1 OPERATIONS MANUAL FOR IMPLEMENTATION AND MANAGEMENT OF A COMMUNITY HEALTH FUND in Tanga Region A MANUAL FOR PRACTITIONERS Second edition January 2006 Contacts The Regional CHF Competence Center (RCCC), Tanga - a regional branch of the Tanzania Network of Community Health Funds (TNCHF)
2 Contents No Topics pg 1.0 2.0 2.1 2,2 2.3 2.4 2.5 3.0 4.0 4.1 4.2 5.0 5.1 5.1.1 5.1.1.1 5.1.1.2 5.1.2 5.1.2.1 5.2.1 5.2.2.1 5.2.2.2 5.2.2.3 5.2.24 5.2.2.5 5.2.2.6 6.0 6.1 6.1.1 6.1.2 6.1.3 6.2 7.0 7.1 7.2 7.3 7.4 8.0 8.1 8.2 8.3 8.4 8.5 Acknowledgement Foreword Introduction The Community Health Fund Concept Objectives of the CHF Definition of the CHF The strengths of the CHF Act Advantages of the CHF scheme CHFplus: Continuous support to CHFs How to join the CHF scheme Steps in establishing the CHF scheme Sensitization and awareness raising Preparation of the By-law Legal bodies for CHF implementation and management CHF management bodies and their function At regional level: Regional CHF Competence Center (RCCC) Regional CHF Steering Team (RST) Organization structure of the CHF scheme at district level Council Health Service Board (CHSB) At district level: The Council Health Services Board (CHSB) CHF Task Force (CTF) Job descriptions for the District CHF Coordinator Health Facility Governing Committee (HFGC) Job descriptions for a CHF agent Characteristics for CHF promoters CHF awareness creation and sensitization to the community Sensitization strategies Know exactly what offerings people want Identification of different audiences Choose appropriate media/tools most suitable to reach communities Sensitization activities Enrolment and funding for the poor Membership How to join the CHF scheme Standard rates of premiums CHF enrolment options Exemptions procedures for the poor Background The problem The solution The pro-poor ORANGE CHF Card programme Selection process of the poor
3 8.6 8.7 8.8 8.9 8.10 8.11 8.12 9.0 10.0 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.7.1 11.7.2 12.0 13.0 Exemption criteria Purchase of Pro-Poor CHF Cards Financial planning for the pro-poor programme Regular information to sponsors of the pro-poor CHF Card programme Another plus: matching grants for pro-poor CHF sponsoring The exemption form The Council pro-poor CHF Program Benefit packages for CHF members Members administration Flow and use of funds Flow of funds Use of funds Where to collect funds? Who to collect the funds? When to collect premiums? Accounting at district level Accounting at CHF Agent level CHF cash book Daily patient / cash ledger Reporting ANNEXES Annex 1. Training for different CHF stakeholders and actors Annex 2. Sensitization materials Recommendations on planning and budgeting in CCHP noch einbauen (s. File) unter TNCHF (ist neu 10.3.06)
4 i. Acknowledgement This manual is developed through the efforts of the Tanga Regional Secretariat, and Tanzanian German Program to Support Health (TGPSH). The collaborators acknowledge the technical support from the Tanzania Network of Community Health Funds and the financial support. In addition the cooperation of District CHF Schemes management in particular DMOs who tirelessly supported the piloting of this model is highly appreciated. Finally the consultants and editors who persistently forged this tool are commended for their efforts and determination to complete this manual. Foreword hightlight that this is a pilot project for selected districts in Tanga Region. Replication to other districts and Regions should take place only after intensive consultation with all involved stakeholders. FOREWORD For the long time the government of German is implementing comprehensive health sector reform programme in Tanzania that implies looking ahead in to the future rather than back to the past. But for so many years health reforms were always the agenda. The Tanzania German Programme to Support Health supports MOH to strengthen health care financing. One main activity is focusing on offering equitable access to health care services under community Health Fund programme (CHF). This is a district community scheme insuring members against payments for the basic care. The scheme has stated 10 years ago supported by World Bank but still facing severe structural and managerial problems. TGPSH one of donor partners in Tanzania is assisting in developing an approach known as CHF plus as a product from CHF to insure the poor out of pocket. The programme now is being tested in Muheza District council Tanga This manual provides guidance for national policy makers but also all health care planners and providers in the field in supporting health insurance system and financial management in the Districts. In this book collogues from TNCHF, Tanga Region and TGPSH Health financing have personally supported this programme with their knowledge and expertise, experiences and the opportunities and obstacles uncounted. Also they were making recommendations through Regional steering meeting as the best way forward.
