Social Protection in an Electorally Competitive Environment (2): The Politics of Health Insurance in Tanzania

Abstract

This paper analyses the introduction and expansion of health insurance schemes in Tanzania. Health insurances were introduced around year 2000 as part of a more general health reform process aimed at improving access to health services. The paper argues that the health insurances were driven by a policy coalition of bureaucrats and transnational actors, who, inspired by international trends, framed reforms as a way for the ruling party to live up to one of its core priorities since independence, namely, improved and, eventually, universal access to health services. The introduction of insurances was expected to help mobilise funds and improve the working of the health care system for this purpose. However, judged by their modest design and slow implementation, the ruling political elite remained ambiguous about health insurances. Politically, a fast rollout was perceived to be risky. Similar political considerations may explain the reluctance to expand health insurance coverage through a mandatory scheme that bureaucrats and development partners have propagated recently. The rejection of the initial design for such a scheme came as a surprise to the policy coalition, which did not enjoy the same access to key decisionmakers as in the past. Concurrently, and driven by increased electoral competition, the ruling party has increasingly focused on improving access through the expansion of physical health infrastructure. This has the additional advantage of being highly visible among the rural majority of the population, who overwhelmingly vote Chama Cha Mapinduzi (CCM). This is our second paper on social protection in Tanzania.

Social Protection and Informal Workers in Sub-Saharan Africa

“…Since up to six family members can be added to the employee's membership, this means that the total number of beneficiaries might be about 3.5 million, equivalent to around 7 percent of the population (Wang et al, 2018). This is in line with estimates provided by Pedersen and Jacob (2018) according to whom existing insurance schemes covered approximately 22 percent of the population (7 percent by the NHIF, 12 percent covered by the voluntary CHF, 1 percent by private insurances, 1 percent by community-based health insurances and 1 percent by the NSSF). 16 According to NHIFs own data, coverage has been steady around 7 percent of the population in the period from 2012/2013 to 2017/2018, whereas a large increase is reported for CHF for the same period (Riisgaard, 2020).…”

“…The interim plan while waiting for the SNHI is to have two coexisting schemes: the NHIF aimed at covering the formal sector and the iCHF intended to cover the informal sector and rural households (Lee, Tarimo & Dutta, 2018). According to Pedersen and Jacob (2018), so far, however, the route taken by the ruling party has been focused more on improving public health infrastructure than health insurances. In addition, even though reforms in health insurance have been pursued, the single mandatory national health insurance heavily pushed by development agencies has so far not materialized.…”

“…13 The criteria that one has to contribute for 180 consecutive months (15 years) to be eligible for pension under the current NSSF pension scheme makes it a very poor fit with the reality of most informal traders (Riisgaard, 2020). 14 See Pedersen and Jacob (2018) for a detailed account and analysis of the introduction and expansion of health insurance schemes in Tanzania. 15 As for NHIF contribution rates by formal sector workers, these are fixed at 6 percent of the total salary, split equally between the employer and employee.…”

Political Settlement and the Politics of Legitimation in Countries Undergoing Democratisation: Insights From Tanzania

“…Indeed, our findings suggest that, under the impression of intensified electoral competition, the ruling party in Tanzania is increasingly targeting the rural majority through expanded social service provision (Jacob and Pedersen, 2018b;Pedersen and Jacob, 2018). This approach was radicalised after the historically competitive 2015 election, when the new president, Magufuli, bypassed the existing political, bureaucratic and economic elites to appeal to the majority of the population and to the party base by invoking national interests, often through attacks on private investors, not least foreign ones.…”

“…Often the emphasis on improving social services accorded with donor priorities, which shifted during those same years, but not always. For instance, the expansion of health infrastructure in the Primary Health Services Development Programme (MMAM) in 2007 came as an unwelcome surprise to Tanzania's development partners, who emphasised improvements in the quality of services over physical infrastructure (Pedersen and Jacob, 2018).…”