Strengthening of Claiming, Reimbursement and Use of Funds for the National Health Insurance

Fund

Experiences from the Pilot Region (Tanga) and Suggestions for Further Roll-out

Gradeline Minja (HSRS MoHSW), Dr. Aifena Mramba (NHIF), Mechard Tiba (GTZ), Manfred Stoermer (Health financing consultant)

developed on behalf of

Tanzania German Programme to Support Health (TGPSH /GTZ)

November 29, 2007

Background

• NHIF contributions and reimbursements 2004/5– Contributions collected 24.0 bn TSh– Claims lodged 4.9 bn TSh– Reimbursements paid 4.2 bn TSh (86%)

• NHIF contributions and reimbursements 2005/6– Contributions collected 31.7 bn TSh– Claims lodged 5.4 bn TSh– Reimbursements paid 4.9 bn TSh (91%)

Overall Aim and Organisation of the Study

• Aim:

Strengthening the system of claims and reimbursement for the benefit of district health services

• Organisation of the Study (Four phases)

I: Situation analysis (January 2006)

II: Pilot implementation in Muheza district (April 2006)

III: Impact assessment (November 2006)

IV: Impact assessment of regional roll-out in Tanga Region and suggestions for national roll-out (November 2007)

Specific Objectives of this Study Phase

• Muheza and Lushoto districts: Assessing the functioning of NHIF claiming/ reimbursement/ use of funds and measure its progress

• Assess the ongoing training on NHIF claiming and reimbursement in Tanga Municipality and evaluate its appropriateness

• Evaluate the activities carried out by the Regional NHIF coordinator Tanga and the District NHIF coordinators in terms of supervision and monitoring

• Follow up of implementation of recommendations for the peripheral and national level submitted during the pilot studies on NHIF support.

• Suggest way forward for national roll-out for facilitating improved claiming/reimbursement/use of NHIF funds

Methodology for present study (phase IV): Impact assessment of regional roll-out in Tanga Region

• Document review

• Semi-structured interviews

• Field visits to Muheza and Lushoto Districts / Tanga Region

• Muheza and Lushoto districts interviews with DED, DMO, DHMT, District Treasurer / accountants, District NHIF Co-ordinator

• 2 dispensaries, 2health centres and 2 district hospitals visited, interviews with in-charges and members of health facility governing committees

• Tanga Region RMO, RHMT, Regional NHIF Co-ordinator, GTZ

• Participatory observation of a training workshop on NHIF claiming and reimbursement in Tanga Municipality

Roll-out in Tanga Region: Training on NHIF claiming and reimbursement

July 2007:

• Trainings in Handeni, Korogwe and Lushoto districts;470 participants from 132 facilities; in total 10 trainings on division level, facilitated by 6 trainers (4 NHIF, 2 RHMT)

November 2007:

• Trainings in Kilindi and Pangani districts and Tanga City;270 participants from 86 facilities;in total 5 trainings on division level, facilitated by 4 trainers (2 NHIF, 2 RHMT)

Costs of the Training Workshops for Tanga Region

Cost Items Cost incurred

Secretarial services 5,838,780

Perdiem for trainers 19,254,820

Printing & photocopying 13,701,310

Bus fare refund 2,838,170

Venue 401,980

Allowance to participant 20,213,500

Fuel 4,933,016

Refreshments to participants

5,882,300

Participants 1,382,820

Total 74446696

Number of participants 740

Unit cost 100,603

Findings: Development of Claims and Reimbursements in Tanga Region

Development of Claims and Reimbursements in Muheza District (govt. health facilities)

Monthly NHIF Funds Claimed and Reimbursed in Muheza District (Govt Facilities)

0

200'000

400'000

600'000

800'000

1'000'000

1'200'000

1'400'000

Jan to Dec2005

March2005

Jan to June2006

July 2006 Aug 06 Sept to Oct2006

Nov 06

TS

HS

.

Aver. amount claimed per month Aver. amount paid per month

Development of Claims and Reimbursements in Muheza District (all health facilities)

Monthly NHIF Funds Claimed and Reimbursed in Muheza District (All Health Facilities)

0

500'000

1'000'000

1'500'000

2'000'000

2'500'000

3'000'000

3'500'000

Jan toDec2005

March2005

Jan toJune2006

July2006

Aug 06 Sept toOct

2006

Nov 06 July2007

TS

h

Aver. amount claimed per month Aver. amount paid per month

Development of Claims and Reimbursements in Lushoto District

Monthly NHIF Funds Claimed and Reimbursed in Lushoto District (All Health Facilities)

0

2'000'000

4'000'000

6'000'000

8'000'000

Apr 0

5

May

2005

June

200

5

July

2005

Aug to

Sep

t

Oct to

Dec 2

005

Jan

to Feb

200

6

Mar

ch to

May

200

6

June

to A

ugus

t 200

6

Sept t

o Oct

2006

Nov to

Dec

200

6

Jan

to M

arch

200

7

June

to Ju

ly 20

07

Aug to

Oct

2007

TS

H.

