Borghi,  J

Kuwawenaruwa , A

Makawia , S

English

Digital Library of the Tanzania Health Community

Community health insurance: a financially
sustainable approach to universal coverage in
Africa? Insights from Tanzania
2nd Global Symposium on Health Research, 
2012: Beijing China 
Borghi J., Makawia S., and Kuwawenaruwa A..Background and Objectives
• Very little evidence of costs of running
community health insurance internationally
• Such information valuable for planning
• Objectives
• Estimate annual costs of running the CHF
at district level and below
• Compare costs to revenue
• Undertake sensitivity analysis to inform
policyHealth Insurance in Tanzania 
• Currently the government is committed to 30%
insurance coverage (17% to 30%).
• A number of insurance schemes operates in
Tanzania, however our focus is on CHF
• The premium ranges from TZS 5,000 – 25,000 per
annum,
• government will match same amount of the premium
collected
• Benefits: Free outpatient care at public primary
level facility of registration and some districts offer
inpatient care
• Facilities are not reimbursed directly
• The CHF is managed at the district level by CHSB
• It mainly targets informal sectorMethods
• Case study of 2 districts and 4 primary
facilities
• Data sources: interviews, meeting minutes
• Perspective: ministry of health at district level
and below
• Cost categories: resource inputs, activities
and fixed and variable
• Ingredients approach used
• Sensitivity analysis
– CHF membership; OPD levels; premium
– Effect of full time coordinator and individual
membership cards
– Premium level: threshold analysis – 30% of totalDefinition of core activities –Facility level
Activities Definition Frequency Type of 
cost
Sensitisation Individual – all OPD users not 
CHF members sensitised by 
provider
Group – weekly integrated into 
health promotion sessions
Community – ad hoc by HFGC 
members
All facilities
3 out of 4 facilities
3 out of 4 facilities
Variable
Fixed
Fixed
Registering 
members
Completing and issuing card, 
receipt and cash book
All facilities Variable
Depositing 
funds
Depositing funds from cost
sharing in district or facility 
account
All facilities Fixed
Meetings Meetings with HFGC to discuss 
use of CHF funds
WDC; 
village; facility mgmt teams
All facilities
3 out of 4 facilities
1 out of 4 facilities
Fixed
Reporting Preparing report on cost sharing 
revenue
FixedDefinition of core activities–District level
Activities Definition Frequency
Meetings CHSB meetings Both districts
Reporting Monthly and quarterly reports to  Both districts
Supervision Routine CHMT
Independent visits to facilities
Both districts
1 district
One-off costs
Training Training of HFGC members  Both districts
Service agreement Entering into contract with 
referral facilities
1 district
Assumption: all district level costs are fixedAverage Annual Facility Level Costs in 1,000 TZS 
Sensitisa
tion
Registrat
ion
Fund 
Mgmt
Meetings Reporting Total
Salaries 1,226 66 131 35 94 1,551
(85%)
Allowance
s
- - - 103 - 103
(6%)
Transport - - 42 - - 42
(2%)
Supplies - 126 1 - - 128
(7%)
Total 1,226
(67%)
192
(11%)
174
(10%)
138
(8%)
94
(5%)
1,823
(100%)
Fixed 21 1 174 138 94 427 (23%)
Variable 1205 191 0 0 0 1396 (77%)Total Annual District Level Management Costs in 
1000 TZS
Urban district  Rural district 
Meeting
s
Reportin
g
Supervi
sion
Total Meeting
s
Reportin
g
Supervi
sion
Total
Salaries 
48 272 44 363 
(61%)
408 457 537 1,402 
(70%)
Allowan
ces 
235 - - 235 
(39%)
392 - 210 602 
(30%)
Total     283 
(47%)
272 
(45%)
44 
(7%)
599 
(100%)
800 
(40%)
457 
(23%)
747 
(37%)
2,004 
(100%)Total Annual District-Wide Costs in 1000 TZS 
by District
Urban district Rural district Average
Dispensaries 
8,576 
28,688  18,632 
Health centres 
3,070 
8,733  5,901 
Total facility costs 
11,646 
(94%) 37,421 
(82%) 
24,534 
(85%)
Total district recurrent 
costs 
599 
(5%) 2,004 
(4%) 
1,301 
(4%)
Training  
174 
5,943  3,059 
Contracting  
-
232  116 
Annualised start-up costs 
174 
(1%) 6,175 
(14%)
3,175 
(11%)
Total 
12,419 
45,601  29,010 Average Annual Administrative Cost per CHF 
member and Cost to Revenue Ratio 
Urban district Rural district Average
Total cost Total cost Total cost
Total costs 
(1,000 TZS)
12,419 45,601 29,010
Total CHF members 683 9,127 4,905
Total cost per CHF 
member (1,000 TZS)
18,186 4,996 11,591
Total cost as % of 
revenue (inclusive 
matching fund)
364% 
(364%)
100% 
(61%) 
118% (74%)Cost per CHF household as a function of OPD 
and CHF membership levels
-
5,000 
10,000 
15,000 
20,000 
25,000 
30,000 
100 400 700 1000 1300 1600
A
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h
Lowest level OPD
6,000 
10,000 
14,000 
18,000 
Highest level OPD
30% of revenue 
at current 
premiumsEstimating the cost of planned 
reforms
• Full time CHF coordinators: 19 fold increase in 
district management costs (urban) 6 fold increase 
(rural)   
• Individual membership cards: facility costs 
increase by 17% (urban), by 42% (rural)
• Total cost per member household increases to 
37,432 Tsh (urban)and 7,838 Tsh (rural)
• Cost to revenue ratio increases to 749% (urban) 
and to 79% (rural)
12Threshold Analysis: Premium level required so 
that the cost to revenue ratio reduces to 30%
Urban Rural Average
Total cost Total cost Total cost
Baseline 61,000 17,000 39,000
Future design 125,000 26,500 75,000Discussion 
• CHF administration places a significant
burden on health workers
• Success of the scheme depends very much
on the personal commitment and initiative
of the facility in-charge, as well as their
ability to devote time to CHF management.
• Time spent on the CHF represents an
opportunity cost to the health systemDiscussion
• Need to increase premiums, which are extremely
low in most districts, in order to enhance the
financial viability of the scheme.
• As coverage increases, premiums can
subsequently be relaxed
• Media campaigns, using community health worker
to undertake enrolment, as well as school
promotion would reduce the health staffs
workload
• To reduce CHF management costs need to limit
the timing of registration to a specific moment in
the year (adverse selection).Limitations 
• Unfortunately, the study is subject to a
number of limitations. We relied on the
• Recall of various stakeholders as to time spent
on administration activities
• We were unable to examine the costs of
administering the CHF regionally or nationally
under the NHIF.
• Government efforts to provide free CHF
cards to the poor, if evaluated would also
clearly add substantially to the costs of
running the schemeConclusion 
• Questionable whether community
insurance is really a viable approach for
achieving universal coverage
• Looking at the costs of running the scheme
vs treating the patients
• Expand fiscal space and finance informal 
sector health care use through tax funding
• This will reduce CHF administrative costs 
• Freeing up human resource capacity to deliver 
and supervise health services

Community Health Insurance:A  Financially Sustainable Approach to Universal Coverage in Africa? Insights From Tanzania

http://ihi.eprints.org/889/1/Presentation(1).pdf

Community Health Insurance:A Financially Sustainable Approach to Universal Coverage in Africa? Insights From Tanzania

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