5 It s our hope that through its new structure and management design on how to strengthen CHF, future challenges of achieving equitable access to health care to the Tanzanian community. We would like to thank all our colleagues for their contribution to this manual. Dr.Balthazar Ngoli Regional Medical Officer Tanga M. Kuper TGPSH The Regional Medical Officer Dr. Balthazar Ngoli
6 1. Introduction This operations manual describes the Community Health Fund (CHF) concept, provides procedures for setting the CHF scheme, and elaborates CHF promotional activities and materials at community level. Capacity building and training activities for CHF actors at different levels are also identified with suggested topics. It also defines functions and responsibilities of different organs and actors in CHF implementation. The organs described in the guide include the Council Health Services Board (CHSB), Council Health Management Team (CHMT), Health Facility Governing Committee (HFGC) and the District CHFTask Force (DCTF). Responsibilities of the key technical team for management are elaborated. This consists of the CHF Coordinator, the CHF Agent, the CHF Promoter and the health personnel. write still on the innovative approach (CHFplus) Elaborate more on this chapter Den Begriff Cook Book erwaehnen 2.0 The Community Health Fund Concept The CHF is a voluntary health financing scheme, which offers to the family an alternative health financing mechanism by making annual prepayment for healthcare services and having access at the time of need throughout the year without any further out of pocket payment. mention existence of CHF act Insurance against out of pocket payment Prevention against shock payments when having no money 2.1 Objectives of the CHF According to the CHF Act of 2001 (Part II, 5)) the Community Health Fund has the following three major objectives: to provide health care services to members by mobilizing financial resources from the community (member view). to provide quality and affordable health care services through sustainable financial mechanism (provider view). to empower the communities in decision making and by contributing on matters affecting their health leading to improved health care services management (community view). Elaborate more on this 2.2 Definition of the CHF According to the CHF Act (Part II, 4 (1)) the fund s functions are defined as follows: 1. voluntary and community based financing scheme and 2. financing the household s b a s i c health care services and 3. complementing the Government health care financing 2.3. The strengths of the CHF Act Studying the CHF Act of 2001 there are various areas of strengths which can be quoted:
7 - user fees have to be part of the CHF. This means that even payments for health services in the form of user fees from those people who have enough money all over the year and who do not want to join the CHF is transferred to the fund. Thus these user fee payments serve to strengthen the CHF and offer better services to the population and especially to the poor. - the CHF is fully community managed (community empowerment) - the exemption exercise for poor who cannot afford out of pocket payments for health services is to be done by the community itself - funding for the poor is to be covered by the Local Governments and their partners which could be business companies, development organizations, NGOs and individuals. - the CHF as a funding tool is not only for CHF premiums and user fees but also open for Government contributions, grants from Councils, development organizations and other sources. CHFplus in line with spirit of CHF act see presentation of Kuper of strong design 2.4 Advantages of the CHF scheme for members CHF enables the enrolled members to overcome the burden of the cost of health services at the time of sickness. Members are protected against shock payments throughout the year: they are insured against out of pocket payments. Especially the poor who cannot afford user fees will not be hindered to access health care services due to those fees imposed at the health facility. more? 2.5 CHFplus: a brief description 2.5.1 in corporate the CHFplus paper 4.0 Steps in establishing the CHFplus scheme In order to establish and sustain CHF in a district, several actions have to be carried out. It should be noted that these are one time activities. However regulations provide room to amend the bylaws following certain procedures in case of necessary important changes. The actions for establishing a CHF include the following:
8 4.1 Sensitization and awareness raising Organization, sensitization and awareness creation on CHFplus to different stakeholders at the district level and the community on benefits of the scheme involve different stakeholders. Sensitization activities may focus to the following groups: The Council Social Services Commission for Water, Health, Education The full Councilor s Assembly District Primary Health Committee Ward Development Committees Ward Health Committees Village Governments Village Health Committees Community Based Organizations Civil Society Organizations such as churches, cooperatives etc. 4.2 Preparation of the By-law i. The Council Lawyer in collaboration with the Council Health Management Team drafts the by-law for regulating the Council Health Services Board. ii. The by law is presented to the Council Social Services Commission for Water, Health, Education for comments before it is forwarded to the Council Health Management Team for review. iii. The CHMT takes the draft to the full council assembly for further refining, comments and approval. iv. After by-law approval by the full council, the draft is then sent to the District Commissioner, then to the Regional Administrative Secretariat. v. Then the draft is forwarded by the Regional Administrative Secretariat to the Ministry of Regional Administration and Local Government (PORALG) in Dodoma for final approval by the Minister. vi. After the approval by the Ministry and publishing in the Government magazine (= gazetting) it becomes an act and legal instrument for CHF implementation in the district. 5.0 Legal bodies for CHF implementation and management The Local Government (Council authorities) Act 1982 gives statutory powers for the establishment of the Council Health Services Board as a body which has among others the mandate for the operations and management of a CHF scheme. The body is tasked to solicit funds from various sources but more specifically to mobilize communities to contribute to health and join the Community Health Fund. The act establishes the following bodies which have to be set before establishing the CHF scheme in the district: Council Health Service Board Hospital Governing Committee Ward Health Committee Health Facility Governing Committees at health centre and dispensary level 5.1 CHF management bodies and their function The following bodies are very supportive for the management of CHF and have to be in place wherever possible.
