1

PROCESS EVALUATION OF NHIF SERVICE PROVISION IN

ACCREDITED HEALTH FACILITIES:

A CASE OF TEMEKE MUNICIPAL HEALTH FACILITIES

2

PROCESS EVALUATION OF NHIF SERVICE PROVISION IN

ACCREDITED HEALTH FACILITIES:

A CASE OF TEMEKE MUNICIPAL HEALTH FACILITIES.

By

Rose Anthony Ntundu

A dissertation Submitted to the School of Public Administration and

Management (SOPAM) of Mzumbe University in the Partial Fulfilment of the

Requirement of the Award of Master Science in Health Monitoring and

Evaluation.

2015

i

CERTIFICATION

We, the undersigned, certify that we have read and hereby recommend for

acceptance by the Mzumbe University, a dissertation entitled “Process Evaluation of

NHIF Service Provision in Accredited Health Facilities: A Case of Temeke

Municipal Health Facilities” in partial Fulfilment of the Requirement of the Award

of Master Science Degree in Health Monitoring and Evaluation.

___________________________

Major Supervisor

___________________________

Internal Examiner

___________________________

External Examiner

Accepted for the Board of……………………

Signature

____________________________________________

DEAN/DIRECTOR, FACULTY/DIRECTORATE/SCHOOL/BOARD

ii

DECLARATION AND COPYRIGHT

I, Rose Anthony Ntundu, declare that this dissertation is my own original work and

that it has not been presented and will not be presented to any other university for a

similar or any other degree award.

Signature ___________________________

Date_______________________________

©

This dissertation is a copyright material protected under the Berne Convention, the

Copyright Act 1999 and other international and national enactments, in that behalf,

on intellectual property. It may not be reproduced by any means in full or in part,

except for short extracts in fair dealings, for research or private study, critical

scholarly review or discourse with an acknowledgement, without the written

permission of Mzumbe University, on behalf of the author.

iii

ACKNOWLEDGEMENT

This work would not have reached this stage, if it were not the effort and

contribution made by several people who gave their time and hard work. I thank all

of them for their assistance. Above all I thank God for keeping me healthy during

and throughout my study time at MU.

Firstly, I wish to express my sincere appreciation to my supervisors Mr. Amani Paul

and Dr Daudi Bunyinyiga for their constructive advice, criticism and corrections

right from the development of the proposal to the final stage of writing this report. I

also wish to extend my heartfelt gratitude and appreciation to the School of Public

Administration, Department of Health System Management for imparting to me the

knowledge and support during the entire period of my study.

Secondly, special thanks are extended to friends and mates for their constructive

ideas and advice towards the success of this work.

Thirdly, I am highly thankful to my employer for the permission to undertake this

study.

Lastly, I am grateful to all the respondents fromTemeke Municipal health facilities

for their cooperation and useful material they gave me during my data collection.

iv

DEDICATION

I dedicate this dissertation to my father Mr Anthony Jacob Ntundu, my husband Mr

Joseph Philip and my lovely daughters Winfrida and Faraja for their calmness,

patience, efforts and encouragement in the course of my studies at Mzumbe

University.

v

ABBREVIATIONS

AAR Africa Airway Rescue

AIDS Acquired Immune Disease Syndrome

CHF Community Health Fund

CHMT Council Health Management Team

CHSB Council Health Service Boards

DMHIS District-wide Mutual Health Insurance Schemes

DMO District Medical Officer

FBO Faith Based Organizations

FFS Fee-For-Service

GDP Gross Domestic Product

HFGC Health Facilities Governing Committees

HIV Human Immune-deficient Virus

HMO Health-Maintenance Organisation

HQ Headquarter

ILO International Labour Organization

MEDEX Medical Express

MOH Mutual Health Organization

MoHSW Ministry of Health and Social Welfare

NBS National Bureau Statistics

NHIF National Health Insurance Fund

vi

NHIS National Health Insurance Scheme

NGO Non-Governmental Organization

NSSF National Social Security Fund

PHC Primary Health Care

PhD Doctor of Philosophy

RHMT Regional Health Management Team

RMO Regional Medical Officer

SHI Social Health Insurance

SHIB Social Health Insurance Benefit

SHIS Social Health Insurance Scheme

SOPAM School of Public Administration and Management

SPSS Statistical Package for Social Science

TIKA Tiba Kwa Kadi

TIRA Tanzania Insurance Regulatory Authority

USD United States Dollar

WHO World Health Organization

vii

ABSTRACT

Background: Social Health Insurance Scheme is a health scheme insurance which

is provided by the governments to its employee. Tanzania introduced social health

insurance by establishment of the National Health Insurance Fund (NHIF) in 1999

with the objective of improving the quality and availability of health services to

Government employees (NHIF,2003). NHIF facilitates access of health care services

to its beneficiaries through a network of accredited health facilities countrywide. This

study evaluated NHIF service provision in accredited health facilities, challenges

encountered and improvement measures.

Methodology: The study was conducted in Dar es salaam, Temeke Municipal.

