Decentralisation of Health Systems and the Fate of Community Health Fund in Tanzania: Critical Review of High and Low Performing Districts
The deterioration of health services provision in Tanzania from 1980s to 1990s made decentralization of health service provision through the Health Sector Reform (HSR) a necessity. HSR aimed at bringing better utilization of scarce resources, improved quality of health services, increasing user access and cutting rising costs. It is through HSR that health insurance schemes were introduced. Community Health Fund (CHF) came as a result of such efforts. The efficiency and effectiveness of CHF rests on district councils which are responsible for ensuring better performance of CHF. Although the Government of Tanzania targeted 85% of the population to be members of CHF, enrollment has remained as low as 9.2% by 2014. The most sticking problem is the variation in enrollment in different districts. There are districts with higher performance in CHF enrollment like Iramba (54%) and Bariadi (40.9%). Whereas, there are districts with very low enrollments in CHF like Liwale (8%), and Rungwe (6.5%). This paper is an effort to shed some light on this phenomenon ofperformance variation of CHF enrolment in districts. It argues that poor performing districts are constrained by their own weaknesses such as poor management and leadership capacities of Council Health Management Team (CHMT) and lack of motivation among health facility staff and allied health workers. Also, poor sensitization and mobilization of people to join CHF, as well as poor quality healthcare to people has deterred performance of CHF in some districts. The papers’ conclusion apart from offering recommendation also adds to the broader ongoing debate of decentralization process mainly through health insurance.
Chakupewa Joseph Mpambije,
Decentralisation of Health Systems and the Fate of Community Health Fund in Tanzania: Critical Review of High and Low Performing Districts, Science Journal of Public Health.
Vol. 5, No. 2,
2017, pp. 136-144.
Kamuzora, P., & Gilson., L. (2007). Factors Affecting the Implementation of the Community Health Fund in Tanzania. Health Policy and Planning 22 (2) 95-102.
Macha, J, Kuwawenaruwa, A, Makawia, S, Mtei, G and Borghi, J (2014) Determinants of Community Health Fund Membership in Tanzania: A Mixed Methods Analysis. BMC Health Services Research 2014, 14: 538.
URT. (2014). The Budget Speech Estimate for the Ministry of Health and Social Welfare (MoHSW) for the Financial Year 2014/2015. Ministry of Health and Social Welfare.
Wobst, P. (2001). Structural Adjustment and Intersectional Shifts in Tanzania: A Computable General Equilibrium Analysis. Research Report 117 International Food Policy Research Institute.
Besley, T., & Coate, S. (2003). Centralized Versus Decentralized Provision of Local Public Goods: A Political Economy Approach. Journal of Public Economics 87: 2611-2637.
Munga, A., Songstad, N. G., Blystad, A., & Maestad, O. (2009). The Decentralisation-Centralisation Dilemma: Recruitment and Distribution of Health Workers in Remote Districts of Tanzania: BMC International Health and Human Rights 2009, 9:9 doi:10.1186/1472-698X-9-9.
Mujinja, P.G.M and Kida, T. M (2014) Implications of Health Sector Reforms in Tanzania: Policies, Indicators and Accessibility to Health Services. THDR 2014: Background Paper No 8 ESRF Discussion Paper 62.
Kopoka, P. (2002). Health Service Delivery in Tanzania in the 21st Century. In Mbele, A et al (eds). The Nyerere Legacy and Economic Policy in Tanzania. Dar Es Salaam. Dar es Salaam University Press.
World Bank and Ministry of Health (2003) A Country Status Report on Health and Poverty: Health, Nutrition, and Population inputs for the PRSP and HIPC process. The World Bank Africa Region Human Development& Ministry of Health Tanzania January 2003.
Wangwe, S. M., & Rweyemamu, D. (2001). The State of Tanzania’s Social Sector in the Development Context. Paper Presented Duringthe CSSC Stakeholders Consultation in Bagamoyo, Tanzania. November 2nd, 2001. Economic and Social Research Foundation (ESRF) Dar es Salaam.
Ndulu, B. (1987). Stabilization and Adjustment Policies and Programmes: Country Study 17 Tanzania. New York: World Institute for Development Economic Research of United Nations University.
Wagao, J. (1990). Adjustment Policies in Tanzania, 1981-1989: The Impacton Growth, Structure and human welfare. Innocent Occasional Paper. Number 9. International Children Development.
Lipumba N. (1997). Theliberalization of foreign Exchange Markets and Economc Growth in Sub-Saharan Africa. World Institute for Development Economics Research, Helsinki, Finland.
Rydenfelt, S. (1984). A Pattern for Failure: Socialist Economies in Crisis. Harcourt Brace Jovanovich 1st Edition.
Rugumamu, S. M. (2001). Africa’s Debt Bondage: A case for Total Cancellation. EASSRR. Vol XVII No 1.
