Stakeholders propose solutions to resolve NHIF, hospital payment disputes
What you need to know:
- The proposed solutions include claims review, regular training and seminars
Dar es Salaam. Stakeholders have put forward a range of measures to address the ongoing payment disputes between health facilities and the National Health Insurance Fund (NHIF), which jeopardise the financial stability and operational capacity of the healthcare providers.
The proposed solutions include claims review, regular training and seminars, independent mediation or expert reviews, revisions to national treatment guidelines, and the enforcement of legal and regulatory reforms.
Other recommendations call for reducing fraud, improving transparency, enhancing the role of the Tanzania Insurance Regulatory Authority (Tira), and strengthening monitoring mechanisms.
On April 4, 2025, The Citizen’s sister publication, Mwananchi, reported on the ongoing issues, with sources proposing immediate measures to address the crisis surrounding Tanzania’s health sector.
In the 2022/23 fiscal year report, Controller and Auditor General (CAG) Charles Kichere recommended a system to review all rejected claims and provide timely feedback to the relevant departments to prevent recurrence.
He also proposed that NHIF engage hospitals in regular training and seminars to improve health service delivery without undermining identified needs.
"I recommend that NHIF and hospitals collaborate to resolve these recurring challenges," said Mr Kichere while presenting the 2023/24 audit report.
He stressed the rise in rejected claims and their damaging impact on hospital finances.
Health insurance expert Dr Anselmi Anselmi said that NHIF only reimburses medications included in the essential drugs guide.
He explained that if a prescribed drug is not listed, an alternative medication must be found.
On treatment decisions, Dr Anselmi emphasised that doctors have the final say, as they directly examine the patient and assess test results.
However, he noted that national treatment guidelines and legal requirements must also be considered, proposing reviewing the national treatment guidelines to address the ongoing disputes.
Dr Anselmi also recommended appointing an independent expert or mediator to resolve disputes between clients and NHIF.
Public health expert Dr Ali Mzige emphasised the need for legal reforms, stressing that individuals with relevant expertise should fill leadership positions.
A bill to amend the National Health Insurance Fund Act was presented to Parliament on February 14, 2025, during the 18th session of the 12th Parliament.
Among the proposed changes is the removal of the verification requirement for health service providers by NHIF, with the Ministry of Health certifying providers instead to streamline the process.
Other amendments suggest that payments for services be made directly to service providers’ accounts rather than through NHIF to ensure timely claim settlements and improve service delivery efficiency.
The Association of Private Health Facilities of Tanzania (Aphtha) CEO Dr Samwel Ogillo identified fraud—often misinterpreted as errors—as a major challenge.
He explained that if a prescription is written incorrectly, such as with an incorrect product code, NHIF may treat it as fraud, leaving no opportunity for clarification.
"If a service provider is accused of fraud, NHIF initiates investigations and often requires receipts that may no longer be available due to the disappearance of many electronic receipts (EFDs), making it difficult to present documents from one to three years ago," said Dr Ogillo.
To resolve this issue, he suggested that TIRA act as a mediator, noting that such a role did not previously exist.
He also highlighted that TIRA currently oversees insurance matters, and all insurance service providers must register with the authority.
TIRA Director Dr Baghayo Saqware confirmed that the authority began addressing complaints in January 2025.
"We have received several complaints from hospitals, and some have been resolved. Anyone with issues can submit a letter or visit our office to follow the procedure or check our website," he said.
The issue of payment claim rejections was raised by CAG in a report released on March 28, 2024, following the audit of public corporations for the 2022/23 financial year.
The audit revealed that NHIF had rejected Sh11.83 billion worth of claims from four public hospitals: Muhimbili National Hospital (MNH), Muhimbili National Hospital-Mloganzila, Muhimbili Orthopaedic Institute (MOI), and Muhimbili University of Health and Allied Sciences (Muhas).
Further presenting the 2023/24 financial year audit report on March 27, 2025, CAG revealed an increase in rejected claims.
He reported that NHIF had rejected Sh11.23 billion worth of claims from MNH and Muhimbili National Hospital-Mloganzila, representing 16 percent of all claims submitted by regional and district referral hospitals.
These claims were rejected due to issues including incorrect pricing, dosage errors, incorrect products, and unnecessary expenses, all of which have negatively impacted the financial stability of these hospitals.
