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Spotlight
December, 2012          Issue 15
 
research | training | services
   
   Key Points
In 2009 the National Health Insurance Fund (NHIF) 
took over the management of the Community 
Health Fund (CHF) to increase insurance coverage, 
efficiency and supervision and access to services.
Key achievements include successful integration 
of CHF within the NHIF organisational structure, 
improved reporting systems and growing 
awareness of the reform since 2011. 
Challenges in the implementation of the 
reform include top-level conception, delays in 
communication to lower levels, failure to secure 
all requested financing. There have also been no 
changes in district level CHF management.
Background
The National Health Insurance Fund (NHIF) is a compulsory 
insurance scheme for the formal sector offering extensive 
benefits to members. The Community Health Fund (CHF) is 
a voluntary scheme established by the Ministry of Health 
and Social Welfare (MoHSW) for the informal sector with 
premiums fixed at between TZS 5,000 to TZS 30,000 for 
care in public primary facilities. Both schemes have been 
in operation since 2001. 
In June 2009, a Memorandum of Understanding (MOU) 
was signed among the NHIF, the MoHSW and the 
Prime Minister’s Office for Regional Administration and 
Local Government (PMO-RALG) giving management 
responsibility for the CHF to the NHIF for a three-year 
period. The objectives were to:
¨ ¨ Harmonise NHIF and CHF management operations; 
¨ ¨ Improve efficiency and supervision;
¨ ¨   Increase awareness of the CHF and increase 
coverage. 
A study was carried out to assess the origins and rationale 
for the shift of management, referred to as ‘the reform’; 
how it has affected CHF management and reporting 
structures; levels of awareness of the reform and 
acceptability. 
In-depth interviews were carried out with six policy 
makers, 11 district managers; six facility in-charges and 
16 facility governing committee members in two districts 
(an urban and a rural district from the same region). This 
brief reports on the findings of the study. 
Origins of the reform
The objective of the reform was to increase national 
health insurance coverage (United Republic of Tanzania, 
2008), address the limitations of CHF management, to 
synchronize the NHIF and CHF, and improve access to 
services by providing support to “Mpango wa Maendeleo 
ya Afya ya Msingi” (MMAM – improving access to primary 
health care). (Table 1). The fact that both the NHIF and 
the CHF report to the MOHSW also facilitated the process 
(Gilson et al., 2012). 
“The government felt that the NHIF has strong experience 
in managing a health insurance scheme, it has experts 
and it has many zonal offices” (National level respondent).
The MoHSW was to cover the recurrent costs of managing 
the scheme along with the matching grant funds, which 
are government subsidies matching the level of CHF 
revenue collected by districts. 
Reform implementation
Shortly after the MOU, the NHIF developed a three year 
action plan. An estimated USD 13.1 million were requested 
from the MoHSW to cover the costs of running the CHF for 
the period. Delays in approval of the action plan and failure 
to secure all of the requested funds in time delayed reform 
implementation. In 2011, a revised and more limited action 
plan was prepared. Later that year a national consultation 
meeting with CHF coordinators was held to introduce the 
reform and its objective and a nationwide information 
campaign was launched to expand CHF enrolment. 
Lessons from Community Health Fund reforms
A review of the past three years2
Spotlight Issue 15 December, 2012
research | training | services
Table 1: Chronology of events preceding and following 
the reform
Date Event
2007
Cabinet directive No 37/2007 to 
synchronise the NHIF and the CHF to 
support the implementation of the Primary 
Health Services Development Programme 
and provide technical and managerial 
support and extend CHF coverage.
31st January- 2nd 
February, 2007
CHF best practice workshop in Dar 
es Salaam funded by SDC and GTZ in 
collaboration with the MoHSW. 
October, 2007
Ten year evaluation of the health sector 
recommending synchronization of NHIF 
and CHF operations conducted by an 
external consultant and commissioned 
by development partners and the 
Government of Tanzania.
March, 2008
Resolution by MoHSW management team 
that the NHIF should oversee CHF.
August, 2008
Regulatory framework feasibility study 
commissioned by the MoHSW which 
included a scenario on merging the NHIF 
and CHF funded by GIZ and SDC.
June, 2009
Signing of Memorandum of Understanding 
between the MoHSW, PMO-RALG and NHIF 
management. Secondment of MOHSW 
national CHF coordinator to the NHIF.
September, 
2009
Country evaluation of the net worth of the 
CHF by the NHIF.
October, 2009 The CHF action plan 2009-2012 developed.
February, 2010
Appointment of staff to oversee CHF at the 
zonal/regional NHIF offices.
March, 2010
The NHIF began payment of matching 
funds to the districts.
