Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders’ perspectives

Abstract

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing policies to expand health insurance coverage and achieve better access to quality healthcare for all. Recent reforms have included improved community health funds (iCHFs), and others are underway to implement a mandatory national health insurance scheme in order to expand access to services and improve financial risk protection. Governance is a crucial structural determinant for the successful implementation of health financing reforms, however there is little understanding of the governance elements that hinder the implementation of health financing reforms such as the iCHF in Tanzania. Therefore, this study used the perspectives of health sector stakeholders to explore governance factors that influence the implementation of health financing reforms in Tanzania. We interviewed 36 stakeholders including implementers of health financing reforms, policymakers and health insurance beneficiaries in the regions of Dodoma, Dar es Salaam and Kilimanjaro. Normalisation process theory and governance elements guided the structure of the in-depth interviews and analysis. Governance factors that emerged from participants as facilitators included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of iCHF enrolment due to digitisation of registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from community level and limited resources due to iCHF design. If stakeholders do not address the governance factors that hinder the implementation of health financing reforms, then current efforts to expand health insurance coverage are unlikely to succeed on their own.

Evaluation of health system resilience in 60 countries based on their responses to COVID-19

“…Even though its government is implementing the Health Sector Strategic Plan IV 2015-2020 to improve the health system, implementation has faced huge obstacles to health financing reform due to low income and low demand, and the lack of health investment will make it difficult to improve the coverage of public health services. 56, 57…”

“…South Africa [37] 0.193 0.064 0.047 0.006 Sri Lanka [38] 0.198 0.046 0.058 0.004 Montenegro [39] 0.187 0.032 0.061 0.007 Fiji [40] 0.184 0.046 0.044 0.005 Peru [41] 0.189 0.039 0.050 0.010 Indonesia [42] 0.219 0.026 0.035 0.003 Bosnia and Herzegovina [43] 0.172 0.050 0.051 0.013 India [44] 0.218 0.009 0.034 0.012 Egypt [45] 0.188 0.029 0.038 0.012 Pakistan [46] 0.164 0.013 0.029 0.004 Papua New Guinea [47] 0.087 0.030 0.039 0.001 Uganda [48] 0.167 0.013 0.022 0.001 Nigeria [49] 0.147 0.006 0.027 0.002 Eritrea [50] 0.103 0.017 0.024 0.001 Liberia [51] 0.046 0.038 0.036 0.010 Tanzania [52] 0.141 0.009 0.027 0.001 Burundi [53] 0.116 0.027 0.022 0.001 Mozambique [54] 0.086 0.022 0.022 0.001 Republic of the Niger [55] 0.116 0.015 0.022 0.000 Benin [56] 0.111 0.004 0.022 0.001 Côte d'Ivoire [57] 0.079 0.006 0.031 0.001 Guinea [58] 0.112 0.005 0.015 0.000 South Sudan [59] 0.039 0.023 0.025 0.002 Burkina Faso [60] 0.067 0.010 0.022 0.001…”

“…Even though its government is implementing the Health Sector Strategic Plan IV 2015-2020 to improve the health system, implementation has faced huge obstacles to health financing reform due to low income and low demand, and the lack of health investment will make it difficult to improve the coverage of public health services. 56,57 Nigeria (0.006), Benin (0.004), and Côte d'Ivoire (0.006) scored the lowest in health financing, with structural imbalances and problems such as a lack of basic health coverage. Under the impact of COVID-19, their health systems were overburdened and health care was placed under serious pressure.…”

Informal Support Networks of Tanzanians With Chronic Diseases: Predictors of Support Provision and Treatment Adherence

“…The provision of material support to insured patients can be further explained by the inclusions and exclusions of social health protection schemes. As access to private pharmacies and tertiary health facilities is often excluded or restricted from benefits packages in Tanzania, beneficiaries whose medications are not routinely stocked by public pharmacies or lower-level health facilities may incur higher indirect costs and OOPs by self-referring to higher level facilities (53)(54)(55). Informal social support fills this gap in social health protection, indicating that health insurance does not adequately protect people with NCDs from the economic consequences of their disease.…”

Savings Groups for Social Health Protection: A Social Resilience Study in Rural Tanzania

“…An annual premium of Tanzania Shilling (TZS) 30000 (about USD 13) entitles a household of up to six persons to access all medical services in accordance with the referral procedure at all levels of government service centers. However, a number of governance issues act as barriers to the implementation of the iCHF [ 14 ], and the active iCHF membership rate (2.84% by the end of April 2021) remains far below expectations [ 15 ]. As outlined in Tanzania’s Health Sector Strategic Plan V 2021–2026 “Leaving No One Behind”, the government plans to “mobilize citizens to join health insurance schemes to ensure that every citizen has access to health care without financial constraints” [ 16 ] (p. xvi).…”