FACTORS AFFECTING THE LOW ENROLLMENT ON THE IMPROVED COMMUNITY

HEALTH FUND SCHEME AMONG THE COMMUNITY IN KONDOA DISTRICT-.

1.1. Background of study

In recent years, equitable access to quality healthcare towards universal health coverage (UHC)
has become priority in many low and middle-income countries. Financial protection, which has
to do with how much people have to pay out of pocket is an integral component of achieving
universal health coverage OECD (2014). There is substantial evidence that show that reliance on
out of-pocket payments (OOP) as the main payment source for healthcare does not only have an
adverse effect on demand for services, but increases the financial burden of households leading
to impoverishment Evans DB (2003). Additionally, available evidence indicates that per capita
spending on health in many low- and middle-income countries is likely to increase rapidly the
long run Rancic (2016)

The idea of Community Health Fund was adapted in Africa from Europe whereby this system is
well developed. In Western Europe, the concept of Social Health Insurance was developed since
1973. Many European countries have introduced this health system in their countries. For
example, this system was introduced in Belgium, France, Germany, Luxembourg, Netherlands,
and Switzerland and this health insurance system is very well developed in these countries
(Salteman et al, 2004)

In Africa, Nigeria has experimented with forms of social health insurance schemes in the past.
For example, the National Health Insurance Scheme introduced in the year 2000, with coverage
of only about 4% of the population, a majority of whom are federal civil service employees
Onwujekwe O(2012) The limited coverage of this scheme has often been attributed to the lack of
acceptability and unwillingness to pay premiums, especially within the informal sector

The concept of Community Health Fund has been adopted from Community Based Health
Financing (CBHF) which has emerged in developing countries as a response to the existing
challenges in the health financing system, which include low economic growth, constraints in the
public sector and low organizational capacity (Mtei et al, 2007). This followed the failure of the
government to provide free health care to all its citizens due to the increased cost of the services
(Mtei et al, 2007).

The Community Health Fund (CHF) in Tanzania was established in 2001. Due to the dual role of
“Provider” and “Purchaser” of health service played by the Council Health Boards (CHBs) such
a design setup has faced challenges of poor management of funds, persistent shortage of services
and unreliable membership data. CHF members access services from dispensary level up to
district hospital within the Council. As such, unsatisfactory performance of the CHF in most of
the councils continue to discourage people to enroll with CHFs subsequently sharply dropout
rate of members each year. National Health Insurance Fund(2017).

NHIF (T) came up with a new initiative and advised the Government to establish “Improved
Community Health Fund” (iCHF) in 2016 where members can access medical services up to
regional referral hospital across regions thereby allowing portability of services.

Enrolment in such schemes is voluntary, and premiums tend not to be according to ability to pay,
nor are they risk rated, with schemes often running on a non-profit basis Ekman B(2004). In some
cases, contributions are collected at a specific period in the year, such as during the harvest
season , in other cases people can join year-round Kamuzora et al (2007). Schemes sometimes
promote individual enrolment, and in other cases couples and their children are enrolled together
Ranson et al(2006).

Tanzania like many countries in Sub-Sahara Africa, face problems like tight public health care
budget and inaccessibility to basic health care to population in rural areas and informal sectors.
As a result, the country introduced different health financing mechanisms namely; user fees,
health insurance, and community health funds (CHF) so as to facilitate individual contributions
in accessing health services.

In Kondoa District, the community health fund has achieved to enroll 4.6 percent of the
population in Kondoa District. This is a very low enrollment rate because only 56637households
are members of the scheme out of 269704 households available in Kondoa District. In Kondoa
District improved Community Health Fund was introduced in 2011 and the scheme has, enrolled
less than 10000 members (HPSS REPORT 2018)
We aimed to fill this gap in knowledge by examining heterogeneity in moderating factors within
the context of the Redesigned Community Health Fund in the Kondoa District in Tanzania.

