Health insurance for all faces uncertainty from informal sector

Dar es Salaam. 28-year-old Magere Mabere earns a living as a bodaboda cyclist in Dar es Salaam. He has decided to join a network of some of his fellow cyclists who can access health insurance through savings in a credit cooperative society group known as the Dar es Salaam Bodaboda Saccos (Dabosa).

However, not all boadaboda cyclists like Mabere, and most other people in the informal sector who spoke to Your Health, have been as keen in attempting to enroll for the health security.

Safielli Samuel (30), a resident of Mabibo in the city feels that he has been neglected in health insurance schemes. “For me to have health insurance, I need to have a job contract. I work as a bus conductor, my employer neither gives a contract nor a health insurance,” says Samuel.

Samuel, who has been working as a bus conductor in Dar es Salaam for three years now, represents a group of people in the informal sector who do not have access to health insurance.

An economist from the Ministry of Health, Community Development, Gender, Children and the Elderly, Mr Kuki Tarimo, believes that there will a great need for mass education campaigns to help more citizens accept the government’s plan for all citizens to enroll.

“We[as the government] are aware that there will be many challenges in trying to make people understand the importance of health insurance. There are people who still believe that health insurance is another form of taxation,’’ he said recently.

But Mabere, the bodaboda cyclist, says that he witnessed a neighbour whose wife was injured a in car accident about six months ago, forcing the family of the accident victim to exhaust their financial resources to pay for her treatment at Muhimbili Orthopaedic Institute (MOI).

“My neighbour is a bodaboda cyclist like me. He came kneeling before me to help him raise money for his wife’s medical care. I felt challenged. When I heard later through friends that such problems can easily be solved through having medical insurance, I decided to join,” says Mabere.

He subscribed to the scheme about five months ago, where he pays Sh20, 000 each month through savings at Dabosa. “Part of the money that I am paying for the savings through Dabosa, is meant for my health insurance,” he says.

For Ms Sauda Akilimali (40), a food vendor who lives in Kilosa, Morogoro Region, being on health insurance did not work for her. She dropped out of the Community Health Fund (CHF) recently after enrolling for two years.

“I found no reason to continue contributing to CHF while there were no drugs at the hospital every time I took my child for treatment,’’ says the mother of three children.

“I came to discover that at the drug shop, you can pay more than half of the fees that you paid to become a member of the scheme. This is like paying twice,’’ complained Ms Akilimali.

If the Bill on mandatory health insurance is passed by parliament next month, it means that Mabere, Sauda and the rest of the Tanzanians, will now be required by the law to access prepaid health services at health facilities across the country.

Healthcare planners and public health researchers caution that the government will have no choice but to invest heavily in the health sector, if the plan to achieve Universal Health Coverage (UHC) through mandatory health insurance is to be achieved.

Dr Samuel Ogillo, the CEO of the Association of Private Health Facilities of Tanzania (APHFTA), says that the adoption of the Health Insurance For All strategy has proved challenging for countries such as Ghana which tried it.

“Ghana started off their Universal Health Coverage plans with high expectations, just to realise that the plans were becoming too ambitious to achieve,’’ says Dr Ogillo.

As a result, he notes further, the Ghanaian government had to quickly introduce additional taxes, including some additional tax cuts in the Value Added Tax as a desperate measure to save the country’s national health insurance fund from collapsing.

For the case of Tanzania, access to health insurance has remained almost a reserve of those who are on formal employment.

As long as one is formally employed, he/she is entitled to a generous package of healthcare from the government and accredited private facilities, with their children and spouses included on the cover.

Health Minister Ummy Mwalimu told Your Health recently that the government is now banking on increasing the national coverage for the informal sector, especially in rural areas, through the CHF.

In recent years, community based health insurance has been promoted within health financing reforms in many developing countries.

Tanzania introduced the CHF as a form of voluntary community based health insurance for the rural informal sector in 2001.

“We will soon embark on massive advocacy campaign through [the local government authorities] in order to raise the agenda of prioritising the CHF in their administrative areas,’’ Ms Mwalimu said.

In the initial phase, the government targets 70 per cent of the population in enrolling for health insurance by the year 2020, she noted.

Currently, only 27 per cent of all Tanzanians are covered on various forms of health insurance, according to data from the Ministry of Health. But, majority of the members are from the formal sector.

According to the World Health Organisation (WHO), the split between the formal and informal population can delay fundamental reforms to reach all the citizens at scale.

The world health agency suggests that a country must set a minimum of USD 30 to 40, which his equivalent to Sh60, 000 to 80,000 per person, in order to be able to provide minimum healthcare package.

But in areas where the government has rolled out the CHF scheme, many challenges still abound. Researches have called for fundamental reforms in an effort to make the CHF more accessible across Tanzania.

For the informal sector to benefit from Community Health Fund schemes, and the urban equivalent of Tiba-kwa Kadi (Tika), studies done in the country suggest that the quality of health services must first be improved.

Done two years ago, a survey titled, “Determinants of community health fund membership in Tanzania: a mixed methods analysis,” suggests that the CHF package has to be raised in order to attract more people in the informal sector to join voluntarily.

The survey was carried out in four districts of the country—Singida, Mbulu, Kigoma rural and Kilosa and through interviews, the researchers revealed the challenges that people in the informal sector faced in trying to enroll into the CHF.

Through interviews, the researchers could tell that some people did not understand the concept of CHF. For instance, some members felt that their contributions should be saved and returned to them if they did not become sick.

“Why should I pay again to join for the next year, while I know my dependents didn’t fall sick this year? I didn’t use my money!” argued one of the people who was interviewed during the research.

Researchers say many dispensaries were found to have no diagnostic equipment. This resulted in people bypassing to higher level referral facilities or private facilities that are not covered by the CHF.

“Sometimes they don’t treat what was supposed to be treated at the dispensary, because there is no diagnostic equipment,” said another person who was interviewed during the same research.

As the government inches closer in introducing the health insurance reforms in the coming parliament, the hope of many Tanzanians is that access to quality healthcare services will now be improved.