9 At regional level: 5.1.1.1 Regional CHF Competence Center (RCCC) Composition: Head of RCCC and/or Training Officer Functions: To act as a Secretariat to the Regional CHF Steering Team (RST) To facilitate activities of the Regional CHF Steering Team To offer technical support to all districts in the Region in CHF management To be an information resource center to the Region and Districts on CHF related issues To organize conceptualizing as an ongoing process the innovative CHF design To coordinate the CHF implementation processes To make follow-ups on recommendations made by the RST, adapt them to their CHF needs and prepare update of the CHFplus operations guidelines such as the Questions & Answers guide. 5.1.1.2 Regional CHF Steering Team (RST) Composition: One CHF Coordinator per district One representative from the RCCC One RMO representative One representative of the faith based organizations operating in Tanga Region Functions: To be a link between the CHSB and the Regional level in terms of CHF matters To coordinate CHF related implementation activities for all districts. To conceptualize the CHF set up according to specific needs of Tanga society To be responsible for monitoring of CHF performance and passing information to respective levels (Districts, RMO, TNCHF and thereby automatically to the MOH) To ensure transparency on CHF management on all levels To elaborate in close cooperation with the MOH key innovative CHF strengthening managerial and organizational areas o Community participation o Marketing and promotional concepts o Financial accounting o Membership administration o Training issues o Provider related modalities such as service improvement To render information on the CHFs accessible to all districts on implementation and management progress of each district To monitor and review the CHF implementation process
10 5.1.2 Organization structure of the CHF scheme at district level COUNCIL HEALTH SERVICES BOARD CHF COORDINATION OFFICE CHF Task Force HFGC 1 HFGC 2 HFGC 3 HFGC 4 CHF AGENT at HEALTH FACILITY 1 CHF AGENT at HEALTH FACILITY 2 CHF AGENT at HEALTH FACILITY 3 CHF AGENT at HEALTH FACILITY 4 CHF PROMOTERS at Village level CHF PROMOTERS CHF PROMOTERS CHF PROMOTERS
11 5.1.2.1 Council Health Service Board (CHSB) Main characteristics on its composition and functioning (following regulations of CHF Act 0f 2001) Composition No. Conditions Status Functions in CHSB Voting right Period of office Limitation of office to periods Community service user 4 at least 2 of them to be female private Represent.of non profit VA health care facility 1 to be appointed by Council private to have service agreement with CHSB Represent.of for profit health care facility 1 to be appointed by Council private to have service agreement with CHSB Head of Council Social Services Commission 1 private elective for chairperson yes 3 years 2 elective for chairperson yes 3 years 2 elective for chairperson yes 3 years 2 elective for chairperson yes 3 years 2 Council Planning Officer 1 public no 3 years - DMO 1 public Secretary to CHSB no 3 years - Representative from District Hospital 1 publ//priv. no 3 years - Representative from RHMT 1 public no 3 years - Total number 11
12 At district level: 5.2.1.1 The Council Health Services Board (CHSB) Composition: Four community services users of whom at least two shall be female members One representative from a non-profit voluntary agency and a private for profit health care facility, appointed by the Council from amongst health care facilities The head of the Council Social Services Committee District Medical Officer (who shall be secretary to the Board) The Council Planning Officer Representative from the district hospital Representative from the Regional Health Management Team (RHMT) Functions: To monitor among others CHF operations and activities To work in consultation with the Council Health Management Team to ensure quality health care and professionalism To mobilize and administer funds for Community Health Fund To set exemption criteria for users of the health care services by the CHF To set targets for the CHF To review reports from Ward Health Committees or any other source To monitor and make verification on collection, expenditure and control of funds To comment on the Comprehensive Council Health Plan (CCHP) prior to approval by the respective Council 5.2.1.2 CHFplus Task Force (CTF) This is a transition organ invented by CHFplus as an innovative step within the sensitization and information activities. The CTF acts as administrative instrument at the initial process of establishing the CHF scheme. It will function for six months only there after its roles will be fully taken over by the District CHF Coordinator. The chairperson of the CTF will be elected among members of the task force. The CTF may be composed of the following team, however each council has to decide individually on the number of members. District Medical Officer District CHF coordinator who is the secretary of the CTF District Community Development Officer District Health Officer District Health Secretary District Education Officer District Treasurer District Legal Officer District Planning Officer Functions and roles of the CTF To make follow ups on CHF implementation To make sure that the strategies towards CHF are implemented
13 To be responsible for organization of sensitization materials at community level To make sure that CHF is of interest to people To be responsible for sensitization activities on CHF for the society in the districts To be responsible for coordination of all CHF activities during the implementation phases 5.2.1.3 District CHF Coordinator Kurzbeschreibung wie unter 5.2.1.1 Functions and roles of the District CHF Coordinator To prepare the annual budget of the CHF To coordinate all CHF related activities at district level To supervise and organize all the CHF related issues at the district To monitor CHF operation and implementation at the district To provide monthly, quarterly, and annual reports To collaborate with the RCCC Provide technical support to the CHF Agents and CHF promoters To issue CHF membership cards for new members To ensure proper filing and membership management To be the in charge of the scheme and report to the CHSB To work in close collaboration with the CHSB, CHMT, CHF Agents, CHF promoters and Health Facility Governing Committee (HFGC). To monitor fund collections and utilization To administer CHF membership To participate at RSC meetings At health facilitiy level: 5.2.1.4 Health Facility Governing Committee (HFGC) Composition: Number Origin 3 Community members 1 Health facility in charge (Secretary) 2 Private health care services providers (Profit and not for profit 1 Representative of the Ward Development Committee 1 Representative from the village government 1 CHF Agent as a co-opted members Total: 9 Functions and roles of the HFGC: To promote the scheme to the community To review and approve the health care implementation plans of the respective facility