Aver. amount claimed per month Aver. amount paid per month

Development of Claims in Tanga Region

NHIF Funds Claimed by District, Tanga Region from 2005 to 2007

-

50'000'000

100'000'000

150'000'000

200'000'000

250'000'000

300'000'000

Muheza Lushoto Handeni Pangani Korogwe TangaUrban

TangaRegion

TS

HS

.

2005/2006 2006/2007

Development of Reimbursements in Tanga Region

NHIF Funds Reimbursed by District, Tanga Region from 2005 to 2007

-

50'000'000

100'000'000

150'000'000

200'000'000

250'000'000

300'000'000

Muheza Lushoto Handeni Pangani Korogwe TangaUrban

TangaRegion

TS

HS

.

2005/2006 2006/2007

Reimbursement of NHIF Funds by Region from 2005/06 to 2006/07

Reimbursement of NHIF Funds by Region from 2005/06 to 2006/07

0

200'000'000

400'000'000

600'000'000

800'000'000

1'000'000'000

1'200'000'000

TS

h

2005/2006 2006/2007

Summary: Development of Claiming and Reimbursement

• In general an upward trend can be observed both for claiming funds and for the reimbursements

• Reduction in reimbursements, and later also in claims, since Feb 2007 because of changing Govt. policy on Malaria treatment (use of ALU as first line drug), and corresponding change in price reimbursed for ALU: drop from TSh 8500/= per treatment to TSh 500/=

Findings: Accessing and Utilising Funds

Accessing and Utilising Funds

Background:

• Health facilities should be able to utilize the NHIF funds for improving their services

• NHIF reimburses funds on a health facility level, based on the claims of each health facility

• NHIF checks whether the claims adhere to the requirements and rejects some of them

Accessibility:

• Presently NHIF funds in Tanga Region are deposited on sub-treasury / regional level for hospitals, on the “CHF account” (sometimes also called “cost sharing account”) at district level for health centres and dispensaries

The Bottleneck of Accessing and Utilising Funds

• So far none of the first level health facilities (health centres, disp.) ever benefited from utilizing NHIF funds

• However, we were informed that the first ever utilisation of such funds is in progress; a first requisitioning of drugs is under way;

• Procedures are expected to take some weeks • No records are kept on the amounts available for each

individual health facility at the levels of DMO, the District Treasurer or the District NHIF Co-ordinator

• The health facilities do not know what is the amount available for them from NHIF funds.

Muheza District:

The Positive Example of how to Access and Manage Funds in Lushoto District (I)

• DMO keeps records on the balance of funds (NHIF, CHF, user fees) for each health facility (sub accounts with codes have been developed)

• District hospital buys drugs at MSD on behalf of first level health facilities and builds buffer stock at District Pharmacy

• District Pharmacy is provided with the balance of funds available for each health facility by the DMO

The Positive Example of how to Access and Manage Funds in Lushoto District (II)

• Health facilities identify their demand of drugs and get approval from the health facility governing committee

• District Pharmacist is empowered by DMO to validate and authorize requests for drugs of the health facilities and dispense the drugs to them the same day (without further signature of DMO)

• Details of the requested and dispensed drugs are reported back to DMO by District Pharmacist

• DMO deducts the value of the dispensed drugs from the respective health facility sub-accounts and compensates the hospital

The Positive Example of how to Access and Manage Funds in Lushoto District (III)

Good general management practice:• DMO instructs all health facility in-charges to report to

district capital by the 15th of each month, for handing in claim forms to NHIF co-ordinator, requisitioning and collecting drugs, and any other business

• In-charges who report later than 15th of the month have to report directly to the DMO and explain the delay

• Travelling costs to district capital are budgeted in the CCHP

• By-annual meetings are held with all health facility in-charges of the district

The Positive Example of how to Access and Manage Funds in Tanga Municipality

• Each health centre keeps an own bank account, which at the same time serves as a bank account for the neighbouring dispensaries

• NHIF funds are deposited on the health facility bank accounts

• Each health facility is exactly aware of the balance of funds

• The in-charges and members of governing committees present at the training workshop in Tanga report unanimously of good experiences with keeping their own bank account

