Fund (NHIF), compulsory for public servants
-    Drug Revolving Fund (DRF) operated by some hospitals

For some districts information on funds collected from NHIF is reported in the Technical and
Financial Progress report on the implementation of the CCHP, but it is not part of the standard
reporting format and the practice varies. Lack of regular reporting on the reimbursement from NHIF
viz-a-viz other sources of funding makes it difficult to spot any problems in claims submission,
reimbursement or cashing in of funds.

Table 2. NHIF reimbursements to districts compared to total health care budget. Selected
              districts.
 District                        Average Annual       Average Annual NHIF   NHIF reimbursements to
                                 health budget        reimbursements        total health budget
                                       Mill TSh              Mill TSh                    %
 Magu District Council                  1,608                   24                       1.5
 (2000-05)
 Handeni District Council              1,459                   8                       0.5
 (2004-05)
 Sengerema District Council             916                    15                      1.6
 (2004-05)
Source: CCHPs and Quarterly Financial Reports on the CCHP

It appears that the NHIF reimbursement as a source of fund at district level is currently of minor
importance. Given that the members and registered dependants are estimated to cover only about
3% of the population and that the NHIF reimburses only the cost sharing part of the costs of
service delivery, this is hardly surprising. It should further be noted, that to the extent that NHIF
reimburses existing user fees otherwise charged to the patient, it would merely replace cost
sharing revenues from out-of-pocket payment. Additional contribution to the budget would thus
either come from an increase in demand, i.e. more patients attending the services, or from
charging for patients or services that are exempted from user payment but eligible for payment
under the insurance scheme, e.g. under fives.

Facility level
While the contribution to the overall budget may seem relatively small, it could potentially be of
some significance at facility level. However, the importance of NHIF reimbursement varies
considerably between levels and ownership of health facilities.

In dispensaries the NHIF seems to be negligible as a funding source, see Box 1. This is likely due
to the fact that dispensaries provide only limited services and appear especially hard hit by the lack
of resources in the sector, for example lack of qualified personnel (Annual Joint Health Sector Main
Review 2005) and NHIF members therefore prefer to use other health facilities. Furthermore, the
services rendered are typically low cost and generates limited revenues. Reimbursements are
therefore predominantly made to hospitals, cf. Figure 1, suggesting considerable bypassing of
lower level health facilities.




                                                                                                     6
  Box 1. Examples of NHIF refund contribution to revenues at facility level.
 Example 1: Mkanyageni Dispensary, Muheza district.
 The Dispensary is located in a town and close to the main road. The dispensary on
 average had 631 outpatients per month in 2005. During the last month 16 NHIF-members
 attended, corresponding to only 2.5% of the average patient load. Claims are submitted
 quarterly and the last claim submitted amounted to 133,000 TSh or on average 44,000 TSh
 per month. The average collection of user fees is estimated to be 450,000 TSh per month.
 The NHIF reimbursement (assuming no claims are rejected) would thus amount to 9% of
 the monthly revenues generated.

 Example 2: Mzunda Dispensary, Handeni district
 The dispensary is found in a very rural area about 20 minutes drive from St. Francis
 Hospital. Over 3 months 17 NHIF members have been treated in the dispensary. The daily
 patient load is 30-40, indicating that less than 1% of patients are NHIF members. However,
 many are reported not to have received their cards. NHIF members are also perceived to
 prefer St. Francis hospital. The claims for the last three months included claims for amoxilin
 which is not reimbursed at this level of care (this practice varies between Zonal offices).
 Excluding the claims for amoxilin the total claims for 3 months amounted to only 8,400
 TSh. In comparison, the in-charge reported collecting approximately 80,000 TSh per month
 in user fees to be deposited in the CHF account.



Figure 1. Reimbursements by level of care. Mwanza, one quarter 2005.




Source: NHIF (personal communication 2006)

NHIF beneficiaries seem to be attracted more by private health facilities, cf. Figure 2, as the faith-
based organisations seem to be collecting relatively more than the government facilities and to
have better accounting and monitoring practices.




                                                                                                         7
Figure 2. Distribution of reimbursements by ownership. Mwanza, one quarter 2005.

             D i s t r i b u t i o n o f r e i mb u r s e me n t s b y o w n e r s h i p . M w a n z a R e g i o n O n e
                                                        qua r t e r 2 0 0 5 .




                                                                                                                             io
                                                                                                                             g
                                                                                                                           Rel i us

                                                                                                                           Gover n men t

                                                                                                                                   e
                                                                                                                           Phar maci s




Source: NHIF (personal communication 2006)

It could appear as if the private facilities were benefiting the most from the NHIF. Number of
clients increases as NHIF members use services more often and as members who previously used
public health facilities start using private health facilities. At the same time, however, NHIF
reimbursement rates are slightly lower than ordinary fees in most private facilities. As many NHIF
members were already clients in private health facilities and used to pay the ordinary fee, private
facilities will incur a loss for these patients as the bill (at lower rates) is taken over by NHIF.

Although the majority of reimbursements are made for hospitals, more than half of the
reimbursement is for outpatient services, registration and pharmaceuticals, cf. Table 3.

Table 3. NHIF Reimbursements by benefit categories as of 30th June 2005. In Million TSh.
 Benefit category          2001 - 02        2002 - 03         2003 - 04        2004 – 05
 Registration fees                 31.2            207.3             444.1            488.2
 Outpatient services              113.5            341.8             851.9          1,677.1
 Investigations                    15.6            227.4             441.2            338.3
 Inpatient care                    29.2            409.1          1,682.2           1,188.8
 Surgical services                 57.9            160.2             323.5            274.5
 Pharmaceutical Services              -                -              65.6            237.7
 Total                            247.4          1,345.9          3,808.4           4,204.6
Source: Facts Figures inside NHIF

The above table shows that in 2004 -5 NHIF reimbursed TShs. 4.2 billion to different facilities in the
country. If this money is spent properly it could bring a positive impact in the health services.


4.2. Recommendations
       For the next PER a consistent way of reporting on the NHIF contribution and expenditures
        should be developed.
       Revise the reporting format for the CCHP progress reporting to include a breakdown of cost
        sharing funds available by collection mechanism, e.g. NHIF, user fees, CHF.




                                                                                                                                           8
5. Accreditation
5.1. Background
The NHIF in principle requires that all health care providers who wish to register with the fund for
providing services to its members be accredited. The accreditation process is done by using pre-
determined criteria prepared by the NHIF using the MOH standard guidelines. The requirements
for accreditation of the health facility include;

          Availability of human resources, equipment and physical structures as required by the
           MOH guidelines.
          The acceptance of a formal program of quality assurance as required by the NHIF.
          Acceptance of the payment mechanism and fees specified by the NHIF Board. Currently
           the system adopted is fee-for-service.
          Adherence to the referral system as required by the Fund
          The acceptance of information system requirements and,
          Recognition of the rights of the patient.

The accreditation process is intended to ensure continuous provision of quality health services to
NHIF members.

Categories of provider
The accredited facilities are categorized according to the MOH levels of service provision
regardless of their ownership i.e whether the facility is privately or government owned. The levels
are Referral Hospitals, Regional Hospitals, District hospitals or Designated Hospitals, Health
Centers, and Dispensaries. Accreditation of private providers is intended to ensure free choice of
provider for the NHIF members. Re-imbursement of services by the NHIF is based on the level of
facility, and this is uniform to all providers regardless of ownership 6.

The NHIF also accredit pharmacies in order to respond to the problem of drug shortages which is
experienced in many facilities. The Pharmacies are divided into two categories; Pharmacies (Part
1) and (Part 2) respectively. The two categories of pharmacies differ according to the types of
drugs they are allowed to dispense, which depends on the qualifications of the prescriber. Any
facility is eligible for accreditation if it has operated for a period not less than three years. NHIF
also considering alternative providers of drugs (ADDO) to ensure continuous supply of drugs and
medicines to the members.