14 To mobilize resources from the community for the provision of health services To monitor CHF Agents operations on CHF implementation weitere Punkte von Oberlin abfragen 5.2.1.5 CHF agent Kurzbeschreibung hier einfuegen Functions and roles of the CHF agent: To collect CHF premiums and user fees at the respective health facility To remit collections to the district CHFplus account To prepare monthly financial reports To keep financial records of CHF contributions To keep statistics on the use of health facility by its clients To encourage the community to join the CHF scheme and to renew membership To maintain and update membership database at health facility level To prepare membership cards To prepare CHF performance reports at the health facility level To coordinate CHF promotion activities via CHF promoters To work in close collaboration with the health facility in charge, HFGC, CHF promoters and the District CHF coordinator To be a member of the health facility governing committee Characteristics of the CHF agents S/he should have a basic secondary education. S/he should have basic knowledge of accounts and bookkeeping. S/he should be a resident of the ward where the health facility is located S/he should not have a history of being involved in any crime events. S/he should have an age of 25 years and above S/he should by priority be a female candidate S/he should have at least one guarantor S/he should be willing and able to carry out CHF promotional outreach activities Procedures for selecting and engaging of CHF agents S/he should apply for the post S/he should have the recommendations from the village government and any other agency to the CHF coordinator S/he will then undergo pre selection done by the secretary of the HFGC S/he will then be interviewed by the CHF Coordinator Successful candidates will be given appointment letters as community agents by the Council Health Services Boards
15 The selected future CHF Agent will then be trained on CHF management by the District CHF Coordinator in collaboration with the RCCC Supervision for CHF agents The activities of CHF Agents need daily and frequent follow up in order to manage CHF activities in the respective health facility location. The CHF agent is answerable to the Secretary of the HFGC and to the District CHF Coordinator. Two main areas of supervision of CHF Agents can be quoted: Review of implementation of work plans. Review of monthly performances reports. Noch besser bearbeiten
16 Remuneration policy of CHF agent A. Fixed monthly allowance 20,000 TSh B. Additional incentives = 3 % (performance based on number of CHF enrollees) e.g. 200 families enrolled per month 5,000 TSh premium per family = 1,000,000 TSh total CHF collection = 3 % 30,000 TSh TOTAL 50,000 TSh CHF Agents are paid fixed monthly allowances. In addition incentives are paid monthly as per the appraisal of the monthly implementation report by the CHF Coordinator. Contract for CHF agents (noch englische Version einfuegen) MKATABA WA UKUSANYAJI WA MICHANGO YA MFUKO WA AFYA YA JAMII MKATABA NA. Makubaliano haya yamefanyika leo tarehe 30 mwezi 5 mwaka 2005. KATI YA BODI YA AFYA YA HALMASHAURI, S. L. P 20, Muheza ambayo katika mkataba huu itajulikana kama BODI kwa upande mmoja, NA S.L..P.... MUHEZA ambaye katika mkataba huu atajulikana kama WAKALA WA MFUKO WA AFYA YA JAMII`` kwa upande mwingine. IKUBALIKE KAMA IFUATAVYO: KWA KUWA BODI imekubali kumpa WAKALA kazi ya ukusanyaji michango ya Mfuko wa Afya ya Jamii katika zahanati/kituo cha Afya cha (ambayo katika mkataba huu itaitwa MICHANGO; NA KWA KUWA WAKALA yuko tayari kupokea michango na kufanya shughuli nyingine ambazo zitaelezwa katika makubaliano haya ili kustawisha mfuko huo; basi MKATABA HUU UNAWEKA MIONGOZO NA KUSHUHUDIA YAFUATAYO:- 1. Kwamba, wakala atatekeleza majukumu yake kwa muda wa miaka mitatu (3) kuanzia tarehe 30 mwezi 5 mwaka 2005 hadi tarehe 30 mwezi 5 mwaka 2008 na Bodi na wakala wanaweza kuingia mkataba tena;
17 2. kwamba, majukumu ya wakala yatakuwa:- a) kupokea na kukusanya michango ya wanachama wa Mfuko wa Afya ya Jamii; b) kuwasilisha makusanyo ya michango katika akaunti ya Mfuko wa Afya ya Jamii wa Halmashauri; c) kuandaa taarifa za fedha za mwezi za Makusanyo ya Fedha za mfuko; d) kuhifadhi kumbukumbu za fedha za michango ya Mfuko; e) kushawishi jamii kujiunga na Mfuko wa Afya ya Jamii; f) kuhakikisha kuwa orodha ya wanachama wa Mfuko wa Afya ya Jamii inaenda na wakati katika ngazi ya Zahanati/ kituo cha afya; g) kuwasilisha makusanyo ya michango kwa Mhasibu wa Mfuko wa Afya ya Jamii wa Halmashauri; h) kuandaa kadi za wanachama ambao wametoa mchango; i) kuandaa taarifa ya utekelezaji katika ngazi ya kituo cha afya/zahanati; j) kushirikiana na Mkuu wa Kituo cha Afya/zahanati, Kamati ya Utendaji ya Kituo cha Afya/Zahanati, Mapromota wa Mfuko wa Afya ya Jamii na Mratibu wa Mfuko wa Afya ya Jamii. 