1.2 PROBLEM STATEMENT

In order to improve UHC, the WHO (2015) suggests that countries need to prioritize on the
poorest, increase reliance on public funding, reduce or if possible eliminate OOP spending and
also develop a strong health system. As a part of its endeavor to achieve universal health
coverage by 2020, the Government of Tanzania thoroughly reassessed the initial CHF approach
and decided to further develop it into a fully operational and effective social health insurance
scheme. In 2015 the government of Tanzania set a goal of achieving 30% of CHF enrolment
amongst households, however only 16.4% was achieved. (Modest et al, 2021). This is the best
option because revenues collected through tax financing and social health Insurance (SHI)
schemes are insufficient to finance the health system due to a low tax base. Low tax base is
caused by a poor economy and the large proportion of people in rural area who are employed in
the informal sector (Ministry of Health and Social Welfare 2009).

Through the CHF Act No. 1 of 2001 introduced the CHF which is the prepayment scheme. CHF
is a pre-payment council’s-based scheme aimed at facilitating the community to access health
care at an affordable premium that is determined by the community itself. It is expected that
household will be well informed about their benefits and choose themselves to join into the CHF.
The CHF management and principal stakeholders include; community, ward leadership, local
authorities and health providers. From the CHF management, funds are being pooled from many
households so as to incorporate the fundamental insurance principles of risk pooling. This
enables the CHF to cover expenses of health care services required by its members. Households
which have not joined CHF pay out of pocket in order to access health services. For the low-
income families sometimes, it had been difficult to access the services.

The HPSS project CHF model has generated knowledge and extensive experience that has
contributed to important design features for the national roll out of the improved Community
Health Fund (CHF Iliyoboreshwa)( Stoermer M 2011). Standard Operating Procedures and
Financial Management Guidelines were endorsed by the President’s Office – Regional
Administration and Local Government and are now employed by the improved CHF nationally.
One important step of the improved CHF is the enrolment that it is now taking place at the
household level and this has greatly reduced the cost of travel to the point of enrolment. It is
envisaged that with the introduction of mobile phone payment and enrolment, this will be
another path breaking innovation of improved CHF. This innovation will make health insurance
easily accessible, reduce operational costs, promote professional governance and strengthen
administrative structures for CHF

The improved CHF today covers a much broader benefit package including hospital care in
public facilities. Users highly appreciate the liberty to utilize health services for a moderate
insurance contribution at any accredited health facility in the country. In the new model, funds
are no longer managed by the District Medical Offices (DMO) but go directly to improved CHF
offices managed by the regional Administration. For health care providers, the implementation of
the improved CHF reduces the administrative workload: They receive reliable and effective
payment according to population covered and services delivered.

Despite the fact that it’s through the community’s and council’s meeting is where premium for
this scheme is determined but still the enrollment rate to this scheme is low which indicated a
gap on whether people did not have proper information on the usefulness and effectiveness of
community health fund, or affordance to pay for premiums or community cannot access services
at the time of their need, trust in the scheme management and low quality of the services from
the health facilities are the reasons for the people to drop out and not to re-enrol into the
schemes.

Thus this study aim to investigate on the possible factors affecting low enrolment of Community
health fund membership. CHF has been on implementation for more than 15 years, in all
councils reports show that there are several challenges which retard CHF success (NHIF, 2011;
Kamuzora & Gilson, 2007). The main challenges are low CHF enrollment (only 24%) which is
lower than the national target of 70% set in 2010 (NHIF, 2019; NHIF, 2010). Other challenges
are limited awareness of the scheme to the wider community, sustainability of the scheme and
non-utilization of CHF revenue for service improvement.

1.3. The General objective

To Assess Factors leading to low Enrollment on the Improved Community Health Fund Scheme
Among the Community members.

1.4. Specific Objective

(i) To find out Perception of community towards community health fund.

(ii) To examine demographic variables leading to low enrollment in CHF
(iii) To examine economic variables contributing to low enrollment in CHF
(iv) To examine socio-cultural variable leading to low enrollment in CHF.