Mohammed, N. A. L (1999). Social Dimensions of Structural Adjustment and Stabilization Programmes in OIC Member Countries.Journal of Economic 20, 2 (1999) 53-87.
Isami, A. (2004). Impoverishing a Continent: The World Bank and the IMF in Africa. [online] Available www.halfaxinitiative.org/updir/Impoverishingacontinent.pdf (5/12/2015).
Rondinelli, D and Nellis, J. R (1986) Assessing Decentralization Policies in Developing Countries: The Case for Cautious Optimism. Developing Policy Review Volume 4, Issue 1Pg 2-23 DOI: 10.1111/j.1467-7679.1986.tb00494.x.
Regmi, K. (2010). Understanding the effects of Decentralisation on Health Service. The Nepalise Experience. Journal of Health Organization and Management, Vol 24 No 4 pp361-38.
Boex, J, Fuller, L and Malik, A (2015) Decentralized Local Health Services in Tanzania: Are Health Resources Reaching Primary Health Facilities, or Are They Gettinh Stuck at the District Level? Reserch Report: Urban Institute, International Development Report.
Mills, A. (1998). Health Policy Reforms and their Impact on Practices of Tropical Medicines. British Medical Bulletin 54 (2) 503-513.
Frumense, G, Nyamhanga, T, Mwangu, M and Hurt, A (2013) Challenges to the Implementation of Health Sector Decentralization in Tanzania: Expereince from Kongwa District Council. Global Health Action Volume 6 http://dx.doi.org/10.3402/gha.v6i0.20983.
Zinnen, V. (2010). Sector-Wide Approach (SWA) as Support to Health Sector Reforms and Result at Operational Level in Rural Environment in Tanzania. University of Catholic de Louvain.
Stoarmer, M. V, Radermacher, R and Vanderyden, M (2011) Transforming Community Health Funds in Tanzania into Viable Social Health Insurance Scheme: The Challenges Ahead. Schweizerisches Tropen-and Public Health (Swiss TPH).
Mtei, G., & Mulligan, J. (2007). Community Health Fund in Tanzania: A Literature Review. Consortium for Research and Equitable Health Systems (CHEHS) London School of Hygiene and Tropical Medicine.
Kawawenaruwa, A., & Borghi, J. (2012). Health Insurance coveris increasing among the Tanzanian population but wealthier groups are more benefiting. Ifakara Health Institute. Spotlight Issue 11.
Karungi, G., & Klazinga, N. (2005). Exploring the Relationship Between Privatisation of Health Care and Infant Mortality in Africa. Health Policy and Development Journal, Vol, 3, No 2, pp 144-153.
Kwesiga, B. (2015). Whopays and Who benefits from Health Care Services in Uganda? BMC Health Services Research 15:44 DOI: 10.1186/512913-015-0683-9.
O’Donnel, W. (2007). Access to HealthCare in Developing Countries: Breaking Down Demand side Barriers. CadSaude Publica, Rio de Jeneiro 23 (12) 2820-2834.
Morestin, F., & Ridde, V. (2009). Theabolition of user fees for Health services in Africa Lessons from the Literature. Université de Montréal.
Laterveer, L Munga, M and Schwerzel, P. (2004). Equity Implications of Health Sector User Fees in Tanzania: Do we Retain theUser Fee or Do we Set User F(r)ee? Research On Poverty Alleveiation (REPOA).
Mushi, D. P. (2015). Financing Public HealthCare. Insurance, Use Fees, or Taxes? International Journal of Current Research in Biosciences and Plant Biology. Volume 2 No 1 pp 16-29.
Haazen, D. (2012). Making Health Financing Workforthe Poor People in Tanzania. Washington D.C. The World Bank.
Borghi, J. M., Makawia, S & Kuwawenaruwa, A. (2014). The administrative Costs of Community Based Health Insurance: A case of the Community Health Fund in Tanzania. Health Policy and Planning, 1-9.
Kiwara, A and Kapinga, A. (2001). Quantitative Evaluation of the Community Health Fund in Igunga. Report submitted to the Ministry of Health and Social Welfare United Republic of Tanzania.
Munishi, G. (2001). Constraints to Scaling Up Health Interventions: Country Case Study: Tanzania, CMH Working Paper Series No. WG5:16.
Shaw, R. P. (2002). Tanzania's Community Health Fund: Prepayment as an Alternative to User Fees.
Basaza, P. G., Pariyo,G., & Criel, B. (2009). What are the Emerging Features of Community Health Insurance Schemes in East Africa?Risk Management and Health care Policy Dove Press Journal.
Msuya, J. M., Jutting, P. J., & Asfaw, A. (2004). Impacts of Community Health Insurance Schemeson Health Care Provision in Rural Tanzania.ZEF.
Humba, E. (2011). Pioneering social health insurance in Tanzania: The case of the national health insurance fund. Paper presented at the meeting.
