An innovative health insurance scheme, jointly funded by BMZ via KfW Entwicklungsbank and Tanzania’s National Health Insurance Fund, improves pregnant women’s access to safe delivery services and provides financial protection for them and their families at a particularly vulnerable time in their lives.
What’s it all about?
Since 2011 a health insurance is in place in Tanzania’s Mbeya and Tanga regions which aims to improve access to maternal and newborn health services of good quality for pregnant women and their babies. The project’s objectives are two-fold:
- to reduce the still high rates of maternal and newborn mortality; and
- to strengthen financial protection for pregnant women and their families.
In the first phase, which ran from 2011 to 2015, Germany, via KfW Entwicklungsbank, invested 13 million and Tanzania’s NHIF contributed 6 million Euros to the cost of the insurance scheme. This article presents some of the highlights and lessons learned to date which have informed the second phase of this project.
The health insurance scheme combines demand-side and supply-side financing aspects: On the one hand it transfers purchasing power to patients – in this case pregnant women – who, once enrolled, can choose freely which health facility they want to attend. On the other it allows providers to claim payment for treating these women from the NHIF, and to use these funds to improve the quality of care. The expectation is that the facilities will work hard and tailor their services to women’s needs so as to attract more clients and increase their income. In this way the health insurance scheme aims to create a ‘virtuous circle’ from which both patients and providers benefit.
After start-up, the project expanded rapidly to cover all 16 districts in the regions of Mbeya and Tanga with their 621 government and 74 faith-based health facilities. Women are enrolled when they first visit a health facility during pregnancy, and are then covered by the National Health Insurance Fund for up to six months after their baby is born. For the same period their families gain membership of their local Community Health Fund, an insurance scheme which covers the costs of medicines and outpatient as well as some inpatient care, thus familiarising them with the benefits of being member of a health insurance scheme.
Why do women need insurance when services are free?
In Tanzania most citizens have to pay fees for health services but pregnant women, children under five and the very poor get these services for free.
However, facilities often lack the funds to purchase the drugs, supplies and equipment they need to perform safe deliveries, so when women go to deliver at a health facility, they may be asked to purchase the required medicines and items such as surgical gloves and sanitary napkins. For many pregnant women, this is a serious barrier to access, often causing distress and embarrassment to both pregnant women and the health workers.
In the Tanga and Mbeya regions this has changed since the introduction of the health insurance scheme: With the funding provided to them in response to their claims, the facilities are now able to purchase the medicines and supplies they need to perform deliveries as well as antenatal and postnatal care, and to tackle small infrastructural problems.
Coverage for all versus targeting the poor
Early on, the project took the decision to provide cover for all pregnant women and their families living in the two regions of Mbeya and Tanga instead of trying to identify and provide cover only for the very poorest. Despite impressive economic growth over the past decade, Tanzania remains one of the world’s poorest countries with around two thirds of people living below the ‘basic-needs’ poverty line. In rural areas, nearly everyone is poor.
Designing and implementing poverty targeting approaches is expensive and time consuming. Providing coverage for all was therefore a pragmatic decision and it ensures that all women can benefit from the scheme.
“It has a lot of advantages for us”, says a member about the insurance. “Now every pregnant woman will get the medical care she needs, whether she can afford it or not.”
Another beneficiary puts it even more strongly: “The insurance is a life saver.”
More recently, the Tanzania Social Action Fund has started to roll out a national, standardized poverty identification scheme. During Phase II, the project will therefore look into the possibility of adopting this national targeting approach once it is fully operational in is target areas.
Client satisfaction is high
A recent client satisfaction survey showed high satisfaction with the project among women in the project areas. Features of the project which the women particularly appreciate are:
- free access to healthcare
- greatly reduced out of pocket expenses
- choice of providers
- being able to turn up without an appointment
- availability of medicines
- good treatment by facility staff
- Shorter waiting times
- More equitable treatment of poor women
The high cost of transport, and other costs associated with travelling to and staying at a health facility, are a source of dissatisfaction among clients and will need to be addressed in the new project phase.
Results to date
So far, the results the project has reached have exceeded both its expectations and its targets. An estimated 8.000 – 10.000 pregnant women join the insurance scheme each month, so that by mid-2016, 450,000 were enrolled.
Also, more women are delivering at health facilities: between 2010 and 2014, facility deliveries increased from 41% of expected total deliveries to just over 60% in Tanga, and from 43% of expected total deliveries to nearly 90% in Mbeya.
According to a study by the Ifakara Institute, out-of-pocket expenditure has been reduced – a clear indication that the schemes is indeed ensuring financial protection for its members.
Right now the average cost of claims per member for all health care services during pregnancy and for the first 6 months of the baby’s life (about a year in total) amounts to some 36 Euros. This compares with the NHIF’s costs for each regularly insured client of approximately 73 Euros per year.
“Given the high rate of return in terms of lives saved, healthier mothers and babies, this is great value for money” says Elke Hellstern, Senior Project Manager at KfW.
Issues to be worked on in the new phase
Based on challenges encountered in the first phase, and on the learnings drawn from these, there are several issues which the Tanzanian and German partners plan to work on in the second phase of their collaboration on the scheme:
- Reducing the burden on busy referral hospitals: Given their free choice of facility and their formerly not so good experiences with lower level facilities, a large proportion of women decided to deliver in a referral hospital rather than at health centre level. In phase 2, the aim is to encourage and enable more women to deliver safely at lower level facilities.
- Helping lower level facilities to reap the benefits of the scheme: Efforts will be made to enable all health facilities to efficiently claim and invest the reimbursements they are entitled to from the NHIF, including through the introduction of information and communication technology (e.g. the registration of new members via SMS, see photograph).
- Making sure that all pregnant women actually know of the scheme: Currently some 40% of pregnant women in the project areas are enrolled in the project. With the help of communication campaigns at community level the project hopes to increase this proportion.
Is it sustainable and what lies ahead?
There is no doubt that the introduction of a health insurance scheme which covers vulnerable and hard-to-reach groups is costly and that, without external assistance, such schemes can be difficult for resource-constrained governments to maintain. In this case, German Development Cooperation considers its contribution a worthwhile investment because it helps build the capacities and the systems needed for a more comprehensive national health insurance system.
Tanzania is committed to the introduction of a national social health insurance scheme in order to realize the internationally agreed goal of universal health coverage. The aim is to overcome the current fragmentation of Tanzania’s insurance sector, enabling more efficient pooling of funds and creating opportunities to cross-subsidise those less able to afford contributions.
And this is where this Tanzanian-German project comes in: In the longer run, it aims to develop mechanisms through which subsidies can be channelled to vulnerable and poorer groups. In the meantime, it is generating valuable lessons learned regarding the implementation of health insurance schemes and it ensures access to safe delivery and healthcare services for poor women and their families.