Status of accreditation
In order to provide services to the members who are scattered all over the country, all the
government health facilities including Designated District Hospitals were given a blanket
accreditation. The government facilities were therefore allowed to provide services to the members
without been assessed against the accreditation requirements.

Further, NHIF has opened for any private or Non-governmental facilities wishing to provide
services to the members to apply for accreditation with NHIF. The facilities which apply are
assessed against the accreditation requirements and required to sign a legal contract with the
NHIF before being allowed to claim payment for treatment of NHIF members.




6
    See details in the claim processing and re-mbursement section.



                                                                                                         9
Number of accredited health care providers
According to the available information, the number of accredited health facilities by September
2005 were 3,952. Out of which 3,358 were owned by government, 594 by faith based and private
institutions respectively.

The figures revealed that only 68% of the facilities are actively claiming reimbursement from NHIF
irrespective of ownership.

Table 4. Accredited and actively claiming facilities.
Ownership      Accredited      Accredited Active                                % active
               facilities      facilities   Facilities                          Facilities
               Dec. 2004       Sept. 2005 Sept. 2005                            Sept. 2005
Government     3,358           3,358        2,285                               68%
Health
Facilities
Faith Based    555             594          406                                 68%
Facilities
Total          3,913           3,952        2,691                               68%
Accredited
Facilities
                                                                                                                      7
Note: The definition of an active facility is a facility that claims on a regular basis; claims covering the full year .
Source: NHIF Performance Review by September 2005.



5.2. Observations
The team explored possible reasons for reluctance to apply for accreditation with NHIF. As
government facilities were given a blanket accreditation, this is only relevant for the private sector.
The quality of services offered by accredited providers influences the decision of beneficiaries to
use services. The team therefore also considered the accreditation process for all providers from
the point of view of ensuring access to quality services.

5.2.1. Factors affecting preferred accreditation status
Level of reimbursement
The rates reimbursed by NHIF are currently unilaterally determined by NHIF, although with some
consideration to market prices. If rates are set too low, some providers may not find it worthwhile to
provide services under the NHIF scheme.

Generally, faith based health care providers are willing to be accredited with NHIF, and find the
rates of reimbursement offered by NHIF more or less acceptable, especially immediately after
revisions of prices. However, they raised concern that the intervals between reviews of the price
list have been too long (previous price lists were issued July 2001 and September 2004; a draft
revised version has been developed and is expected to be issued in the spring 2006). Especially
with increasing prices on drugs, the prices reimbursed will be inadequate before the new pricelist is
developed. Similarly, the interviewed pharmacies found the reimbursement rates reasonable,
although they too voiced the need for more frequent price revisions.

Some facilities voiced concern about the limits on number of inpatient days per admission. It was
not clear to facilities whether NHIF would continue to pay after the limit in inpatient days has been
exceeded even though it may in some cases be necessary to keep patients longer. Cases
mentioned were malaria patients admitted in health centres. Health centres are not supposed to

7
    Personal communication, Dr. Hema, NHIF.



                                                                                                                           10
keep patients more than 3 days after which they should be referred to a hospital. If the patient’s
condition is improving such referral seems unnecessary, but the additional inpatient days will
nevertheless not be covered by NHIF, although NHIF would pay, if patients were referred to
hospital.

Awareness
In the very limited sample of private for profit providers the team found that there was inadequate
knowledge of the details of the NHIF. Such details would be necessary for an assessment of
efforts required and potential advantages, which would allow an informed decision on whether to
apply for accreditation. The team, however, recognises that the private for profit health care
providers have not yet been targeted in the step-wise mobilisation of service providers to join the
NHIF.

General perception of government operations
Mutual scepticism between the public and the private sector has been reported, especially as
regards the private for profit sector (Technical Review 2005). In the private for profit sector, as also
observed by the team, there is some tendency to discard the NHIF based on previously perceived
inefficiencies (bureaucracy, delayed flow of funds etc.) in government related agencies, bad
experience and misperceiving NHIF as a government structure. Such perceptions are barriers to
even seek more information on NHIF.

Accreditation criteria and process
The accreditation criteria and procedures do not appear to be widely known. Facilities that had
been accredited had no complaints about the process. No applications for accreditation with NHIF
have been rejected so far, which could raise some concern about the quality or effectiveness of
such a screening procedure.

In Mwanza, however, NHIF terminated a contract with one pharmacy which was accredited as part
one pharmacy, but did not have a qualified pharmacist. This was done after liaising with Tanzania
Food and Drug Authority (TFDA).

The accreditation guidelines of NHIF presently contain an extensive checklist of quality criteria
(staff, equipment, laboratory services etc.). The criteria are, however, reflecting an ideal situation
which probably very few health facilities in the country would comply with. There are no practical
conclusions in the guidelines on what to do if these criteria are not all being fulfilled. No “minimum
criteria” are formulated which could be applied to deny accreditation to health facilities not even
reaching minimum standards.

Perceived advantages
There were mixed experiences with the advantages of being accredited with NHIF. Some were of
the view that it had increased business by attracting more clients, while others were of the opinion
that the patient load and mix were more or less the same, but that it was good for the patients.
Likewise some were of the opinion that the treatment on credit and bad debts had decreased,
whereas others did not have this experience as the people normally running bad debts were not
the civil servants. The interviewees overall found that the advantages outweighed the
disadvantages and none regretted that their facility was accredited with NHIF.

5.2.2. Access to services/Actively pursuing quality
The team noted that government facilities were initially given blanket accreditation, although some
facilities may not meet the accreditation criteria. This ensures access to some kind of services for
all members, but does not ensure access to a certain minimum standard of services, cf. above. In
line with many others, the team has observed that the government facilities are understaffed, under




                                                                                                      11
equipped and often lack drugs. (Annual Joint Health Sector Main Reviews (various years),
Kurowski et al. 2003, Three Regions Study 2005)

Pharmacies are accredited in only very few places. When facilities are out of stock, NHIF members
cannot easily take out their prescription, but have to pay local drug sellers. A study in Ruvuma
Region in 2003 showed that Accredited Drug Dispensing Outlets (ADDOS) would play an
important role in improving drug supplies in the rural areas for NHIF clients (Kiwara 2003). The
study showed that for ADDOS to work well, the following factors among others, are important:
timely payment for services rendered is necessary because of their small volume of business, and
registration with the Tanzania Food and Drugs Authority. The ADDO review team currently
(January 2006) in the field will have more updated views on this issue.

In order to be able to access the services, the users have to know which providers are accredited
with NHIF. Information on accredited facilities is not always easily available. In Tanga region the
RMO does for example not have a list of the accredited facilities in the region and does not receive
information on new accreditations on a routine basis. In Mwanza, updated lists were said to be
distributed to employers for easy access for the employees, but the team did not have the
opportunity to test their accessibility and distribution at that level. The NHIF has a list of accredited
facilities on its web-page, but it does not appear to have been updated for some time.

5.3. Recommendations
To attract and retain providers for service provision for their members, the team recommends that

      Reimbursement rates should be reviewed and adjusted at least annually.

      Advocacy and sensitisation of private providers be undertaken with regard to details of
       NHIF system and fee levels. Mobilisation of private hospitals or health clinic would,
       however, primarily benefit the small urban elite that already have access to reasonable
       service quality and the team does not see it as an immediate priority for active mobilisation.

      Accreditation criteria be disseminated on the NHIF web page and in local mass media to
       enable potential applicants prepare themselves for the process.

      The performance of NHIF is improved assuming this will improve reputation (especially
       reliability in issuing cards and avoiding delays in reimbursement, see chapter 6-8)


To stimulate the development of increased access to quality services, the team recommends that

      Accreditation guidelines be developed that clearly define the “minimum standards” required
       by a health facility in order to be accredited, and not just describe the ideal (maximum)
       standards. National accreditation criteria presently being developed by CSSC, MOH, NHIF
       with consultation of TBS should not only spell out the recommended standards, but also
       clearly define the minimum standards below which no health facility can be granted
       accreditation. Assessment of fulfilment of minimum standards is part of the regular
       inspections carried out by the NHIF Zonal Offices.