3. kwamba, sifa za wakala zitakuwa ni-: a) awe na elimu ya Sekondari; b) awe na Elimu ya Ufahamu wa uhasibu na utunzaji Mahesabu; c) awe ni mkazi katika eneo la Kata ambapo kituo cha Afya kipo; d) hajawahi kujihusisha na makosa ya jinai; e) awe na umri wa miaka 25 au zaidi; f) awe na wadhamini watatu ambao watamdhamini; g) awe tayari kutekeleza kwa uaminifu shughuli za kuutangaza mfuko wa Afya. 4. kwamba, utaratibu wa kuchagua wakala utakuwa kama ifuatavyo:- a) awe ameandika barua ya maombi ya nafasi hiyo; b) awe amepata barua ya uthibitisho kutoka katika Serekali ya Kijiji anachoishi; c) amepitishwa katika mchujo uliofanywa na Kamati ya Utendaji ya mfuko wa Afya ya Jamii [CHFGC]; d) asailiwe na Mratibu wa Mfuko wa Afya ya Jamii wa Wilaya; e) apewe barua ya kuteuliwa kama wakala wa Mfuko wa Afya ya Jamii wa Wilaya; f) asaini mkataba wa uwakala na Bodi. 5. kwamba, Shughuli za mawakala zitakaguliwa mara kwa mara kwa kuzingatia muongozo wa utaratibu wa kufanya ufuatiliaji wa wakala kama ifuatavyo:- a) kupitia orodha ya majukumu ya wakala[job descriptions]; b) kupitia mpango wa kazi zake[work plans]; c) kupitia taarifa za utekelezaji wa kazi za kila mwezi[monthly performance reports]; 6. kwamba, malipo ya wakala yatakuwa kama ifuatavyo; a) elfu ishirini [20,000] ya posho ya mwezi; b) asilimia tatu ya ongezeko la wanachama waliojiandikisha; 7. kwamba, taarifa za akaunti zitakuwa bayana na kupatikana wakati wote kwa Jamii husika, Bodi na Mkurugenzi Mtendaji wa Halmashauri; 8. kwamba, wakala atalazimika kukusanya shilingi elfu tano kwa kila kaya itakayojiandikisha. Malipo hayo yatakuwa ni kwa kipindi cha mwaka mzima; 9. Kwamba, Wakala atawajibika kukusanya michango ya mfuko wa Afya ya Jamii kulingana na vipengele vya sheria Ndogo za uanzishaji wa mfuko wa Afya ya Jamii na Hati Rasmi ya Uanzishaji wa Bodi ya Afya; 10. Kwamba, majukumu ya Bodi juu ya wakala yatakuwa kama ifuatavyo:- a) itahakikisha Wakala analipwa posho na asilimia zake kama kawaida b) itahakikisha kuwa Wakala anapata vitendea kazi vinavyohitajika; c) itahakikisha kuwa wakala anapata ushirikiano kutoka kwa Jamii; d) itahakikisha kuwa pale ambapo wakala anafanyiwa uhalifu Bodi itampa ushirikiano; 11. kwamba, endapo kutapatikana ushahidi wowote wa matumizi holela au mabaya ya fedha za mfuko wa Afya ya jamii, Bodi inayo haki ya kusitisha mkataba na Wakala atalazimika kurejesha fedha za mfuko wa Afya ya Jamii; 12. Kwamba, Endapo upande wowote wa mkataba huu utafanya kinyume na makubaliano haya, Sheria za Tanzania zitatumika.
18 Kwa kuthibitisha vipengele vyote vya makubaliano haya, pande zote husika zimetia saini zao hapa, wote wakiwa wanaelewa matokeo na athari za kila kipengele cha vifungu vya mkataba huu. KWA NIABA YA BODI YA AFYA YA HALMASHAURI MWENYEKITI WA BODI Jina:.. Saini:. Tarehe... KATIBU WA BODI YA AFYA YA HALMASHAURI Jina: Saini: Tarehe.. MRATIBU WA MFUKO WA AFYA YA JAMII Jina:. Saini: Tarehe.. KWA NIABA YA WAKALA WAKALA Jina:.. Saini.. Tarehe.. MDHAMINI WA KWANZA Jina:. Saini.. Tarehe. AFISA MTENDAJI KATA Jina: Saini: Tarehe.. MBELE YA MWANASHERIA (W) Jina: Saini:.. Tarehe....
19 At village level: 5.2.1.6 CHF promotors Characteristics for CHF promoters S/he should be a secondary school leaver or primary school education with additional training on community programs. S/he should be a resident of the respective village S/he should be aged 18 years and above S/he should have respect and acceptance to the majority of community members in the respective locality with good social track record. S/he should have been trained on CHF concepts and social marketing Functions and roles of CHF promoters The promoter will act as community animators for awareness and sensitization of people to join the scheme and refer those interested to CHF agents for enrollment. The will be responsible to the villages governments and their respective hamlets. To sensitize and mobilize the community on CHF issues. To promote CHF services and benefits to the community. To provide adequate information to the community so that they can join the CHF scheme To make CHF attractive to the community and collect opinions on CHF evaluation by the community. To work in close collaboration with the CHF agent at health facility, village governments, local leaders, religious leaders, hamlet leaders and active NGOs in the villages. Selection procedures for CHF promoters S/he has to be nominated by the village government 6.0 CHF awareness creation and sensitization to the community Sensitization of the families to join the CHF is a continuous activity which needs to be done in a professional way. The sensitization teams at different levels need to be informed on different issues which one might need clarifications before deciding to join the scheme. 6.1.1 Know exactly what offerings people want Make the CHF products as interesting as possible Perfectly define the offered services before spreading the news Choose messages before transmission CHF to be introduced to the community Setting sensitization time frame Not making false promises to the people
20 6.1.2 Identification of different audiences Different audiences have to be identified when sensitizing CHF at different levels. The following audiences should be considered by promoters. Social marketing and gatherings at community level o Use village primary health care meeting o Mobilize community leaders o Social mobilization o Using religious leaders o Mobilization through schools o Use of political leaders o Use of influential people Use council organs and teams to mobilize the community o Social committee [Functions of the councils] o Planning committee o Community meetings at all levels o Teachers to be involved in sensitization o Full council, WDC, Village council, hamlets 6.1.3 Choose appropriate media/tools most suitable to reach communities The following tools/media are recommendable in order to mobilize the communities on CHF issues. Interactive media o Meetings, drama group, Group discussion, Seminars, Workshops, o Child to child education o Community meeting at all levels Paper media o Posters o Leaflets and flyers o Local news prints like Ngijangija na Afya Tanga Electronic media o Video shows o Radio o Visual aids like Cinema o CD roms Using the right social networks famous people Important people like traditional leaders traditional healers and birth attendants Communication news letters Use of councils e- mails Public Internet café Information Communication Technologies (ICT) activities in the Region and districts Different networks (RCCC,TNCHF and others) 6.2 Sensitization activities
