How Tanzania can achieve universal health coverage

Dar es Salaam. The government envisions a country where mandatory health insurance for all is the key driver of healthcare delivery.

Nonetheless, making the scheme workable will require making tough decisions and working out a strategy, which would help all Tanzanians appreciate the value of being insured.

As heath advocacy organisations convened in Dar es Salaam on Wednesday to ponder on how to guarantee healthcare access to the poor and marginalized, the big question The Citizen posed to all health stakeholders was: What will it take for Tanzania to achieve the mandatory health insurance plan?

The question comes more than a year since the minister for Health, Community Development, Gender, Elderly and Children, Ms Ummy Mwalimu announced that a bill would be tabled in parliament as part of the country’s plan to introduce the mandatory health cover. However, it has not been tabled yet.

In other countries, reports show that two low income countries in Sub-Saharan Africa have achieved high health insurance coverage. They are Rwanda and Ghana.

By 2012, in Rwanda the coverage was over 80 per cent while in Ghana it was over 60 per cent, according to a study, “Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage,” in Lancet Journal.

The coverage may have increased further in recent times.

In Tanzania, only about 30 per cent of the people can access health insurance, according to current government data.

The rest, over 35 million people are forced to dig into their pockets when they want to access services at health facilities.

The government is now striving to expand health insurance coverage to 50 per cent of all Tanzanians by 2020, said Ms Mwalimu during the last budget parliament.

In view of this, the government’s vision of ensuring that every Tanzanian gets mandatory health cover is seen as a game-changer. But, there are roadblocks to overcome if the plan is to sail through.

“First and foremost, the government must not monopolise the implementation of the plan. It should be largely inclusive,’’ suggested Mr Irenei Kiria, the Executive Director of Sikika, a health advocacy organisation.

“Or rather, it should be left to the general public, private health stakeholders and NGOs to implement.

“The government must only focus on streamlining policy issues and mobilising the health stakeholders as it paves the way for implementing the plan,” he told The Citizen on the sidelines of a health dialogue meant to raise voices high for the poor and marginalised people living in Dar es Salaam, especially on access to health insurance.

The dialogue was organised by the Christian Social Services Commission (CSSC) and a Germany social welfare organisation known as Diakonie-Hamburg.

It involved authorities in the municipal council, led by the Dar es Salaam Mayor, Mr Isaya Mwita.

The point that Mr Kiria raised about the government’s monopoly over health insurance was also discussed in other forums, but the National Health Insurance Fund (NHIF) has always downplayed the arguments.

The health minister announced in parliament early this year that all public servants in the parastatals must leave private health insurance companies and join the NHIF as part of the plans to expand the coverage of health insurance in the country.

There has been a clamour from various stakeholders, asking the government to review the strategy. Private health sector investors have specifically cautioned about the monopoly of Universal Health Coverage (UNC) strategies, whereby the government relies on the NHIF for implementation, side-lining the private sector.

The NHIF Director General, Mr Bernard Konga has until recently assured the private health stakeholders that there is room for discussion on how the NHIF would partner with them.

“The issue of monopoly is being taken care of,’’ he said during the East Africa Health Federation Conference in Dar es Salaam last month.

But Mr Kiria of Sikika, whose organisation has been carrying out research on delivery of health services in Tanzania for many years, insists that it was risky to surrender this huge healthcare plan to the government. This, he says, will require making tough decisions.

He says government structures have been known for not having stable administrative strategies.

“We (as a country] now have the head of state whose administration is tough, but he will leave at the end of his tenure. We cannot guarantee that the coming leader will be as tough in making government institutions to keep the same pace,’’ he noted.

“When it comes to this health plan, we would be let down by a poor administration again in the future. That’s why I insist that people [not the government alone] should be left to drive this health insurance plan. And, the people should have powers to question how it will be implemented,’’ he said.

Burden of not being insured

Currently, the government shoulders a burden of over 70 per cent of people who receive healthcare by exemption.

“This is a big burden which could be relieved if a workable health insurance plan is rolled out and all these people are accommodated,’’ says Mr Kiria.

Health insurance is what will save the poor and marginalised people from the challenges of accessing healthcare. Tanzania guarantees health covers for people who are formally employed—those who are in the informal sector have to pay out of their pockets to access health services.

The out-of-pocket payment system has far-reaching financial implications on the lives of the poor majority because of catastrophic health expenditures, various reports on Tanzania and other countries indicate.

In 2015, the World Bank (WB) released a report, which showed that the rate of impoverishment for people who pay out of pocket for healthcare stood at 2 per cent.

In its first ever report tracking down the worldwide coverage for health, the WB revealed that the poverty situation was worse among the people who could not access the prepaid health services, especially in countries that have invested a small share of their national budget for health.

’Finally, it is clear that focusing on people’s pockets and what comes out of them when paying for the health services, runs the risk of missing the bigger reality of the health–finance interface,’’ said the report compiled by the WB in collaboration with the World Health Organisation(WHO).

And in Tanzania, the National Health Accounts (NHA) once admitted that the out-of-pocket payments are a “serious equity concern as they limit access to care for the poorest group.”

Need for advocacy campaigns

In an interview with The Citizen, the Christian Social Services Commission Executive Director, Mr Peter Maduki said Tanzania is well positioned to implement the mandatory health insurance plan successfully if it puts huge investment in raising awareness among the people on the importance of health insurance.

“You see, if all the people appreciate the value of health insurance, it means many things will be made possible. First, people will be ready to raise contributions for it and second, they will also know the importance of working to help other people to enrol in the scheme,’’ he said.

He had earlier told participants of the dialogue held in Dar es Salaam that it was now time the county mapped out the population and established the level of poverty so that the poor and marginalised people can be tracked down.

“I believe the poor and marginalised people need a form of health insurance that relates to their situation. The current system we have in Tanzania, only allows the formal sector—people who are on formal employment to get access to prepaid health services. What about the poor people,’’ queried Maduki.

The World Health Organisation had once cautioned that a split between formal and informal populations can delay more fundamental reforms to reach citizens at scale.

But for Mr Willem Koster, the Management Advisor of CSSC, Tanzania must not relent on its efforts to bring about mandatory health insurance for all the people.

“Where I come from, we don’t have the challenges such as those faced by Tanzania. Investment in healthcare is huge. I know the financial obstacles that Tanzania has to deal with to make this possible,’’ the Dutchman told The Citizen during an interview in Dar es Salaam.

“What I see as a step forward is that the country has to remain positive about it, inject in enough funds, political will and make it a multi-sectoral.

But above all, there is a need for substantial amount of research on how this can be achieved,’’ he added. Studies done in Tanzania have pointed out the factors that must be addressed in an effort to rollout a successful health insurance.

One study, titled: “Determinants of community health fund membership in Tanzania: a mixed methods analysis,” analysed the determinants of community health fund membership.

The study, published in 2014 says, “[the determinants] are diverse and improving the quality of health services and expanding the benefit package should be prioritized to expand voluntary health insurance coverage.”

According to the WHO, a country must set a minimum of USD 30 to 40(Which is equivalent to Sh60, 000 to 80,000), per person, in order to be able to provide a minimum healthcare package.