      The quality of each government facility be reviewed with the objective to identify which
       facilities do not fully fulfil the criteria stipulated in the Ministry of Health Standard Facility
       Guidelines and accreditation criteria for NHIF. The facilities that do not meet the criteria
       should be given a transitional accreditation of 2-3 years against a “Health Facility
       Development Plan” which would spell out how to improve the situation over that period and



                                                                                                       12
       be integrated in the CCHP. Number of accredited and temporary/transitionally accredited
       facilities per district should be reported in the Annual District Health Report and progress
       towards accreditation of all government facilities should be commented on. For
       development work the recently established Joint Rehabilitation Fund as well as funding by
       development partners such as KfW could be a source of funding and the plan on how to
       achieve accreditation could be used to justify the need for such funds.

      The NHIF should explore the possibilities for extending accreditation to more pharmacies
       and drug outlets, particularly in the rural areas (e.g. the ADDO – system, depending on the
       findings of ongoing consultancy missions on ADDO)

      Directory of all accredited facilities be developed and regularly updated (monthly on the
       internet and annually in paper form). When new facilities are accredited or facilities are dis-
       accredited, a circular should be issued on monthly basis. The comprehensive list should be
       made available in centrally located places such as the internet and DMOs office. Further a
       reduced list containing the accredited facilities in the Region could be distributed to NHIF
       members or kept with the employer.

      Accredit at least 2 private pharmacies in each urban setting in order to increase access.



6. Registration/deregistration of beneficiaries
6.1. Background
Statutory Aspects
The law establishing NHIF states that all contributing employers and employees shall be registered
with the Fund.

The scheme covers
   (a)   All civil servants;
   (b)   Their spouses:
   (c)   Their children or dependants not exceeding four in number.

In the event of both spouses being civil servants, the Board may set criteria for enrolment of more
than four children or dependants as beneficiaries under this Act.

The law further clarifies that any person who has been employed as a civil servant shall be entitled
to the benefit package after payment of three months contribution. On retirees the law states that
“A retiree who was a beneficiary of the Fund shall be entitled to the benefit package for a period of
three months after the retirement, after which the benefit package and membership shall cease”.

Similarly the law clarifies that “The board shall issue health insurance identity card to any
beneficiary for identification, verification and utilization recording purposes”.

Membership volume
By the end of 2004, the Fund had registered over 240,000 public servants as contributing
members. The registered members have brought with them nearly 900.000 dependants. The Fund
therefore is now catering for over 1.1 million beneficiaries in the country. Out of the total number of
principal members 56% of them are teachers and the remaining percentage is made up of the
other categories of public servants. The Fund's membership has grown from 164.708 in 2002 to
242.580 in 2004 an increase of 47%.



                                                                                                     13
This growth in membership is a result of the amendment of the law on recruitment of new members
of the public sector and inclusion of new categories of employers in the public service, e.g. local
government. The Fund's beneficiaries are spread throughout the country, the bulk of them residing
in rural areas.

Table 5. NHIF Membership Strength
                               Total No.
 Financial   Govt  Executive             Percentage Estimated
                                  of
   Year Employees Agency      Members Growth-of Number of
                   Employees              Members Beneficiaries
July 2001 178,889            * 178,889                 751.334
July 2002 164,708            * 164,708     -8% **      691.774
July 2003 232,834         973 233,787       42%        705,554
July 2004 239,126       2,779 242,580        4%      1.115,868
July 2005 245,923       2,895 248,818        3%      1,144,563
 * Before change of the NHIF Act these were excluded.
 **This was due to deregistration of Local Government staff that were erroneously included.

Figure 3. Growth of the NHIF membership from 2001-02 to 2004-05 Financial Year




                   2004-05



                   2003-04


 Financial Year
                   2002-03



                   2001-02


                             0           50000         100000          150000         200000   250000

                                                 Number of Principal Members



The sex distribution of members during the same period showed that 56% were male and 44%
were female. According to the age distribution of principal members, by June 2004, 60% of
members were more than 40 years. In view of the retirement age, more than 40% of the Fund's
members are likely to exit employment in 15 years. This may to some extent impact member
contributions to NHIF depending on to what extent replacement of staff occurs.

The total labour force in the country has been estimated at 17.8 million people (as of 2001 by
National Labour Survey) of which 2% are employed by the government and 0.5% by the para-
statal sector. Therefore, the estimated public service catchment's volume is 445,000 workers and
NHIF has been able to register only just about half of these, 54.5%, as principal members. The



                                                                                                        14
remaining 45.5% employees are accounted for by para-statal organizations, some executive
agencies and some cadres in Local Government who constitute a pool of potential members which
NHIF needs to target in its effort to encourage member to register for cards. The growth in member
pool of the Fund will depend on the growth of the public sector or expansion of the scheme to the
non-governmental formal sector.

During this period, the Fund has received a number of requests by some groups from outside the
public service to also register themselves as members. This shows that the principle of health
insurance is gaining ground in the country and that the potential for membership growth is large.

Table 6. NHIF membership 2004-05
                 Status by     Status by Increase        Status by Increase
INDICATOR        31.12.04      30.06.05    Dec to June 30/9/2005 July to Sep REMARKS
Membership
strength               248,895     248,818           -77    266,131      17313
Expected
beneficiaries        1,144,917 1,144,563            -354 1,224,203       79640
NHIF 1 Forms                                                                   The drop by
collected              213,462     216,949          3487     220561       3612 77 members
% performance                                                                  from Dec to
on forms                                                                       June is due to
collected                 86%         87%                       83%            normal
Expected ID's        1,144,917 1,144,563            -354 1,224,203       79640 members
ID's produced                                                                  termination
and distributed        946,322      974935         28613    995,441      20506
ID's Performance
rate                      82%         85%                       81%


Identity cards
Under section 15 (1) of the NHIF Act, the Fund is obliged to issue an identity card to every
registered member. However, in order for the identity card to be issued, members are required to
properly fill NHIF registration forms and pass them to the employers for certification before being
sent to the Fund offices. Likewise the Fund is required to produce identity cards and distribute
them to employers so that they can be handed over to members. The Fund devised a special NHIF
"sick sheet" to be used with the employers' identity cards whenever members require accessing
services from the accredited health facilities. As of 31st January 2005 the Fund had produced and
distributed 946,153 (83.1%) identity cards out of 1,142,378 expected to be produced if all members
submit their forms to the Fund offices. No beneficiary can have access to health care services
without the NHIF identity card. There are plans in place to revamp all the existing ID cards. .

6.2. Observations
Problems with cards

           o   Complaints were voiced in Tanga Region that a substantial number of members
               have not received their cards, although they have filled and submitted the
               registration form. For example, Bombo Hospital receives 4 – 5 patients per day who
               are not in possession of NHIF cards. The team met several health staff who had
               also not received any cards for themselves and their dependants.
           o   In Mwanza Region temporary permissions are issued by NHIF Zonal Office for
               members who are not yet in possession of NHIF cards




                                                                                                15
           o   Some members that have received their NHIF cards complain about mistakes like
               the names being changed, names not matching the photos, not all dependants
               having received a card or wrong dates of birth being indicated.
           o   The explanation given for the missing cards is that some of the cards have been
               sent to the wrong places by NHIF.


Membership Compliance Problems:

       o   Some members are not filling registration forms for NHIF because they perceive
           government services as offering lower quality of care than alternative private providers
           (especially in urban set-ups with private for profit providers).

       o   Members who never utilised the services are not aware about the quality to expect and
           the usefulness of being insured.

       o   There is no method of deregistration and withdrawal of card for members who are
           terminating their employment. As NHIF has started operations relatively recently this is
           yet deemed to be a minor problem, but it will be an increasing financial burden in the
           future.

       o   Patients are aware of their membership status and present their pay slip to be treated
           free at point of service. Some facilities collect user payment from such persons, others
           treat them for free and use the pay check number for filling the form and do not get
           reimbursed.

       o   Procedures for replacing lost membership cards are not clear to members, including
           health facility staff that therefore cannot advise patients with missing cards.

