Health facility in Zanzibar

What is unique about a global programme’s technical support when it comes to setting up a sustainable health financing system in a low-income country? Zanzibar’s story, and how the GIZ global programme BACKUP Health facilitated it, is a case in point. 

‘We want every resident in Zanzibar to have access to essential health care services. That’s why we have developed this scheme – so that we can fund health care fairly and sustainably and protect the population from catastrophic out-of-pocket expenditure.’

So says Yaasin Juma, acting Director General of the Zanzibar Health Services Fund (ZHSF), the country’s new universal health insurance scheme which was officially established by the act in March 2023 and started its operations in July 2023.

The Revolutionary Government of Zanzibar has provided universal access to public healthcare since independence in 1964, with no user fees at the point of access. However, the provision of health services faced both financing and quality challenges. The lack of adequate public facilities increased demand for private health providers and resulted in high out-of-pocket expenditure (19% of total health expenditure in 2017/18).

Determined to address this, the Revolutionary Government of Zanzibar asked the German government for technical support in introducing universal health insurance. Recognising the need for careful co-ordination with both international and local partners, the Ministry for Economic Cooperation and Development (BMZ) tasked the GIZ global programme BACKUP Health to build on its strong global relationships to provide this support. This turned out to be a wise decision.  

The benefits of providing technical support as part of a global network 

BACKUP Health has been providing its support to Zanzibar’s health financing system through the Providing for Health (P4H) network, a global network of countries and bilateral and multilateral development partners committed to supporting health financing and social health protection reform to achieve universal health coverage. Its aim is to ensure coherence across global, regional and national levels as well as across health, finance and social sectors. BMZ and its implementing organisation the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) have been strong supporters and core members of the P4H network from the start. 

By working through P4H, BACKUP Health was able to tap into its close links to the multilateral organisations setting standards in health financing, namely the WHO, World Bank and International Labour Organisation. It was also able to provide support in close co-ordination with all relevant development partners in Zanzibar. For example, hearing of Zanzibar’s desire to introduce universal health insurance, Germany’s trusted fellow P4H member Switzerland coordinated with GIZ BACKUP Health in its decision to also provide technical support in form of capacity strengthening where most needed.

A global networked approach proved hugely powerful. It prevented duplication and ensured effective, resource-efficient support that met Zanzibar’s particular needs. As principal partner, we were also able to use P4H to bring in lots of global and national expertise, different opinions and perspectives, so enriching the process and making it very inclusive.

Nina Siegert, Component Lead Health Financing, GIZ BACKUP Health—Global Programme Health Systems Strengthening

Strong political will: Ideal conditions for effective technical cooperation 

The commitment of Zanzibar’s president, His Excellency Hussein Ali Mwinyi, to universal health insurance has been key in focusing ministerial energy on the scheme. Having trained and worked as a doctor himself, he takes a keen interest in the scheme’s progress. 

‘Zanzibar had the best scenario you can have for development assistance – a government that knew exactly what it wanted to achieve and was actively looking for partners to assist it,’ says Nina.

_{Sitting: Nina Siegert, GIZ; Hon. Nassor Ahmed Mazrui, Minister of Health; Mr Mbarouk Omar Mohammed, Zanzibar Health Services Fund. Standing: ZHSF team.  Copyright: GIZ}

One of the main ways in which P4H works is through Country Focal Persons. These are health financing experts (funded by P4H bilateral members) who work on the ground to facilitate joint working between national ministries (e.g. health, finance and labour) and international players. 

A P4H country focal person ensures continuous co-ordination between local and international partners

In Zanzibar’s case, the P4H country focal person’s role was to ensure that both the international development partners involved as well as all relevant national stakeholders were consulted, got on board, stayed on board and validated all project outcomes. He also helped facilitate the smooth passage of legislation needed to create the Zanzibar Health Services Fund. For example, he did a lot of awareness-raising, explaining to members of the House of Representatives the benefits of introducing universal health insurance. According to Yaasin Juma, this support was invaluable.

It was very important to Zanzibar to have an expert on the ground with a global knowledge of health finance systems. Kuki Tarimo was able to share different ideas with us and tell us what had worked well in other countries and what challenges they had experienced.

Yaasin Juma, acting Director General of the Zanzibar Health Services Fund (ZHSF)

Both technical and operational support were provided

As part of the German support a team of international experts worked hand in hand with the twelve-strong local team to provide both the technical and the operational support needed to get the new universal health insurance scheme up and running. 

For example, in collaboration with government statisticians they carried out a socio-economic study to determine the willingness and financial ability of different groups to pay insurance contributions. This information was used in actuarial modelling to establish affordable but realistic insurance premiums for those in both formal and informal employment. An actuarial tool was then developed which enables Zanzibar to model different inputs and understand the impact of these inputs on the sustainability of the health insurance scheme. For example, the tool can be used to analyse the impact of different contribution levels. 

To cover the poor, the Government has established an equity account, which will be under the President’s Office of Finance and Planning. The account will receive funds from different sources, including earmarked tax revenues and development partner contributions. Further funding options, such as a special tourist levy, are currently under review by the Revolutionary Government.

A collaborative, partnership approach

All support was delivered in close collaboration with local decision makers who had the final say and chose the options that they felt best fitted Zanzibar’s needs. For example, the proposed legislation to establish the scheme was given to P4H experts to comment on. But the Zanzibar team then decided what feedback to take on board and what to disregard.

The whole process was driven by what the Zanzibar government wanted and what their goal was. We didn’t come in and say: “This worked in this other country so you should use the same model.” Instead, we listened to the views of Zanzibaris and involved them in the work to develop all the tools and processes.

Kuki Tarimo, P4H Focal Person for Tanzania and Zanzibar

At the same time, the scheme has been carefully designed to reflect the local context. For example, mindful of Muslim sensitivities around the concept of insurance, the scheme is called a health services fund, not an insurance scheme. Given that some Zanzibaris live in polygamous relationships, men can enrol two wives as dependants under the scheme. And, because many Zanzibaris are farmers and only receive an income when they harvest their crop, people in informal employment can make one annual rather than twelve monthly contributions. 

For Yaasin Juma, this careful tailoring has proved critical in winning the support of Zanzibaris.

People in Zanzibar know that this scheme is for them and has been designed to meet their culture and needs.

Yaasin Juma, Acting Director General of the Zanzibar Health Services Fund (ZHSF)

A success story in the making

The high level of collaboration and co-ordination is one of the key factors in Zanzibar’s speed in launching the scheme, according to P4H Country Focal Person Kuki Tarimo.  He says, ‘The whole process happened very quickly. For example, it took just one year to develop the legislation. This was testament to the outstanding collaboration between the different development partners.’ 

Already, Zanzibari residents are being enrolled, starting with those in the public sector. Residents who cannot afford to contribute will be subsidised by the government. 

In recognition of the fact that implementation of any new health financing system is bound to encounter a few teething problems, German support via BACKUP Health-Global Programme Health Systems Strengthening will continue its technical support until 2025.

Meanwhile, Sierra Leone, which is also considering introducing universal health insurance, has reached out to P4H to learn from Zanzibar’s experience.

For Nina Siegert, this further validates the decision to support Zanzibar through a global programme and global network approach.

Learnings from what happened in Zanzibar are already being fed back into a global community of practice. So the global networked approach continues to pay off, facilitating peer learning and future innovation and enabling others to benefit.

Nina Siegert, Component Lead Health Financing, BACKUP Health-Global Programme Health Systems Strengthening

Zita Adamson,
September 2023