Stoarmer, M., Hanlon, P.,Tawa, M., Macha, J., & Mosha, D. (2012). Community Health Fund in Tanzania: Innovation Study. Report submittedto GIZ.
Mpambije. C. J. (2014). Management and Leadership Practices and the Performance of Community HealthFund in Tanzania: A Comparative Study of Iramba and Iringa Districts. Un-published MA Dissertation, University of Dar es Salaam.
Kessy, F. L. (2014). Improving Health Service Through Community Participation in Health Governance Structure in Tanzania. Journal of Rural and Community Development, 9(2), 14-3.
Paul, F. (2009). Health Workers Motivation and the role of performance BasedfinanceSystems in Africa: A QualitativeStudy of Health Worker Motivation and the Rwandan Performance BasedFinanceInitiative in District Hospital. Working Paper Series No 08-96 London School of Economics and Political Science.
Tabor, S. R. (2005). Community- Based Health Insurance and Social Protection Policy. Social Protection Discussion Paper Series No 0503. Social ProtectionUnit, Human Development Network, the World Bank.
Kessy, F. (2008). Technical Review of Council Health Service Boards and Health Facility Governing Committees in Tanzania: Reportprepared for the Ministry of Health and Social Welfare, Dar Es Salaam, Tanzania.
Marwa, B., Njau, B., Kessy., & and Mushi, D. (2013). Feasibility of Introducing Compulsory Community Health Fund in Low Resource Countries. Views from the Community in Liwale District of Tanzania. BMC Health Service Resarch 13;298 DOI:10.1086/1472-13-298.
Jutting, J. (2004). Community Based Health Schemes Improved Poor People’s Access to Health Care? Evidencefrom Rural Senegal. World Development. 32(2)288-378.
White, J., Hanlon, B., Chee, G., Malangalila, E., Kimambo, A., Coarasa, J., Callahan, S., Lerey, I.R., & McKeon, K. (2013). Private Health Sector Assessment in Tanzania: Washington. The World Bank.
Platteau, J.P and Ontivero, D.U. (2013).Understanding and Information Failures in Insurance: Evidence from India. University of Namur, Centre for Researcher in Economic Development and University of Oxford.
Defourny, J., & Failon, J. (2008). Community Based Health Insurance Scheme in Sub Saharan Africa: Which Really Influence Enrollment? Working Paper. Centre for Social Economy. [Online] available http://orbi.ulg.ac.be/bitstream/2268/11566/1/CBHI%20Defourny-Failon%202008.pdf. (March 15, 2015).
Faty, P. Mwanga, J., & Shimoda, M. (2012). Best Practice Handbook: Tanzania Osaki Alumni. Dodoma. Prime Ministers’ Office Regional Administration and Local Government.
USAID. (2012). Tanzania: Iramba Health Supply Chains Goes From Failing to Model System Project, Task 4 and SCMS. Available at scms.pfscm.org/scms/docs/papers/DELIVER_ToolsNewsAugust2013.pdf accessedon 10/03/2015.
United Republic of Tanzania (2001). Community Health Fund Act. Dar-es-Salaam: Government Printer.
Maluka, S & Bukagile, G. (2013). Implementation of Community Health Fund in Tanzania: Why do Some Districts perform Better than others?The International Journal of Health Planning and Management. Doi:10.1002/hpm.2226.
Mathauer, I., & Imhoff, I. (2006). Health Worker Motivation in Africa: The Role of non-financialIncentives and Human Resource Managementtools. Human Resources for Health, 4:24. [Online] available http://www.human-resources-health.com/content/4/1/24 accessedon 27/02/2015.(February 27, 2015).
Munga, M., & Mbilinyi, D. (2008). Non-financial Incentives and the Retention of Health Workers in Tanzania: Combined Evidence from Literaturereview and Focused Crosssection Study. EQUINET Discussion Paper Series NIMRI, EASA-HC, EQINENT.
Iramba District Council. (2013). Comprehensive Council Health Plan 2013-2014 Iramba. Iramba District Council.
Poncian, J., & Mpambije, C.J. (2015). The Fallacy of Limited Financial Resources for Development in Tanzania: Evidence from Local Government Authorities Audit Reports. Paper accepted for Publication in the journal of Public Policy and Administration Research. Volume 5(2).
NAO. (2014). Annual General Report of the Controller and Auditor General on the Financial Statements of the Local Government Authorities for the Financial Year Ended 30th June, 2013. [Online] available:http://nao.go.tz/?wpfb_dl=82.(March 10, 2015).
NAO. (2012). Annual General Report of the Controller and Auditor General on the Financial Statements of the Local Government Authoritie for the Financial Year Ended 30th June, 2011. [Online] Available: http://nao.go.tz/?wpfb_dl=78. (Retrieved March 10, 2015).
Maro, P. S., & Mlay, W.I.F (1977). Decentralization and Spatial Equity in Tanzania: A Proposal for Assessing Achievements. East African Geographical Review No 15. PP 33-42.