6.3. Recommendations
      The increasing problem of how to treat retired people or people terminating their jobs that
       are in principle no longer NHIF members have to be addressed. A quick options analysis of
       the consequences, costs and practical problems of alternative solutions that would feed into
       decision-making process should be undertaken. Alternatives to consider include
       o The employer should be responsible for withdrawing the card when employment is
           terminated. This could be a requirement at the time when the employee comes for
           his/her last payment. A temporary card with an expiry date of 3 month could be issued
           to cater for the 3 months grace period included in the NHIF regulations. The employer
           would not have any particular incentive to comply with such regulation and some
           incentive would need to be developed.

       o   When issuing new cards they should show the expiry date as far as known. E.g. the
           registration form for the members should contain the year of planned retirement, which
           would serve as an expiry date for the family’s membership cards. The practical aspects
           would, however, need careful consideration.

       o   In the longer term the NHIF should consider expanding the benefit package to other
           groups (retired members and their spouses provided they have contributed for a certain
           number of years; possibly at reduced membership contribution). The costs should,
           however, be assessed carefully.




                                                                                                 16
      Based on the list of pay check numbers the NHIF could supply the employers with
       information on the status of the employees as regards membership cards on an annual
       basis. This will allow the employer to follow up with members that have not registered for a
       card, and to resubmit registration forms. Further, it will allow identification of those for which
       NHIF cards have been issued, but where these have never reached the member. For such
       cases, reissuing of cards after appropriate verification should take place.

      Health care providers could list patients who are members or dependants of members who
       present themselves in the facility without a card. This list could be used for follow up with
       NHIF on the status regarding issuing of cards. A list could be forwarded on a monthly basis
       along with the claims submitted to the DMO. The DMO would forward the list along with the
       claims to NHIF for further action.

      Clarify procedures for replacement of lost or missing membership cards to members and in
       particular to health staff.

      Advocacy and information of members by NHIF should be reinforced in order to inform
       members about NHIF benefits, especially the extent and limitations of their health
       insurance coverage.

      NHIF co-ordinators working in or with the District Health Management Team should
       facilitate that all eligible NHIF members have membership cards.

      Quality improvements of government services, especially presence of qualified staff and
       permanent availability of drugs and diagnostic services, would increase the willingness of
       NHIF members to register for membership cards and to subsequently utilise the services.



7. The claiming system
7.1. Background
During the field visits in Tanga Region and Mwanza Region, the consultancy team looked into the
system of processing NHIF claims at health facility and DMO level. The original assumption of the
team was that health facilities may not perceive the immediate benefit of these funds to them as
they are processed at District level, and thus may be reluctant to fill in the claims. The consultancy
team, however, found that this assumption was wrong.

7.2. Observations

7.2.1. Processing of claim forms
Motivation of filling in claim forms
At facility level the claim forms are generally filled. The staff is aware that in the process of treating
NHIF members claims for reimbursement have to be filled, and that the claims have to be
collected, summarized, and sent to the DMO on a monthly basis. Further, the staff of most health
facilities visited was aware that the funds reimbursed will be earmarked for their health facility and
may be utilised for requisitioning drugs, for small supplies, and for other diverse purposes like
repairs and painting. The original assumption of the consultancy team that health staff may be
reluctant to fill in the claims did not prove to be right. At Sékoutouré Hospital incentives for staff
who fill in the forms have been introduced. This has lead to a substantial increase of NHIF
reimbursements. At dispensary and health centre level no staff incentives are paid presently, but in




                                                                                                       17
many places the staff suggested to introduce some motivational measures as for example
providing tea and sugar for work breaks.

A particular issue relates to claims for treatment of children fewer than five years old and pregnant
women. While these services are provided free of charge, health facilities can still claim
reimbursement from NHIF. For the health facility this represents extra revenues and many health
facilities do claim for such services, but there is also in some places confusion about whether
claims can be made for such services that are otherwise provided free of charge. At the same time
patients do not have any particular incentive to show their NHIF card as they will in any case not
pay. Mobilisation of all potential revenues therefore requires that health staff actively pursue it, by
asking for NHIF membership whenever providing services to pregnant women and children.

Technical problems with filling in claim forms
The forms generally do not present major difficulties in being filled in. The major problem with filling
in forms is the coding of diseases (choosing the correct code for the diagnosis, using code instead
of name of the diagnosis, adding a second code in case of two conditions diagnosed). Some
facilities do not have the summary page of the coding for the most common diseases. Many
facilities do not have the new price list of 1st September 2004. They will, however, still be
reimbursed along the new price list.

Lack of qualified staff creates problems also for processing NHIF claims
A major problem identified by the consultancy team is the lack of qualified personnel at health
centre and dispensary level. The majority of rural dispensaries and health centres presently seem
to be operated without a single qualified clinician, and also lack other qualified personnel (see e.g
Three Regions Study 2005, Annual Joint Health Sector Main Review 2005, RMO report Mwanza).
This, in turn, has consequences regarding the ability of the in-charges to understand and properly
use the coding system. Responding to this human resource crisis, the MOH already started posting
qualified staff again from central level to rural areas.

Training of staff in the processing of NHIF claims
Many staff members have been trained in properly filling the forms in the beginning of the NHIF
scheme, but as some have been transferred often the one who fills the form in the meanwhile has
not been trained.

Appropriateness of the form design
Some health facilities suggested to add more space to the “Description of In-patient Management”
(section E of the claim form). However, it is not clear whether such an extension of space is really
advisable, and for which part of the claim form the space should be reduced in such a case. The
claim form in the present design seems to be quite appropriate to the consultancy team. One
problem identified during the field visits, however, is the lack of any space for comments on special
conditions, e.g. justifications for keeping patients longer admitted than foreseen in the guidelines.
Claim forms do not have a place for explaining deviations from standard treatment (e.g. child with
severe burns being kept long time in the facility; non-response to malaria treatment etc.) One
health facility visited in such cases attaches a separate note with explanations to the claim form.


7.2.2. Submission of claim forms, feedback on and monitoring of reimbursements
Submission of claim forms
Although claims are filled at health facility level, they are not always submitted to NHIF for
reimbursement. This is particularly critical when it happens at the DMO’s office as has been
discovered by the consultancy team in one case. In some cases submission of claims collected in
the DMO’s office awaits the submission of forms from all health facilities causing delay in the




                                                                                                     18
process. Districts with an NHIF coordinator seem to be doing better in terms of submission of
claims.

Feedback to health facilities
NHIF provides hospitals and DMOs with fairly detailed feedback on the problems with filling of
forms and reasons for rejection with specification of form number. In some cases this is passed on
to the lower level health facilities. At these facilities, especially when poorly staffed, there are
sometimes difficulties identifying which problems are relevant for their facility as well as to
understand the explanation. Mwanza Zonal Office of NHIF gives prompt and regular notification to
DMOs when health facilities are submitting claims too late (after 60 days), which seems to be quite
helpful in ensuring prompt submission of claims.

No correction of mistakes possible
Facilities do not get a chance to rectify claims. If the claim contains a mistake (e.g. forgotten
signature, forgotten inclusion of a second diagnosis, inserting the diagnosis with full name instead
of code number, etc.) the health facility is notified about the mistake and the claim is partially
rejected, with no possibility of correction. Some facilities perceive that the whole claim is rejected
and that they are denied payment for services delivered.

Lacking monitoring instruments
Most health facilities do not keep records of how much they claimed and how much was
reimbursed out of these claims. Some few health facilities, however, created their own monitoring
sheets. At the district level the DMO (or NHIF co-ordinators where existing) in most cases tried to
keep track of the NHIF reimbursements with monitoring sheets of varying quality.

Monitoring role of NHIF co-ordinators
Districts who appointed a member of the District Health Management Team as an NHIF Co-
ordinator had better quality control and monitoring in place than districts without such a focal
person.