September, 
2011
CHF directorate created within the NHIF.
Late 2011 CHF action plan revised for remaining year.
December, 
2011
Meeting of CHF coordinators from across 
the country to inform about the reform 
and set targets to meet 30% coverage 
nationally.
February-April, 
2012
¨ ¨ National client days to gather opinions 
on CHF implementation; 
¨ ¨ Printing and distribution of CHF 
leaflets and posters;
¨ ¨ Districts are instructed to budget for 
use of CHF cars that can be used to 
promote CHF, showing promotional 
films to communities.
June, 2012
NHIF and CHF management teams 
expected to report on 3 years experience 
and present plan for coming years to the 
MoHSW and PMOLARG.
Management structures Pre and Post reform
The reform has not led to any changes in district level 
structures defined by the CHF Act. These cannot be 
changed without a change in legislation, which was 
beyond the scope of the MOU. The CHF, at district level, 
remains under the management of the Council Health 
Service Board (CHSB) and a CHF coordinator (Figure 
1). Ward Health Committee and the Health Facility 
Governing Committee along with health workers have the 
responsibility of mobilising people to join the CHF (Figure 
1). The reform has, however, led to significant changes in 
national and zonal/regional level management systems.
Pre-reform national, zonal and regional 
structures
Prior to the reform, the national CHF coordination unit 
was headed by a coordinator and 2 assistants, who trained 
district managers on CHF, and oversaw the enactment 
of bylaws for the CHF which set out the CHF design for 
the district (premium level and benefits for members) 
(Figure 2). 
Supervision of districts was done once per year and 
during annual regional management meetings where 
stronger CHF coordinators would support weaker ones. 
Matching fund requests were channeled through the 
district authorities to the national CHF coordinator, along 
with reports of membership/enrolment, which were 
often incomplete. There was no reliable national data 
on CHF coverage. 
Figure 1: Overview of management structures from the 
district level down
Post reform changes
Since the reform, a CHF Directorate within the NHIF 
headed by a CHF Director supported by a team of seven 
people oversees CHF operations centrally. The CHF 
Director also reports to the Health Financing Coordinator 
at the MoHSW (Figure 2). NHIF staff in 13 NHIF zonal 
and regional offices have been appointed to support 
district CHF coordinators across the country. Matching 3
Spotlight Issue 15 December, 2012
research | training | services
fund requests and payments are managed by the NHIF 
zonal/regional offices, although funds themselves are still 
provided by the government.
The national CHF coordinator (pre-reform) and the CHF 
Director (post reform) work closely with the national CHSB 
coordinator who supports the establishment of the CHSB 
within districts, and the development of district by-laws. 
CHF supervision is integrated into the routine visits of NHIF 
staff which take place one a month or every two months.
Figure 2: Overview of management structures from the 
central to district level before and after the reform
The NHIF has modified the requirements for matching 
fund claims, to reduce the risk of fraud. District CHF 
coordinators must submit names of all CHF member 
household heads along with proof of revenue received. 
A computerised system is being prepared by the NHIF 
that will facilitate future data capture. 
Communication & Awareness of the reform 
at district level
In February 2010, the MoHSW sent out a letter 
informing the districts that they should claim the 
matching grant.
 “We were not involved in this discussion but we were 
only informed and when we went to claim the matching 
fund for the CHF we were told that we should claim it 
from the NHIF not from the Ministry of Health (District 
manager, rural district)
Generally, all stakeholder groups felt there had been 
insufficient information about the reform as of August 2011. 
 “Communication was not enough from the national or 
regional level to inform the district level about the reform” 
(District health manager, urban district)
There was a greater awareness of the reform within 
the district following the Morogoro meeting of CHF 
coordinators at the end of 2011.
Acceptability of the reform at the district level
Most district level respondents thought the reform would 
improve efficiency. 
“Both are insurance schemes, I think they can support 
each other, for instance supervision can be done using 
NHIF zonal offices in one time and save money and time” 
(District manager, urban district.)
However, the new NHIF system for claiming matching funds 
has increased workload (and limited capacity to claim). 
“The NHIF requires that when you are applying for 
matching fund you should attach receipts, a list of CHF 
members, bank statement, bank reconciliation etc. 
This makes work very difficult and many people have 
failed to apply for matching fund” (District manager, 
rural district ).