21 Conduct meetings Conduct seminars and workshops Exchange visits from one scheme to another Use the electronic print media like leaflets, posters, exercise books and local news papers like Ngijangija na Afya Tanga. Use telecommunications media like Information Communication Technology (ICT), video shows and Television (TV) and Radio programs. CHF plus logo, pencils and ball pens with catch words on CHF Use T-shirts, caps and Khanga with catchy CHF promotional sentences printed on them e.g. CHF is for you, CHF is your access to health service at low cost. 7.0 How to join the CHFplus scheme Participation in CHF is voluntary Communities participate as a family, a social group or an individual Interested persons become CHF members after paying membership contributions and issuance of membership cards Each members pay to the CHF Agent an annual membership contribution (=premium), which rate is decided by the Council. New members receive from the CHF Agent at health facility a receipt for the money paid Members are entitled to a basic package of curative and preventive health care services at public or private not for profit health facilities Members will be expected to choose the health facility of their choice, usually the closet one to where they live The CHF agent sends to CHF Coordinator at district level the signed ID-cards with the photos, the amount of money each paid and the receipt number for purposes of registration After receiving the information from the CHF Agent, the CHF Coordinator registers the members The CHF Coordinator sends the registered cards back to the CHF Agent. hier den Topic von vorne zu Membership einfuegen 7.1 Standard rates of premiums The amount of premium for a unit of 6 persons (excluding all children under 5 years) is 5,000TSH per annum in the piloted districts of Tanga Region. This covers all Out Patient Department services (OPD) and In Patient Department services (IPD) at Dispensaries and Health centers and some of the health services offered at the district hospital level as clarified under the benefit package. Each additional wife can join the CHF as an additional family member or as a family (depending on the number of her children to be covered). Unmarried people over 18 years without children may join the CHF scheme as individuals and will pay 50% less of the premiums paid for families. In general each additional family member is free to benefit from this enrolment option.
22 Schools are advised to organize students who do not have National Health Insurance Cards and have not been enrolled by their guardians into the scheme in sub groups of ten people. They will contribute for the premium like families. Consequently they will be registered into the scheme and will be provided with identity cards. Describe also economic groups 7.2 Membership Membership is restricted to a paid premium. This concerns also enrolment of the poor for whom the Council or its partners will fund the membership as issued under the provision of the CHF Act. 7.3 CHF enrolment options Product Characteristics Number of enrollees Rate Premium/year Premium/person FAMILY FAMILY Plus Standard product Plus product Family of 6 persons (of any age) 100% 5,000 TSh 833 TSh plus all children under 5 yrs (inclusion of grand parents is possible) Additional family members 20% 1,000 TSh 1,000 TSh (only if the family is already enrolled) INDIVIDUAL Plus product Individual person 50% 2,500 TSh 2,500 TSh (e.g. singles, dependants of NHIF members not enrolled in NHIF) GROUP Plus product Group of 6 persons 100% 5,000 TSh 833 TSh (e.g. professional groups, companies, cooperatives and associations) STUDENT Plus product 10 primary/secondary students 100% 5,000 TSh 500 TSh
23 8.0 Enrolment of the poor ersetzen durch neue Partnership brochure mit Hinweis auch auf Council Rolle 8.1 Background The Ministry of Health, in developing its cost sharing programme in the health sector some years ago, developed protection mechanisms that would ensure access by the poor and medically needy. To this end, the MOH introduced the system of exemptions and waivers. Exemptions are intended to excuse from payment certain groups of patients (i.e. children under five, women for MCH, elderly) or patients with certain illnesses (i.e. tuberculosis, leprosy, polio, cancer, diabetes) regardless of whether they are poor or not. 8.2 The problem There are significant problems with the actual implementation of the exemption and waiver system put in place by Government. While exemptions are given to the above mentioned groups of patients there is a policy for poor people not falling under these categories to receive special waivers. Waivers are intended to assist the poor by releasing them from payment of user fees because of their inability to pay. Several studies carried out in the country indicate that many poor are not going to receive services if they do not have the respective money for the health care services. The studies also mention that many people do not come to the health facility because they are not aware that they would be eligible for a waiver of the fees. The procedure itself to obtain a waiver is cumbersome and does not meet the needs of giving access to health care in time. 8.3 The solution In order to solve the exemption problem the provisions of the CHF Act foresee coverage of poor families and individuals in the Community Health Fund (CHF). The Act in its part II, 10 (1) prescribes that Councils have to seek for alternative means of compensating the CHF for the poor. This means that Councils should cover funding from their income but also could seek funding from partners. The latter could be development partners, business companies, any other institutions and also individuals. The CHF itself is a protection mechanism that can be used to ensure access for the poor to health care services after the introduction of user fees. It offers a safeguard mechanism designed to protect the poor from the effects of user charges. The CHF Act expresses that health care is a basic right, and its access should be based on need rather than on one s ability to pay. 8.4 The pro-poor ORANGE CHF Card programme The functioning of the ORANGE CHF Card programme is derived from the street light system. One has to imagine that this light system is placed in front of each health facility and regulates access to the health care services by the users. Like the street light the ORANGE programme is located between the red and the green lights. The red light stands for user fees and means no access to health care for the poor as money has