7.3. Recommendations
In order to improve the processing of claims at different levels, it is recommended to

      Introduce in all districts focal persons who can effectively support the health facilities in
       correctly processing their claims. They should be part of or work closely with the District
       Health Management Team. The present practice that such focal persons (where they exist)
       perform their role as NHIF Co-ordinator part time and additional to their other duties seems
       to be working well. For the moment, as long as the role of NHIF Co-ordinator is performed
       part time without additional payment, no merging with the role of CHF co-ordinator seems
       required or advisable (too much workload, only feasible if transformed into paid full-time
       job). In the future it could, however, be considered to have a more comprehensive health
       care financing focal person.

      Distribute updated materials (price list, summary sheet of disease coding) on a regular
       basis and identify a person (NHIF coordinator) responsible for ensuring that such
       information is disseminated to all health facilities.

      Undertake short training on how to fill the forms, with focus on some of the issues that by
       experience needs clarification, (e.g. clarify that more than two diagnoses are allowed and
       even required sometimes, how to add justifications , coding system etc). The short training
       should be a regular activity targeting new in-charges, staff in facilities that have many




                                                                                                     19
          rejected claims and acting in-charges that have not previously received any training and be
          budgeted for in the annual budget.

         Sensitize Health Facility Governing Committees (HFGC) on their roles, such as decision-
          making powers on the utilisation of cost sharing funds (i.e. user fees, CHF were applicable,
          and NHIF funds). Mobilisation of the HFGC for follow-up with DMO on submission of
          claims. Copy of letter from DMO to NHIF claiming reimbursement should go to HFGCs.
          Such sensitisation should also involve DHMTs, CHSBs, RHMTs to ensure awareness at all
          levels.

         Improve the feedback letter from NHIF to DMO providing reasons for rejection of claims by
          spelling out the feedback per facility in an understandable language.

         Develop and disseminate to all accredited facilities an NHIF Claims Handbook with the
          Costs (price list, investigations, surgery), the Code(the international diseases code or a
          simplified version).

         Include NHIF claims status as an item on the health care services supervision forms.

         Initiate a widely publicised award (cash or otherwise) for the best performing District. The
          award to be presented by the Guest of Honour during the Annual DMOs meeting. The five
          poorest performing districts to be announced simultaneously.

         NHIF Zonal Offices should give regular and prompt notification to DMOs when health
          facilities are submitting claims too late (after 60 days), with copy to RMO (and maybe also
          to MOH?).

         Inform health facilities that justification for the need for additional days of admission may be
          attached to the claim form as a note and that NHIF if found well-justified may reimburse
          such additional days This is already done by some health facilities under at least one Zonal
          Office, and the possibility of doing this should be made known to all health facilities.

         Give specific attention to ensuring that claims are submitted for health care rendered to
          children under 5 years and pregnant women by increasing awareness among health facility
          staff to actively ask for NHIF membership.


8. Reimbursement and use of funds
8.1. Background
NHIF was introduced in line with other complementary sources of financing mechanism with the
broad objective to generate additional resources to complement the government budgetary
allocations which have been insufficient to meet all the requirements of the health sector 8. After the
introduction of the Cost – sharing in 1993, the MOH issued a guideline on how the money collected
should be used. The guideline clarified that the money generated should be used by the respective
facility for procurement of additional drugs, minor repair and other services of similar nature to
improve delivery of health care services in the facilities. The flow of funds back to facility level and
the ability to use the funds at facility level are important factors for motivating the careful filling and
submission of claims and for reaching the objective of contributing to the improvement of services


8
    Other complementary sources include Cost sharing and CHF.



                                                                                                        20
for the NHIF members (from NHIF perspective) and for the population in general (from GOT
perspective).

Reimbursement
After claims have been received and approved, the NHIF Accounts Office in the Headquarter is
requested to issue a check to the institution submitting the claim. This means that for faith-based
facilities and for hospitals that send their claims individually, the reimbursement is made directly to
the institution. For health centres and dispensaries that claim through the DMOs office, the
reimbursement is made to the DMO, for further distribution to facilities. Following the submission
of claims, the NHIF by regulation is required to reimburse the claims within 60 days.

Use of funds
Before NHIF started its operations there were already two systems for revenue collections in place,
the Health Services Fund for hospital user fees and the partly implemented Community Health
Fund for lower level health facilities. For both of these operations guidelines stipulate where to
deposit and how to use the funds. According to NHIF regulations
             “a public health facility shall retain the charges for services rendered which shall be
             kept in a Health Services Fund Account and be used in accordance to the laid down
             procedures but not limited to defray operating costs to maintain or upgrade
             equipment, plant or facility, and to maintain or improve the quality of services in the
             public sector except for remuneration of personnel services.” (National Health
             Insurance Fund Regulations 2000)

   - The Health Service Fund Account (hospital level)
The Health Services Fund Account (Account No.6) was established in 1997 for revenue collected
from user fees in government hospitals. The revenue was to be retained in the health facility and
not submitted to Treasury, but to be deposited in a separate Health Service Account to be opened
for each hospital (Operations Manual for Cost-Sharing Policy in the Hospital 1997). Hospitals were
to report on the revenues on a monthly basis to headquarter. For several years there have been
problems with data gaps as some hospitals are not reporting on revenues collected or are bringing
forward negative balances (PER Update 2005). Recently a regulation was issued stipulating that
user fee revenues collected in the hospitals be submitted to Treasury, reportedly to address the
problem of non-compliance with the reporting on revenue collections.

The regional and district administrations, i.e. in practice the RMO and the DMO, are responsible for
the administration (collection and management) of the HSF for their respective hospitals. Funds
are required to be used with the approval of the hospital management committee/hospital boards
according to an annual expenditure plan.

The HSF can be used for purchase of essential drugs and payment of MSD drug bills and cost of
collection at MSD, essential supplies and equipment, minor rehabilitation of buildings and
equipment as well as office stationary and communication necessary for HSF administration. The
fund cannot be used for payment of salaries, utilities or allowances (Operations Manual for Cost-
Sharing Policy in the Hospital 1997).

   - The Community Health Fund (primary health care level)
For the CHFs that have been established, the contributions from the households as well as the
user fees payable for non-members at government health centres or dispensaries are among the
permissible sources of funds. A separate CHF account is established exclusively for community
and government contributions (matching grant) to the programme. The DMO has the primary
responsibility for the administration of the CHF account. Procurement will be made at district level
on behalf of communities and based on the ward health plans and indent lists from facilities.




                                                                                                     21
The CHF revenues can be used for health related purposes specified in the District Health Plan.
Eligible purchases include “drugs, hospital equipment, rehabilitation and/or m aintenance of health
facility, furniture and equipment for the facility, materials and supplies for facility use; uniforms for
nurses, top-up and/or double shift allowances for clinical staff and nurses, travel and per diem
expenses incurred by staff on duty if specified in the ward health plan.” (Community Health Fund
Operations Guidelines 1999)

8.2. Observations
Timeliness of payment from NHIF
There are delays in payment not caused by late claiming. The NHIF is supposed to reimburse
within 60 days, but payment was in several instances found to be made only after 3-5 months.
There are examples of checks being wrongly addressed (e.g. check for Pangani sent to Handeni).
This problem appeared to be much more pronounced in Tanga than in Mwanza Region. This could
be due to Mwanza Region benefiting from the location of the NHIF Lake Zone Office in Mwanza
City, but could also reflect the fact that the NHIF Lake Zone Office has been operating longer
whereas the NHIF Zone office in Moshi (covering Tanga Region) has only been established
recently.

Practices for depositing reimbursements
The district and regional hospitals are required to submit their NHIF reimbursement to the HSF
account, currently (according to recent directives) maintained in the sub-treasury at regional level.
This practice is less of a problem for the regional hospitals as they are close to the regional
administration, but for the district hospitals the process of accessing funds becomes very
cumbersome. Many hospitals that have previously reported regularly on the cost-sharing revenues
have thus been punished in the attempt to capture the revenues of those who failed to account
appropriately for the cost sharing revenues. The centralisation to the sub-treasury seems to be a
step backwards and works against the intention to strengthen collection and use of revenues
through improvement of local accountability.

