Determinants of community health fund membership in Tanzania: a mixed methods analysis

Abstract

BackgroundIn many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods.MethodsA cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data.ResultsThe quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment.ConclusionsDeterminants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage.

Understanding the limitations of “quasi‐mandatory” approaches to enrolment in community‐based health insurance: Empirical evidence from Tanzania

“…The overall enrolment has been less than 10% of the target population during the more than 20 years of implementation . The reasons for this low performance are associated with design issues, the enrolment strategies used, and the management capacity of the local government . In order to improve uptake, the government of Tanzania decided to redesign the scheme, with assistance from development partners .…”

“…To understand the reasons behind this low uptake, researchers have been assessing what determines enrolment on both the demand and the supply side. The common demand side features that influence enrolment decisions include social‐economic and demographic factors, especially those related to access to and quality of healthcare; knowledge on health insurance; and willingness and ability to pay . On the supply side, attention has been paid to schemes' design and management issues, where premium prices, benefit packages, methods of premium collection, and administration capabilities have been reported to affect CBHI uptake .…”

“…The common demand side features that influence enrolment decisions include social-economic and demographic factors, especially those related to access to and quality of healthcare; knowledge on health insurance; and willingness and ability to pay. [11][12][13][14][15] On the supply side, attention has been paid to schemes' design and management issues, where premium prices, benefit packages, methods of premium collection, and administration capabilities have been reported to affect CBHI uptake. [16][17][18] The voluntary nature of CBHI schemes has also been described as challenging their sustainability, since people who experience illness appear to be more interested, resulting in a low rate of participation of healthy population groups.…”

Decentralisation of Health Systems and the Fate of Community Health Fund in Tanzania: Critical Review of High and Low Performing Districts

“…At the national level, the Ministry of Health, as well as President's Office Regional Administration and Local Government render policy guideline and subsidies [24]. At the district level CHF is headed by the Council Health Service Board (CHSB) 2 [24]. Nearly all districts have introduced the CHF, but few municipalities have introduced Tiba kwa Kadi (TIKA) 5 .…”

“…This system, which operates through prepaid system, was introduced targeting to enroll 85% of the citizens of Tanzania by the year 2015 [1]. However, low enrollment has been repeatedly identified as the persisted limitation to effective performance of CHF [2]. In fact, CHF has been found to attain penetration rates which rarely exceed 10%, given the fact that by 2014 CHF enrollment stood at 9.2% [3].…”