NHIF: Why health insurance sector needs oversight body

With no body to regulate costs, health providers charge as per their whims thus making it difficult for some people to access services at some facilities despite holding insurance cards.

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“We are talking of a body likened to Ewura [Energy and Water Utilities Regulatory Authority] that would regulate prices that health providers charge to patients,” said NHIF’s Marketing and Customer Service manager Hipoliti Lello.

According to him, with no one regulating the health care charges, service providers have the freedom to charge at their own discretion, thus inflating pricing remains not uncommon.

“As NHIF, we are regulated by the Bank of Tanzania (BoT) on issues pertaining to investments while the Ministry of Labour, Youth, Employment and Persons with Disabilities under the Prime Minister’s Office, is responsible for supervision of the fund,” he said.

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Mr Lello was of the view that having a pricing regulatory authority, will not only encourage healthcare providers to keep costs down without skimping on quality, but will also result into enrolling more clients.”

He was speaking when a delegation of senior officials made a familiarisation tour of Mwananchi Communications Limited (MCL).

It is said that such authority will serve as an instrument to control pricing, while providing incentives for quality, coverage, and efficiency and that in recognition of its complexity, many countries have established specific entities to carry out price setting and regulation.

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In recognition of health care service complexity and importance, many countries have established or designated specific entities to establish pricing by negotiating with stakeholders, he said.

The team, which was led by NHIF’s information communication technology (ICT) director Alexander Sanga also detailed how the fund was working hard to combat fraud through the implementation of effective technology solutions.

According to him, the majority of health care providers are honest and well-intentioned, moreover, there are some with fraudulent behaviours which has a direct negative impact on health care utilisation.

Adding: “It is a fact that some individuals will always look for a way to make gains where there is opportunity, therefore, NHIF as an organisation, need to have a robust process in place that will prevent, detect and respond to fraud and corruption.”

“Our system offers such solutions, and since we have integrated it with Rita [Registration Insolvency and Trusteeship Agency], Tanzania Revenue Authority (TRA) and Business Registrations and Licensing Agency (Brela), we are able to verify all submitted claims,” he said with confidence.

As a result, the NHIF delegation told The Citizen that in 2021/22 fiscal year, the fund managed to recover Sh7.9 billion that was to be lost through fraudulent means.

It also investigated a total of 86 fraud cases while 65 practitioners, suspected to have taken part in fraudulent activities, had been reported to their professional regulatory bodies for further actions.

NHIF has also taken 61 cases to court while 29 persons have been referred to the Prevention and Combating of Corruption Bureau (PCCB) for their alleged involvement in fraudulent undertakings involving the fund.

On the other hand, at least 141 policy holders have been stripped off their membership while 14 health service providers have been banned from issuing services to NHIF health insurance card holders.

“Out of the 14 service providers that have been blacklisted and banned from working with NHIF due to forgeries, 10 have been declared fraud facilities, the move has an impact which can be irreversibly harmed, but we have no alternative as this is public money and we need to be accountable for,” he said.

Then delegation reiterated the government’s position that the rise in the number of cases of non-communicable diseases (NCDs) was a thorn in the fresh of health insurance providers, calling upon Tanzanians to cultivate a culture of living healthy lives, including exercising to defeat the challenge.

Towards a proposed universal health coverage, the NHIF team suggested for the need to ensure that it should be mandatory to all Tanzanians.

The fund is dedicated to providing quality services, thus accessing health care services through a wide network of 9,000 accredited health facilities.

According to him, an insurance awareness campaign was needed to be carried out to successfully enhance people’s understanding of health insurance schemes as the majority shy-away questioning themselves on the reason behind paying for premiums, yet they might not need to use such a service.

“If one doesn’t buy his/her health insurance now, and then if he/she get sick in the meanwhile, he/she will probably be out of luck because he will need to wait for a month if he is above 18 and three months if he is below 18 to be covered by NHIF,” he warned.

Furthermore, Mr Lello explained that NHIF stands between its clients and service providers, saying improvements have been incorporated and that a policyholder will not be turned down simply for visiting a hospital more than once a day.

“Due to numerous emergences, our clients are allowed to visit service providers as many times as they fell ill. Of course, the system might deny you, but we have an ‘emergency window’ to cater for the matter and all service providers are aware of it and will advise you accordingly,” he clarified.

He also encouraged the general public to make use of the fund’s app which offers general information and updates on NHIF as well as providing customers with an easier way to access services provided by the Fund. It has also information on how to report lost cards, view contributions and get notified on insurance cards expiry dates.

NHIF, a government entity that operates under the health ministry, was established with the main objective of ensuring accessibility of health care services to Tanzanians.

The Fund considers health insurance as a societal affair rather than an individual need, thus operates under the principles of risk sharing and solidarity among its members.

Despite the compulsory enrolment arrangement to public servants, the Fund has expanded its coverage to include other groups such as local councils, private companies, education institutions, private individuals, children under the age of 18, farmers in cooperatives as well as organised registered groups which includes, ‘Machinga’ and Bodaboda groups.

The Fund is also administering the Bunge Health Insurance Scheme and also covers Members of the Zanzibar House of Representatives.