For the lower level health facilities it is less clear where the funds collected should be deposited
and practices vary considerably. The team found the following practices for depositing NHIF
reimbursements:

    Account #6 at district level
   This is the account used for government health block grant and health basket funds at district
   level. This practice implies that the health facilities and their governing committees do not have
   direct control over the funds. As the funds are not earmarked for specific health facilities they
   can be spent for district health expenditures not directly benefiting a specific health unit.

    HSF account in the sub-treasury at regional level
   This means that deposits are made together with user fees and NHIF reimbursement to
   hospitals. There is a risk that the reimbursements for health centres and dispensaries will be
   absorbed and used along with the hospital cost sharing funds. Access to the funds is
   cumbersome for the hospitals, but even more cumbersome for the lower level health facilities.

    A common cost sharing account at district level
   This account can either be separate or combined with the CHF-account – using different codes
   for CHF and NHIF as well as for facilities for easy identification.




                                                                                                        22
    A cost sharing account at facility level
   In some districts health facilities have opened, or are in the process of doing so, their own
   accounts for cost sharing funds, which would include user fees collected under the CHF
   programme as well as NHIF reimbursements.

Monitoring of the balance of funds and performance on NHIF reimbursements
Most health facility in-charges do not keep track of the amounts claimed, the amounts received and
their balance of funds available. In some districts, the letter to the DMO providing the breakdown of
reimbursement per facility is not always shared with the health facilities or not systematically so.
Many in-charges did not seem to perceive that the funds were for the facility to control.

Furthermore, not all DMOs keep track of the amounts claimed, reimbursed and collected, neither
by facility nor in total. Such laxity sometimes results in stale cheques, as cheques are not being
deposited and the lack of monitoring makes follow up difficult. Two cheques were found stale at
one DMO`s office, allegedly because it was unclear to which account it should go.

Some districts reported that they had/were planning to have orientation of facility governing
committees on their roles in relation to planning and management and financial issues.

No clear guideline on how to access funds
In the government health facilities especially in the dispensaries and health centers, the majority of
in-charges does not understand how to access the NHIF refunds as no clear guideline was issued
by the MOH on how to use the NHIF reimbursements. They were also not aware of how to access
cost sharing and CHF funds, despite the existence of guidelines. Some facilities receive
information from the NHIF on how much was reimbursed from the claims submitted but they never
get any feedback from the DMOs on how to use the money. Some facilities receive additional
drugs from the DMO, but it was not clarified whether the money was spent from their NHIF
collections.

There were no problems in the private and voluntary facilities on how to use the collections from
the scheme.

8.3. Recommendations
Recommended interventions that will address the problems found are:

      Training of health facility staff, facility governing committee members and DMOs office in
       procedures for accessing funds.

      Tools and training for health facility staff and facility governing committees for keeping track
       of funds collected, claims submitted and reimbursed, expenditure and balance available
       should be kept at health facility level and at DMO / NHIF co-ordinator level.

      All funding to be managed by the health facility, e.g. NHIF reimbursement, CHF and user
       fees, should be deposited in the same account at district level and be accessed the same
       way. For health centres and dispensaries the relevant account would be the CHF account.

      The facility governing committee should be empowered to decide on the utilisation of funds
       and should be encouraged to follow up on the reimbursement of funds, the balance
       available and the use of funds. This would entail active involvement in the CCHP process.

      Guidelines on how to access and use funds for cost sharing should be revised by MOH and
       PMORALG and should include also NHIF funds.



                                                                                                     23
      MOH and PMORALG should issue clear guidelines on where to deposit NHIF
       reimbursement (preferably in a district “cost sharing” account combining all cost sharing
       funds in one account, for example the CHF account, for easy access for facilities)

      Recruit more staff at the Zonal and NHIF head office to reduce reimbursement delays.
       Alternatively (in the long run) the presently applied procedure of checking each and every
       claim form could be replaced by a procedure where only a sample of claim forms are
       scrutinised in detail and more time is used for checking known problem areas.

      NHIF should liaise with the health providers to ensure that the cheques are addressed
       correctly as some of the stale cheques have incorrect address.



9. Benefit package and quality of care received
9.1. Background
The ToR of this consultancy mission do not include an assessment of the NHIF benefit package as
such. However, during our field visits the consultancy team made some observations concerning
the benefit package which we still would like to share. Our angle of looking at the benefit package
within this mission was not whether the package as such is appropriate or not. Our observations
and recommendations are, instead, restricted to the questions of in how far health facilities are
informed about the extent and limits of the benefit package, and in how far they face problems
regarding the package.

9.2. Observations
Reimbursement of drugs
Not all drugs supplied to health facilities in their regular kit allotments seem to be reimbursable.
This causes some confusion. In some facilities, especially dispensaries, claims were rejected by
NHIF for the reason that the facilities are not allowed to prescribe such medicine, despite being
part of the kit received. One example is Amoxilin which is provided by MSD in the kits to
dispensaries. Despite availability, claims for Amoxilin are not reimbursed at the dispensary level in
Tanga Region. However, the practice varies between NHIF Zonal Offices. Mwanza Zonal Office
follows the policy that all drugs supplied to health facilities in their regular allotments of kits are
reimbursable. Such complaints, therefore, have not been noticed for Mwanza Region.

Limitation of inpatient days
In health centres the limit of three inpatient days is perceived as very restrictive. Faith-based
facilities are concerned about the low rates of reimbursement and the limits on number of inpatient
days per admission. There is additionally a limit to the maximum number of inpatient days per year
per member (i.e. including all dependants) that NHIF will reimburse. It is, however, difficult for the
facilities to keep track of the total number of days used during the year, especially if the patients
have been admitted to other facilities.

Unawareness among NHIF members about the benefit package
Unawareness among NHIF members about the extent and restrictions of the benefit package (e.g.
compensation of optical services) seems to be a problem most health facilities face. No documents
are available at the facility level to inform members about their benefit package.




                                                                                                     24
Complicated procedures
Procedures for approving of reading glasses are being perceived as too complicated and
cumbersome. Members have to be examined by eye doctors who will fill the forms and forward
those to NHIF for seeking approval. It is unclear on which grounds such approval will be given and
why such a long procedure is necessary.

Bypassing of referral system by NHIF members
NHIF members often bypass the referral system. They bypass the first level government health
facilities as they perceive the quality of care as being low, and directly access either second level
(district hospital) or even third level (regional hospitals) governmental health facilities and utilise
them as a first access point (i.e. as a primary level facility). Reasons given are: General lack of
qualified staff, especially of Clinical Officers, at health centre and dispensary level; dispensary in-
charges are often not qualified for diagnosing patients and prescribing drugs; problems with stock-
outs of drugs and lacking diagnostics tools; NHIF-members come with specific expectations on the
kind of drugs to be prescribed (especially for antibiotics) and tests to be performed.

Lacking alternatives of drug providers
When only one private pharmacy is accredited there is no competition on service provision, e.g.
pharmacy may close for holidays.

9.3. Recommendations
For addressing the above mentioned observations, the consultancy team recommends the
following measures:

      Sensitise NHIF members on the benefit package.

      Prepare a brochure on the ABC of National Health Insurance Scheme and distribute to
       members through their employer and to health facilities for distribution to patients whenever
       discussions arise.

      Undertake a review of the quality of all health facilities, including government facilities, by
       NHIF and grant only transitional accreditation to health facilities not staffed or equipped
       according to government standards. The transitional accreditation should be given against
       a “Health Facility Development Plan” which would spell out how to improve the situation
       over that period. See also chapter 5.3.

      NHIF to liaise with the Chief Pharmacist on the appropriateness of the contents in the kit
       and indent system. All drugs contained in the drug kits for regular supply of health facilities
       should be reimbursable by the NHIF.

      NHIF should communicate to the health facilities whenever new treatment regimes
       introduced by MOH are reimbursable (e.g. malaria treatment with ALU).

      NHIF should provide clear guidelines for procedures for obtaining reimbursement for
       additional inpatient days exceeding the stipulated limits if medically required.