24 to be paid for the services. Those who have no funds are consequently excluded from access to health care. The second light which is orange stands for access to basic health care for the poor as a third party is paying for those who have no means. In this case procurement of the Community Health Fund card is done by the Councils and their partners and by doing so it is the Council and its partners who insures poor families against the negative effects of user fees for the poor. The third light is the green one. This light gives access to full health care. This is given by health insurances such as NHIF who cover access to all medical services for its members. The ORANGE programme with its CHF cards for the poor is consequently located between the two extreme red and green systems meaning between user fees and full health insurance. 8.5 Selection process of the poor Following the CHF Act exemption is done by the community at village level. Consequent approval has to be given by the Ward authorities. The procedures foresee the following steps: The Council Health Service Board (CHSB) sets the exemption mechanism and criteria for the poor in general. The exemption mechanisms are described in the CHF Act of 2001. The criteria itself on who is poor have to be set individually by the Councils. a) According to the CFH Act the Village Council in a first step has to recommend on basis of these exemption criteria individual exemptions to the Ward Health Committee (WHC). Exemptions can be recommended for entire families but also for individual needy persons. b) In a second step the Ward Health Committee then issues individual exemptions. This is done by using an Exemption Issue Form. The WHC forwards the Exemption Issue Form to its respective Council requesting inclusion of the exemption into the pro-poor ORANGE CHF Card programme of the Council. c) In a third step the Council will give authorization for inclusion of the exemption case into the pro-poor ORANGE CHF Card Programme. e) Renewal of granting exemptions process for the poor is done on annual basis. 8.6 Exemption criteria o Income level, those who can not make enough to eat who extremely low income earners o Cannot produce due to disabilities or handicapped persons o Those with continuous illness or chronic diseases o Widows, orphans and elderly people who have no one to depend upon The community will identify the persons who qualify to be exempted. Catastrophic reasons/disasters may be considered for those applying if had such experienced such events (e.g. Floods etc). 8.7 Purchase of Pro-Poor CHF Cards The Council engages in procurement of CHF membership cards for the poor families taken into the list of exempted families and individuals. These cards are procured from the district CHF. Any procurement by third parties such as companies and development partners should be done in coordination with the Council. Payment by third parties can be done directly to the respective CHF
25 account. Procurement of cards from the CHF is taking place on annual basis. The following procedure is undertaken: a) The Council announces a list of exempted families/individuals to be sponsored to the District CHF Management Team namely the CHF Coordinator b) The CHF Coordinator produces an invoice containing the amount of money to be paid for the exempted families and individuals c) In return the CHF Coordinator instructs the respective CHF Agency to proceed for the establishment of a CHF membership card for the concerned poor applying the CHF operations guidelines for establishing CHF membership cards. CHF cards for the poor are the same than in use for all other CHF members in order not to create a two class card system. d) Based on the invoice sent by the CHF the Council respectively transfers funds to the CHF s bank account at district level. In order to fasten financing by third parties respective funding has not to go via the Council account but can be done directly to the CHF Account. 8.8 Financial planning for the pro-poor programme The Council is estimating annually the expected number of poor in its administrative area. Reference is made to national statistics such as the Tanzania poverty index quantifying the number of poor per district. Based on this quantification a financial valuation of the expected needs is undertaken by the Council. Depending on the result the Council has to decide how much funding it can budget and allocate within the respective fiscal year for the Pro-Poor CHF Card programme and how much funding would be needed from third party side. The following formula of need determination is applied: Number of poor families in the Council CHF premium rate per family/ year* Budget needs / year e.g.: 4,000 families 5,000 TSh 20,000,000 TSh The expected need of the Council and its partners for complete funding of the pro-poor ORANGE CHF Card Programme is 20,000,000 TSh per year. ----------------- * The CHFplus system offers also reduced rates for enrollment into the CHF such as for Individuals (2,500 TSh per year) For simple visualization of application of the formula these complementary options are not included in the above calculation example. 8.9 Regular information to sponsors of the pro-poor CHF Card programme Information on funding the pro-poor ORANGE CHF Card programme is given on quarterly basis by the Regional CHF Competence Centre. Funding partners obtain the following documentation:
26 number of poor families in the district, number of poor families covered presently by the ORANGE CHF Card programme, amount of money sponsored by individual partners to the programme. The information will also be available on the website of the Tanzania Network of Community Health Funds (TNCHF) being the autonomous monitoring institution at national level. 8.10 Another plus: matching grants for pro-poor CHF sponsoring The Ministry of Health is paying annually matching grants subsidizing the functioning of the CHF. The amount of this targeted subsidy is 100 % of the CHF premiums collected per year. The matching grant is paid by MOH once a year upon request of the DMO into the district CHF account. The CHF is eligible for payment in case the list of the members enrolled in the respective year is produced and the premiums collected are shown proof of. By buying CHF cards for its poor the Council and its sponsoring partners will automatically contribute to receiving a topping up of 100 % from Government. 8.11 The exemption form Exemption Issue Form (EIF) No. Based on the recommendation of the Village Council of Village (see attached document) the Ward Health Committee of Ward issues hereby the exemption certificate for the following person to be enrolled in the District CHF: Surname: First name: Date of birth: Sex: Adress: Names of dependants also to be exempted: 1. Surname: 5. Surname: First name: First name : 2. Surname: 6. Surname: First name: First name: 3. Surname: 7. Surname: First name: First name 4. Surname: 8. Surname: First name: First name: Criteria for exemption:
27 Date : Place: Name WHC Chairman: Signature: Name WHC Secretary: Signature: Forwarded to the Council for approval: Date: Name/ Signature: Approved for exemption and funding for CHF membership (to be filled in only by DED) The District Executive Director Date: Name: Signature/ stamp:
28 8.12 The Council pro-poor CHF Program ORANGE An initiative by the Councils for access to basic health care by the poor Red no access to health care User fees Orange access to basic health care CHF Green access to full health care Insurance
29 9.0 Benefit package for CHF members The benefit package for CHF members at different levels of the health facilities in the district are clarified below i) Dispensary and health centre level All services of Dispensary and Health Centre level including revisits at a later moment. Free inpatient care for 3 days or as may be required by the clinicians. The referral system within the pyramid of health serving has to be respected. ii) District Hospitals The following benefits will be offered Basic primary health care services Minor Surgery Basic Laboratory tests Free inpatient care for 5 days Life saving interventions including caesarian section Those living around the hospital may access services offered within CHF for dispensary and health center level directly from the respective hospital. All other CHF members will not be served if not referred to by a health centre. 10.0 Members administration a) CHF Membership Cards Design and operations guidelines Card Design: One card for each CHF subscribed Member (i.e. for each beneficiary) front view Community Health Fund Membership Card Photo of Individual Member CHF Coordinator Stamp Council Stamp (District) & Signature & Signature Name:. Card Nr.: Address:.... Date of Birth:.. Sex:.. Serial Number Member s Signature Serial Number back view Issue Expiry Date Day Month Year Date Day Month Year 1 st Payment: 2 nd Payment: Date, Agency Stamp Yr 1: ------------------ & Signature Amount paid Date, Agency ------------------ Amount paid Stamp Yr 2: ------------------ & Signature Amount paid Date, Agency ------------------ Amount paid Stamp Yr 3: ------------------ & Signature Amount paid Date, Agency ------------------ Amount paid Yr 4: ------------------ Amount paid Stamp & Signature ------------------ Amount paid Date, Agency Stamp Yr 5: ------------------ & Signature Amount paid ------------------ Amount paid Date, Agency Stamp & Signature Date, Agency Stamp & Signature Date, Agency Stamp & Signature Date, Agency Stamp & Signature Date, Agency Stamp & Signature II. Production and Distribution Process: The blank card template is printed and stocked by the Regional CHF Competence Center and stocks are supplied to the CHF Coordinators at District level upon request.
30 The CHF Coordinator is responsible to estimate how many cards to order and keep in stock for his District, in order to ensure constant availability of cards (but at the same time also prevent over-stocking) The CHF Agent, at facility level, orders a stock of cards from the CHF Coordinator and is responsible to ensure that upon payment of the first premium the Member: o supplies a photo (with name of member on back and current date) o signs the blank CHF card o is issued a receipt stating his/her CHF number and enrolment date and the CHF Agent him/herself: o keeps a copy of the receipt o enters the CHF ID number (consisting of: health facility code, district code and member serial nr.) onto the now member-signed CHF card o attaches the member s photo onto the card o enters the enrollment date o On the back of the card: fills in date and amount of payment, signs and stamps the card for the year for which the premium has been paid by the member o Puts the card into plastic envelop o Transfers all the membership data onto a CHF member register o Once all the above is completed the card is sent to the CHF Coordinator The CHF Coordinator o Places the District CHF Coordinator stamp and his/her signature onto the designated area on the front of the card o Glues photo on ID card o Inserts metal ring into photo for security purpose o Closes the plastic envelope with the final card inside o Transfers data into his/her register o Sends card back to the CHF Agent b. ID Card handling graph
31 Operations guidelines on establishing new CHF membership cards RCCC Final Card CHF Coordinator: - glues photo CHF Coordinator - places District stamp - signs - puts card into plastic bag - seals plastic bag - transfers data to register - sends card to CHF Agency 1 2 3 supply of receipt books & card processing card emission blanco CHF cards Receipt Final Card CHF Agent: CHF Agent: - enters serial CHF Card No - enters serial number - notes date of enrolment - notes date of enrolment CHF Agency - puts CHF Agency stamp - puts CHF Agency stamp - signs - signs - lets new member sign - lets new member sign - keeps copy of receipt - transfers data to register - gives original to member - sends card to CHF Coord New member c) Membership registration form 1. Personal particulars a) Titular member i) Surname. ii) First name. iii) Date of birth.. iv) Sex.. b) Names of dependants i) Surname ii) First name. iii) Date of birth. iv) Sex i) Surname.
32 ii) First name. iii) Date of birth. iv) Sex i) Surname ii) First name iii) Date of birth. iv) Sex i) Surname. ii) First name. iii) Date of birth. iv) Sex i) Surname. ii) First name.. iii) Date of birth.. iv) Sex 2. Location a) Address.. b) Village.. c) Ward. d) Division. e) District... f) Region 3. Information on enrolment to CHF scheme a) CHF agency.. b) Date of 1 st enrolment c) Expiration dates of card.. d) Card number e) Membership no.. 4. CHF product options (select one product only) a) Family b) Family Plus c) Individual e) Group f) Student 5. Status of membership a) Titular member b) Dependant 6. Premiums for membership a) Full amount of annual premium paid: TSh