Financial Monitoring Tools

• During phases I-III of the study financial monitoring tools were developed for monitoring inflows, outflows and balance of funds (for NHIF, CHF and user fees) at the levels of DMO, District Treasurer and health facility

• These financial monitoring tools are not being utilised in the districts visited

• Lushoto set up an own financial monitoring system, Muheza has no financial monitoring in place

• It is still maintained by the team that financial monitoring of NHIF funds and communication of the balances available to health facilities is of utmost importance

• The financial monitoring tools should be mainstreamed and integrated in the routine financial administration system

Summary: Accessing and Utilising Funds

• The lacking access to NHIF reimbursed funds for health facilities has to be seen as a major obstacle regarding improvement of the quality of health services, and regarding motivation of health staff to do the claiming

• The examples of Lushoto (sub-accounts and drug buffer stocks) and Tanga Municipality (own bank accounts) show that this problem can be overcome with good management practice

• Complicated financial administration procedures at district level and remoteness of the account keeping (sub-treasury at region for hospitals) create major costs in terms of expenditures and delays

Findings: Appropriateness of the Training Workshops

Participants for the training:

• Representatives from all health facilities from Bombo Regional Hospital, District hospitals, health centres and dispensaries in Tanga Municipal Council, Kilindi and Pangani districts respectively.

• At Bombo Hospital: participants from each department• Health centres: maximum of four people, dispensaries: in-charges • Ward Executive Officers from the participating districts• Chairpersons of the Facility Governing Committees.• Representative from Workers from Tanzania Local Government

Workers Union TALGWU).• Representatives of NHIF members from the Education department

(District Education Officers for Kilindi and Pangani districts, primary school teachers)

• Comment: the selection of participants is appropriate

Objectives of the workshop

• Reduce the number of rejected claims by training the providers on how to fill the NHIF cards and provide clarification on problem areas.

• Provide information on recent changes in NHIF operations, i.e. benefit package, prices, approved drugs

• Clarify the roles of the NHIF Coordinator• Provide information about NHIF Quality control analysis and

payment procedures.• Strengthen the financial monitoring of NHIF reimbursements

at facility level to enable follow up by in-charge or health facility governing committee if information on reimbursements corresponding to claims is not received

• Enable health facility in-charges and health facility governing committees to take on an active role in monitoring total revenues collected, spent and available and how to access such accumulated funds.

Curriculum applied / Contents of the Workshop

• The workshop adequately addressed the NHIF procedures for filling membership forms, claiming and reimbursement and informed on recent changes in NHIF benefit package and role of the NHIF Coordinator

• The question of how the new health financing schemes fit into the context of health sector reform was discussed too briefly

• The issue of how to access and utilise funds is not captured in the workshop programme

Trainers / Facilitators

• Two facilitators: one from NHIF HQ in Dar es Salaam and the other one from the Regional Health Secretariat.

• With exception of the health Sector reform topic, all the sessions were provided by the NHIF facilitator.

• The facilitators used active participation methods throughout the training session. However, in order to make the sessions more lively, the trainers should change more frequently.

• The trainers were very knowledgeable on the subjects of claiming and reimbursement procedures of NHIF.

• The training on health sector reform was too brief and did not adequately explain the objectives of the new financing schemes

Training Methodology

• Training methodology was mainly lecturing, with question and answer sessions

• Exercises were asking the participants to identify mistakes in wrongly filled forms and comment on good forms

• However: no active group work where participants are asked to fill in forms themselves

• All forms used by NHIF are presently in English language. For easy understanding a Kiswahili or bilingual version would be helpful

Training Materials

• Information on the procedure to follow when a member requires changing the name of his / her beneficiaries, or putting additional person as a beneficiary.

• Procedure to take when a membership card is lost.• The amount to be paid as a penalty on requests for

another membership card if the previous one is lost. The current charge is TShs. 20,000/= but this is not written anywhere.

• Retrieval of cards when the membership ceases.

Forms for NHIF operations were used. Some lack detailed information to assist the person who is filling them:

Summary: Main Findings on the Appropriateness of the Training Workshops

• Participants are appropriately selected• Contents should be extended to include accessing of

funds• Curriculum should be developed with definition of key

contents• Facilitators are appropriately chosen, but should take

turns in taking over training sessions • Training methodology should be supplemented with

some activating exercises / group work

Findings: Regional and District NHIF Co-ordinators

Regional and District NHIF Co-ordinators (I)

• NHIF co-ordinators are in place in all districts of Tanga Region except Tanga Municipality.

• The District NHIF Co-ordinators do collect the claim forms and pass them on for payments.