                                                                                                     25
10. Key recommendations
10.1. Summary of key recommendations
The NHIF is collecting a significant amount in contribution from its members. Although on the
increase, the actual reimbursement for services rendered to members or their dependants remains
relatively low. This is a cause of concern.

The level of reimbursements made depends on the extent to which beneficiaries have cards, the
extent to which accredited facilities are available and provide services of such quality that they are
utilised, the extent to which such facilities correctly fill and submit claims and the extent to which
reimbursements flow to the health facilities and are used for improvement of services. The team
found that there were problems in all these areas.

While there are still improvements to be made in the claiming process, the team found that
generally attention has been given to claims processing. There is, however, a need for clarification
of procedures and practices in certain areas and a need for strengthening monitoring and follow up
on submission of claims. Non-use of services by members constitutes another problem both
relating to a technical problem with availability of beneficiary cards as well as to a problem with the
quality of services available in accredited facilities resulting in bypassing of lower level facilities and
preference for private providers.

In the preceding chapters the detailed recommendations relating to each of these areas have been
outlined. These include a number of technical recommendations that can be implemented in the
short term as well as recommendations that would require policy change or that would be a priority
for implementation in the longer term. The purpose of this chapter is to summarise the main
recommendations, some of which cut across the problem areas.


With regard to the institutional set up to support the improvements in the functioning of the claims
and reimbursement system with a view to increasing expenditures and use of funds at facility level
the team recommends that

       The process of decentralisation in NHIF to zonal office continues and that these offices are
        adequately staffed and equipped.

       A focal person for NHIF is appointed by the DMO at district level. The responsibilities of the
        focal person should include
            o supporting health facilities in timely and correct processing of claims,
            o ensuring short introduction of new in-charges to the claiming process
            o assisting in follow up of members with missing NHIF beneficiary cards.

            In the longer term it could be considered to have a more general health financing focal
            person.

       The health facility governing committees are empowered through training and tools in
        relation to
            o the financial monitoring, i.e. in monitoring revenues collected, claims submitted and
                reimbursed, expenditures and balance available
            o decision-making on the use of revenues collected in the facility including the NHIF
                reimbursements (also in the context of achieving minimum quality standards)
            o planning and budgeting.



                                                                                                        26
           This would of course be relevant also for other sources of financing.

      NHIF reimbursements are treated as other revenues collected at facility level in terms of
       where funds are deposited and procedures for accessing the funds in order to avoid parallel
       systems. Preferably such funds should be kept in a “cost sharing” account at district level.
       Clear guidelines on where to deposit funds and which rules for accessing funds that apply
       should be issued and effectively disseminated by MOH/PMORALG.


With regard to improving beneficiaries’ access to quality health services, the team recommends
that NHIF:

      Develop accreditation guidelines clearly defining the “minimum standards” required by a
       health facility in order to be accredited. National accreditation criteria presently being
       developed by CSSC, MOH, NHIF with consultation of TBS should not only spell out the
       recommended standards, but also clearly define the minimum standards below which no
       health facility can be granted accreditation.

      Review the quality of each government facility with the objective to identify which facilities
       do not fully fulfil the criteria stipulated in the Ministry of Health Standard Facility Guidelines.
       The facilities that do not meet the criteria should be given a transitional accreditation of 2-3
       years against a “Health Facility Development Plan” which would spell out how to improve
       the situation over that period. This plan could also be used as a tool for the Health Facility
       Governing Committee for mobilisation of funds as well as for prioritisation of use of
       revenues generated at facility level. The plan should be integrated into the CCHP.

      Explore the possibilities for extending accreditation to more pharmacies and drug outlets,
       particularly in the rural areas (e.g. the ADDO – system, depending on the findings of
       ongoing consultancy missions on ADDO).


In order to ensure that all eligible beneficiaries have cards the team recommends that

      A survey of eligible members and their membership card status is undertaken at district
       level in order to assess the magnitude of the problem and to address the problem of
       missing cards.

      A routine system for, in future, capturing eligible members without cards is set up.

      Clear guidelines for replacement of missing cards is disseminated to members and
       providers.

      In the short to medium term, the issue of retrieval of cards from members that become
       ineligible, due to retirement or change in job situation etc., is resolved. A starting point
       would be an options analysis taking into account costs and practicalities of alternative
       options.


Basically, the claiming and reimbursement system set up is sound, but there is lack of clarity on
some details and acceptable ways of claiming. Further, monitoring of submission and




                                                                                                        27
reimbursement needs to be strengthened. In addition to strengthening the monitoring role of the
health facility governing committees mentioned above the team recommends that

      NHIF based on experience with areas that have caused confusion provide clear guidelines
       and effectively disseminate these, including such areas as
          o procedures for paying additional inpatient days exceeding the stipulated limits, if
              required
          o procedures for replacement of lost or missing membership cards
          o new treatment regimes that are reimbursable

      NHIF improve routine procedures
          o Give notification to health facilities through the DMO (copy to RMO) when health
              facilities have not claimed within 60 days
          o Regularly check that the address used for communication and payment to facilities
              are correct
          o Regularly update directory of all accredited health facilities
          o Undertake annual review of price list
          o Improve feedback letter from NHIF to DMO to provide reasons for rejection of
              claims not just by claim number, but also by facility.




                                                                                                  28
10.2. Table of key recommendations
Issues                                            Recommendations                                                                                        Timing            Responsibility
Cross cutting recommendations
Strengthening district level support
District support to health facilities are of      1.   Introduce in all districts focal persons who can facilitate that all eligible NHIF members have   Short term        DMO
varying quality                                        membership cards and who can effectively support the health facilities in correctly processing
                                                       their claims. In the long run, this can be a focal person for coordinating all health care
                                                       financing options.
                                                  2.   Include financial issues, including NHIF claims and reimbursement status, as a regular item in    Short term        DMO
                                                       the DHMT supervision report. This should also include checking availability and completeness
                                                       of key reference material (codebook, price list)
                                                  3.   Initiate a widely publicised NHIF-award for the best performing district to be presented by the   Medium Term       MOH
                                                       Guest of Honour during the Annual DMOs meeting.
Strengthening the capacity at facility
level
Health facility governing committees are an       1.   Sensitisation and empowerment of HFGCs in their roles in relation to                              Short term        DMO
under utilised resource and have to be                 -    financial monitoring, i.e. monitoring revenues collected, claims submitted and
activated for accessing funds.                              reimbursed, expenditures and balance available
                                                       -    decision-making on and procedures for the use of revenues collected in the facility
                                                            including the NHIF reimbursements (using the CCHP development process actively)
                                                       -    planning and budgeting (also in the context of minimum quality standards required for
                                                            accreditation)
Practices for depositing and accounting for       1.   NHIF reimbursements are treated as other revenues collected at facility level in terms of         Short term        MOH/MPORALG
funds vary.                                            where funds are deposited and procedures for accessing the funds. Preferably such funds
                                                       should be kept jointly with CHF revenues in a “cost sharing” account at district level. Clear
                                                       guidelines on where to deposit funds and which rules for accessing funds that apply should be
                                                       issued by MOH/PMORALG
Some health facility staff are confused about     1.   Retraining of health facility staff on their role and issues in relation to                       Short term        DMO/NHIF
the claiming and reimbursement system and              -    claims processing rules and practice
unaware about how to access funds.                     -    financial monitoring, i.e. monitoring revenues collected, claims submitted and
                                                            reimbursed, expenditures and balance available
                                                       -    decision-making on and procedures for the use of revenues collected in the facility
                                                            including the NHIF reimbursements
                                                       -    planning and budgeting (also in the context of minimum quality standards required for
                                                            accreditation)
                                                       -    possibility of using the funds to motivate staff
Specific recommendations
Accreditation
Need to attract and retain private providers in   1.   The price list stating reimbursement rates must be reviewed at shorter intervals, at least        Annual            NHIF
the scheme                                             annually
                                                  2.   Advocacy and sensitisation of private providers, pharmacies and drug-outlets especially in        Short term for    NHIF
                                                       rural areas. Dissemination of information on accreditation criteria and fund operations to        pharmacies/drug