At the facility level, committee members expected CHF 
members would get access to a wider range of services 
like NHIF members.
 “If they will be administered by a single organ it will be 
good because [...] they will try their best to improve health 
insurance [benefits], and not create differences [between 
schemes] of what we can get when we fall sick” (HFGC, 
urban district).
Community members interviewed had difficulty voicing 
opinions about the reform due to limited knowledge of 
the reform and the NHIF. 
Health insurance coverage 
The number of CHF districts increased from 92 to 111 
between 2009 and 2011 (NHIF, 2011). At the end of 2009 
about 43% of CHF districts had no members (United Spotlight Issue 15 December, 2012
Ifakara Health Institute. Plot 463, Kiko Avenue, Mikocheni.  P.O. Box 78373, Dar es Salaam, Tanzania.
Web: www.ihi.or.tz ; E-mail address: info@ihi.or.tz Phone: +255 (0)22 2774756 Fax: +255 (0)22 2771714
Republic of Tanzania, 2011), this had been reduced by 
half by 2011 (NHIF, 2011). 
National CHF coverage increased from less than 2% to 
over 5% between 2008 and 2011 (Figure 3). While the 
reform has facilitated this process, independent district 
initiatives have also been influential. In the study districts 
the rural site significantly increased coverage as a result 
of such initiatives, whilst the urban district saw no change 
in coverage. 
In June 2011, the NHIF released funds to pay for CHF cards 
for the poor in a number of districts across the country. 
It is expected this will further enhance coverage over the 
coming years. 
In many districts, CHF funds are pooled at district level, 
allowing for cross subsidisation across health facilities. 
However, there has been no move to pool CHF funds at a 
higher level. A growing number of districts are introducing 
facility bank accounts which could reduce the size of the 
risk pool and limit cross-subsidisation. 
Figure 3: Trends in health insurance coverage for the 
NHIF and CHF/TIKA between 2008 and 2011
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
2008 2009 2010 2011
CHF membership NHIF membership
Source: NHIF: Msambichaka & Humba. 2011; CHF (MOHSW, 2008, NHIF 
2009-2011), using population projections based on 2002 census data.
Conclusions
The reform was conceived at the top and communication 
to lower levels was slow. Delays in approval of the action 
plan and failure to secure all of the requested funds in 
time delayed reform implementation. The reform has not 
led to any changes in district management structures and 
remains in the hands of individuals who are inexperienced 
in insurance management. However, the reform has 
resulted in substantial achievements:
¨ ¨   Successful integration of CHF within the NHIF 
organisational structure at national, zonal and 
regional levels, bringing more intensive and 
qualified supervision closer to the districts;
¨ ¨   Improved reporting systems leading to 
availability of national coverage and matching 
grant data;
¨ ¨ G  rowing awareness of the reform since 2011 
and high levels of acceptability; 
¨ ¨ National CHF membership has more than doubled. 
Policy recommendations
¨ ¨   Full harmonisation between NHIF and CHF can 
only be achieved by changing CHF legislation 
and altering district management structures. 
It will be important to address this within the 
next phase of the reform.
¨ ¨   While changes to matching fund claiming 
procedures are well intended, it is important 
to monitor whether this delays fund 
disbursement, and review manageability of 
new reporting system over time.
References 
Gilson et al., 2012 Using stakeholder analysis to support 
moves towards universal coverage: lessons from the 
SHIELD project. Health Policy and Planning, 27, i64-i76.
Msambichaka & Humba. 2011 A historical development 
of the National Health Insurance Fund of Tanzania. From 
resistance to radiance. Dar es Salaam.
United Republic of Tanzania, 2008 Health Sector Strategic 
Plan III: “Partnerships for Delivering the MDGs” July 
2009 – June 2015. Dar es Salaam: Ministry of Health and 
Social Welfare.
Acknowledgements 
This study was a product of Bima Pamoja Project. We 
acknowledge that the study was financially and technically 
supported by the Alliance for Health Policy and Systems 
Research, World Health Organisation (WHO). We also wish 
to acknowledge the inputs of the Health Systems Financing 
Department, WHO and the late Guy Carrin, in particular. 
We are also grateful to the Ifakara Health Institute Resource 
Centre for editorial support. 

A historical development of the National Health Insurance Fund of Tanzania. From resistance to radiance. Dar es Salaam.

Health Sector Strategic Plan III: “Partnerships for Delivering the MDGs”

Using stakeholder analysis to support moves towards universal coverage: lessons from the SHIELD project.

Lessons from Community Health Fund reforms:A Review of the Past Three Years

http://ihi.eprints.org/1800/1/Sportlight_issue_%2D15_final.pdf

Lessons from Community Health Fund reforms:A Review of the Past Three Years

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