• They distribute payment advice letters from NHIF to the health care providers

• They supervise and screen claim forms to ensure that they are properly filled.

• The follow up of health facilities which do not submit claims in time, however, seems to be weak in Muheza and stronger in Lushoto

• They collect operational problems related to NHIF implementation and discuss with CHMT members and NHIF zonal office

Regional and District NHIF Co-ordinators (II)

• It was noted that supportive supervision takes place in Lushoto with regard to NHIF operations by CHMT members as part of regular supervisory visits to all governmental health facilities. However, this was not very clear for Muheza.

• They facilitate that health facilities get feedback on amounts claimed and paid. The balance of funds available for the health facilities is only communicated in Lushoto and Tanga Municipality, not in Muheza

• They disseminate information on changes in package, prices, procedures etc. of the NHIF to the health facilities

• NHIF co-ordinators presently do not assist in follow up of members with missing NHIF beneficiary cards. Such members are presently not registered at health facility level and reported to the NHIF co-ordinators

Summary: Main Findings on the Role of Regional / District NHIF Co-ordinators

• The establishment of Regional / District NHIF Co-ordinators is very helpful for improving NHIF claiming / reimbursement

• They fulfil most of the roles expected from them• Some improvements could still be made in regard to

follow up of health facilities not submitting claims and follow up of members without ID cards

• A merging of the roles of NHIF co-ordinator and CHF co-ordinator into a “Health financing co-ordinator” would be desirable, but needs re-adjusting of the workloads

Recommendations

Recommendations: Making NHIF Funds Accessible to Health Facilities (I)

1. Developing a guideline on where to deposit NHIF funds

Recommended: in a district level „cost sharing account“ together with CHF and user fee funds

Suggested responsible level: “Health Financing Committee“ to take up the issue and co-ordinate with responsible units in MoHSW, PMORALG and MoF

Recommendations: Making NHIF Funds Accessible to Health Facilities (III)

2. Develop financial monitoring tools for tracking the funds at the level of each individual health facility (for NHIF, CHF, user fees) and integrate them in the routine district accounting system (Epicor)

Recommended: consider allowing health facilities to open own bank accounts;otherwise at least sub-accounts for the district level account should be created;consider how DMOs could be followed up on whether they provide the health facilities with their respective financial break-down

Suggested responsible level: MoHSW / RHMT for guiding, instructing and following up the DMOs; DMOs for informing health facilities

Recommendations: Making NHIF Funds Accessible to Health Facilities (II)

3. Training of DMOs in accessing and utilisation of funds and in avoiding shortages in drugs and supplies

Recommended: informing and instructing DMOs in how to build up a buffer stock of drugs from which health facilities can easily draw their requirements; obliging them to report reasons in case of failure and stock-outs

Suggested responsible level: MoHSW/RHMT and PMORALG

Recommendations: Roll-out of Training Workshops on NHIF funding (I)

4. Restructure the training workshops on NHIF funding:• Develop a curriculum / guideline for the trainings to be

applied countrywide, which should contain e.g:• training session on how to access and utilise the funds;

training on how the health facilities can monitor the balance of funds from NHIF, CHF and user fees available to them;

• practical exercise where participants fill in forms themselves

• invite DMO / DHMT to exactly explain how the health facilities can access their funds e.g. for drug supplies, and how buffer stocks for drugs will be maintained at district level;

Recommendations: Roll-out of Training Workshops on NHIF funding

(II)5. Conduct training of trainers:• Consider conducting ToT to the zonal training centres in

order to speed up the roll-out• Begin the roll-out on the presently poorly performing

regions (annual reimbursements below TSh 200 M):- Coast- Kigoma- Lindi- Mtwara- Shinyanga- Singida- Tabora- Rukwa

Recommendations: Empowering of NHIF co-ordinators

• 6. Consider formally establishing the post of a “Health Financing Co-ordinator” to deal with all the health financing issues in the district (incl. NHIF, CHF, user fees) After establishing such a position consider reallocating the workload

• 7. Whenever a new employee joins the district health services he/she should first undergo an orientation with the “Health Financing Co-ordinator” for some days before proceeding to the work station

Recommendations: Strengthening communication between

MoHSW and NHIF

• 8. Consider appointing a focal person in MoHSW responsible for health care financing aspects at the national level

Way Forward:

• NHIF together with MoHSW should prepare a roll-out plan for implementation of all above mentioned recommendations, pointing out time frame, resources and responsibilities

• Estimated costs of roll-out for the 8 poorest performing regions in the country:approx. 8 x TSh 75 M = TSh 600 M (= approx. 500.000 USD)(to be calculated in detail per district)

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