                                                                                                                                                                                         29
Issues                                           Recommendations                                                                                         Timing                 Responsibility
                                                      enable private providers to make informed decisions on applying for accreditation.                 outlets. Medium term
                                                                                                                                                         for private clinics.
Need to ensure access to quality health          1.   Develop accreditation guidelines clearly defining the “minimum standards” required to be           Short term             NHIF/MOH/CSSC/TBS
services                                              accredited with NHIF.
                                                 2.   Review the accreditation of each government facility. Facilities that do not meet the standards,   Short to medium term   Overall principle: MOH
                                                      should be required to develop a “Health Facility Development Plan”. The continued                                         Inspection & accreditation: NHIF
                                                      accreditation status will be evaluated regularly against progress on the implementation of that                           Health Facility Development
                                                      plan.                                                                                                                     Plan: DMO/Health Facility
                                                                                                                                                                                Governing Committee
                                                 3.   Number of facilities fully and conditionally accredited must be reported in the Annual District    Short to medium term   NHIF
                                                      Health Report.
Registration
Some NHIF members and other beneficiaries        1.   Undertake census of NHIF contributors in the district with regards to NHIF card holding status     Short term             DMO/ NHIF
do not have cards                                2.   Sensitise NHIF members on the benefits of the scheme and procedures for obtaining a card           Short term             NHIF
                                                 3.   Clarify and disseminate information on procedures for replacement of lost or missing               Short term             NHIF
                                                      membership cards.
                                                 4.   Develop routine system: providers to list those without cards and send monthly notice together     Short term             NHIF/DMOs
                                                      with submission of claims to DMOs office for follow up.
Facilities treat retirees free, but do not get   1.   Analyse effects, practicality and cost implications of alternative solutions:                      Medium to long term    NHIF
reimbursed                                            –     making the employer responsible for withdrawing the cards and to develop an incentive
                                                            for the employer to comply.
                                                      –     expanding the benefit package to include retirees
                                                      –     issuing cards with expiry date
Claims processing and reimbursement
There are confusions and inconsistencies in      1.   NHIF should based on experience with areas that have caused confusion provide clear                Short term             NHIF
the perceptions and practice.                         guidelines and effectively disseminate these, including such areas as
                                                      -    procedures for paying additional inpatient days exceeding the stipulated limits, in
                                                           exceptional cases where medically required
                                                      -    benefit package and eligible groups for claiming (e.g. under 5s and pregnant women)
                                                      -    procedures for replacement of lost or missing membership cards
                                                      -    new treatment regimes that are reimbursable
                                                 2.   NHIF should                                                                                        Short term             NHIF
                                                      -    simplify procedures and disseminate them to members on what to do to replace lost or
                                                           missing membership cards
                                                      -    develop a routine feedback system from health facilities to NHIF on patients with missing
                                                           cards, which can then be followed up by NHIF
                                                 3.   NHIF should improve routine procedures, including                                                  Short term             NHIF
                                                      -    Give notification to health facilities through the DMO (copy to RMO) when health facilities
                                                           have not claimed within 60 days
                                                      -    Regularly check that the address used for communication and payment to facilities are
                                                           correct
                                                      -    Feedback letter from NHIF to DMO on reasons for rejection of claims should spell out
                                                           the feedback per facility in an understandable language
                                                      -    Provide room for appeal for rejected claims

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11. Phase two implementation

The team has made a number of recommendations, some of which can be implemented
immediately without piloting, some of which requires political decision making and some of which
might be suitable for immediate implementation, but for which testing and fine-tuning would be
useful before considering rolling it out to the whole country. Therefore the

Objectives
The objectives for phase two implementation (over a period of 3-4 weeks) is to test the feasibility of
some of the recommendations developed as a result of the preceding situation analysis and with a
view to make recommendations for wider implementation based on the experiences with
implementation in selected districts. For selected districts the objectives of phase two are to:

           1.    Increase the number of NHIF members in the district with cards
           2.    Reduce the rate of claims being rejected
           3.    Increase the number of health facilities submitting their claims
           4.    Increase the awareness of the financial status of the facilities and ways of using
                 balance funds.

Methodology
The proposed activities to address the objectives are outlined below. It is further proposed that the
specifics of the implementation are further developed in a workshop with stakeholders.

           1. Develop a job description for the NHIF focal point, select and train focal persons.

           2. Undertake a census of eligible NHIF members and their card-holding status.
              Based on the list of pay check numbers the NHIF could supply the employers with
              information on the status of the employees as regards membership cards. This will
              allow the employer to follow up with members that have not registered for a card,
              and to resubmit registration forms. Further, it will allow identification of those for
              which NHIF cards have been issued, but where these have never reached the
              member. For such cases, reissuing of cards after appropriate verification should
              take place.

           3. Develop routine reporting on NHIF members without cards.
              Health care providers could list patients who are members or dependants of
              members who present themselves in the facility without a card. This list could be
              used for follow up with NHIF on the status regarding issuing of cards. A list could be
              forwarded on a monthly basis along with the claims submitted to the DMO. The
              DMO would forward the list along with the claims to NHIF

           4. Empower the health facility governing committees and health staff
              Training of health facility governing committees and health facility staff in principles
              of the NHIF, claims rules and regulations, financial monitoring as well as division of
              roles and responsibilities. Development of simple monitoring tools. This advocacy
              would also include DHMTs, CHSBs, RHMTs.

                 Prerequisite: Rules and regulations for claiming are updated. Rules and regulations
                for depositing and use of funds are clearly defined.




                                                                                                      31
Based on the experience from the pilot implementation in these four areas, guidelines can be
developed for methods for assessing and addressing problems of members with missing cards,
including routine reporting on NHIF members without cards and for simple financial monitoring at
health facility level. Further, the scope for a health care financing focal person more broadly can be
considered based on the experience with the NHIF focal person. Such guidelines and experiences
would then form the basis for replication in other districts.

Time schedule (initially envisaged)

Mid February               Identification of local implementation team

End February               Workshop on specifics of the implementation arrangement;
                           development of material and training of trainers.

Early March                Implementation starts

End March                  Writing of final report based on experiences from the field.


Due to clash with the Joint Health Sector Review, the time schedule was revised in March 2006,
see Phase Two Report.




                                                                                                   32
References
Health sector PER update FY 2005, Final Version, Prepared by PER Task Team, Ministry of
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Health sector PER update FY 2004, Final Version, Prepared by PER Task Team, Ministry of
Health, United Republic of Tanzania

Ministry of Health (2003). "Public Expenditure Review Health Sector Update for 2003. Final report."
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Technical Review of Health Service Delivery at District Level, Independent Technical Review on
Behalf of the MOH, PORALG and the Government of Tanzania, March 2004, Final Report, HERA

Joint Rehabilitation Fund for Primary Health Care Facilities Procedures Manual, Final, December
2004, President’s office – Regional Administration and Local Government, United Republic of
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Technical Review 2005, Public Private Partnership for Equitable Provision of Quality Health
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Report of the 6th Tanzania Joint Annual Health sector Review, 4 th-6th April 2005, Kunduchi Beach
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Health, United Republic of Tanzania. Including Progress against milestones set in March 2004

Health Care Financing in Tanzania 2005, Fact Sheet No. 1 – Cost Sharing, No.2 – National Health
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Human Resources for Health: Requirements and Availability in the Context of Scaling-Up Priority
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Guideline for Reforming Hospitals at Regional and District Levels, Ministry of Health, United
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Local Government Capital Development Grant System, Manual for the assessment of councils
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MOH 1997. Operations Manual for cost-sharing policy in the hospital. Dar es Salaam, December
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MOH. Circular to hospitals under the hospital capitalisation program. Circular … CP1/1999.

MOH 1999. Community Health Fund Operations Guidelines. Dar es Salaam, June 1999.

NHIF Corporate Plan for 2005 – 2006.




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