Prepayment schemes in Tanzania: examining their potential for increasing access to health care

Presenter: Jane Macha, Ifakara Health Institute (IHI)

Abstract

Background:

Prepayment schemes have been promoted as improving access to health care and making services more affordable. Previous studies have examined access to health care in terms of utilization and found that insurance increases service utilization and reduces out-of-pocket spending. However, few studies have considered the potential of insurance to reduce a broader range of access barriers. We investigated access barriers to health care in Tanzania and whether local insurance schemes reduced these barriers. The following dimensions of access were considered: availability, affordability and acceptability of care.

Methods:

Focus group discussions (FGDs) were carried out with members of the two main health insurance schemes: the Community Health Fund (CHF), a voluntary scheme for the rural populations, providing primary and, in some cases, secondary care in public facilities; and the National Health Insurance Fund (NHIF): a mandatory scheme for civil servants, providing services at all levels in public and private facilities. FGDs were also conducted with the non-insured; health facility committees and council health service boards (CHSB) designed to oversee the quality of health care in the district. In-depth interviews were carried out with doctors in charge of primary care facilities. Data were collection in two rural (Kigoma and Mbulu) and two urban districts (Ilala and Kinondoni). In total 22 FGDs and 2 in-depth interviews were carried out.

Results:

The main access barriers indicated by respondents were related to acceptability: poor quality health services; and availability: shortage of drugs and human resources, lack of diagnostic equipment at lower level facilities, and distance to referral care at the public hospital. Affordability was an issue in cases of repeated illness; multiple cases of sickness at the same time; and inpatient admission.

Respondents felt that insurance was not fully able to overcome these barriers. CHF members expressed dissatisfaction at limited service availability through the scheme: access was limited to a single public provider perceived as poor quality, and resulted in high rates of drop out. CHF and NHIF members also complained of a lack of information regarding the benefit package they are entitled to which limited the capacity of insurance to increase service availability. Delays in obtaining identity cards were reported by the majority of NHIF members, further limiting their access to benefits. Although services should be provided for free to the insured, affordability was still a concern, with members of both insurance schemes mentioning having to pay out of pocket when accessing health services for drugs, and transport in the case of referral. For CHF members inpatient care was not covered in many areas.

Conclusions:

For insurance to better improve access to health care, service availability and acceptability need to improve through: better quality care at public facilities and the accreditation of mission or private facilities for CHF members; and better sensitization of the insured as to their entitlements. The inclusion of transport for referral and inpatient care as a benefit for all CHF members would make services more affordable. Mechanisms for reimbursing drugs purchased at private pharmacies should also be explored.