Facility based multiple case studies of both quantitative and qualitative nature was

carried to evaluate NHIF service provision in selected accredited health facilities. A

total of 80 respondents from 10 selected accreditted health facilities participated in

the study. The study population comprised of both male and female health workers

aged 18 to 60 years with the education level from secondary to university and above,

close to fifty percent (45%) had a working experience of more than ten years. Data

was processed and analyzed by using Microsoft excel and Statistical Package for

Social Sciences (SPSS) software.

Results: Over half of the respondents (51.3%) agreed that NHIF objectives were

achieved and there are several benefits gained by the beneficiaries and community

from accredited health facilities. Besides, a number of challenges were reported to

have been encountered by the accredited health facilities in the process of

implementing the NHIF service provision. For example, 41.3% mentioned low

Government health budget to the facilities as the main challenge and 36.3%

mentioned lack of active monitoring mechanism to ensure appropriate and timely

reimbursement of funds from NHIF. In addition, 20% recommended that

stakeholders‟ involvement in decision making is one of the strategies to improve the

NHIF service provision.

Conclusion: From these findings, the following recommendation can be drawn;

more effort is still needed to address the challenges encountered by accredited health

viii

facilities. These efforts include regural supportive supervisions to the facilities,

training to health workers, timely distribution of working tools and timely claims

reimbursement. However, measures to be taken to improve performance include;

active monitoring mechanism of NHIF funds, reviewed NHIF quarterly reports,

develop NHIF in charges at all facility levels, train NHIF coordinators, facilitate

head of departments and increase health budget. The information contained in this

evaluation is intended to create opportunities for multi-sectoral dialogue, to enhance

collaborative planning efforts, and ultimately to facilitate partnerships that lead to

increased health systems efficiencies and sustained health services.

ix

TABLE OF CONTENTS

CERTIFICATION ..................................................................................................... i

DECLARATION AND COPYRIGHT ................................................................... ii

ACKNOWLEDGEMENT ....................................................................................... iii

DEDICATION .......................................................................................................... iv

ABBREVIATIONS ................................................................................................... v

ABSTRACT ............................................................................................................. vii

LIST OF TABLES .................................................................................................. xii

LIST OF FIGURES ............................................................................................... xiii

CHAPTER ONE ....................................................................................................... 1

INTRODUCTION ..................................................................................................... 1

1.1 Study Overview ..................................................................................................... 1

1.1.1 Social Health Insurance Scheme in Tanzania .................................................... 1

1.2. Description of Program to be evaluated ............................................................... 2

1.2.1. Expected Program effects/objectives ................................................................ 2

1.2.2. Major strategies ................................................................................................. 3

1.2.3. Programme activities ......................................................................................... 3

1.2.4. Logic model ...................................................................................................... 4

1.2.5. Stakeholder analysis .......................................................................................... 4

1.3 Statement of the Problem ...................................................................................... 5

1.4 Objectives of the evaluation .................................................................................. 6

1.4.1 General objective ............................................................................................... 6

1.4.2 Specific objectives ............................................................................................. 6

1.5 Evaluation Questions ............................................................................................ 6

1.6 Significance of the Evaluation .............................................................................. 7

CHAPTER TWO ...................................................................................................... 8

LITERATURE REVIEW ......................................................................................... 8

2.1 Theoretical Literature Review............................................................................... 8

2.1.1 Programme evaluation ....................................................................................... 8

2.1.2 Health Insurance System in Tanzania ................................................................ 9

x

2.1.3 Types of Health Insurance ................................................................................. 9

2.1.4. National Health Insurance Fund...................................................................... 10

2.2 Empirical Literature Review ............................................................................... 10

2.3. Theoretical framework of the evaluation ........................................................... 12

CHAPTER THREE ................................................................................................ 14

EVALUATION METHODOLOGY ..................................................................... 14

3.1 Evaluation Approach ........................................................................................... 14

3.2 Evaluation Design ............................................................................................... 14

3.3 Evaluation Period ................................................................................................ 14

3.4. Description of the Study Area ............................................................................ 14

3.5. Study Population ................................................................................................ 15

3.6. Units of analysis ................................................................................................. 15

3.7. Variables and their measurements ..................................................................... 15

3.8. Sample size and sampling technique.................................................................. 16

3.9. Types and sources of data .................................................................................. 17

3.10. Data collection methods ................................................................................... 17

3.11. Validity issues .................................................................................................. 17

3.12. Data management and analysis methods.......................................................... 17

3.13 Ethical issues. .................................................................................................... 18

CHAPTER FOUR ................................................................................................... 19

PRESENTATION AND DISCUSSION OF EVALUATION FINDINGS ......... 19

4.1 Introduction ......................................................................................................... 19

4.2 Sample and its characteristics ............................................................................. 19

4.3 NHIF performance in compliance with accredited health facilities .................... 20

4.3.1 Responses on NHIF objectives achievement ................................................... 20

4.3.2 Responses on overall achievement of NHIF objectives. .................................. 21

4.3.3 Reasons for NHIF to initiate accredited health facilities ................................ 22

4.3.4 Benefits gained by the community from NHIF accredited health facilities .... 23

4.3.5 Attitude on NHIF services in accredited health facilities ................................ 24

4.4 To determine challenges faced by NHIF through accredited health facilities .... 25

xi

4.4.1 General challenges encountered in health facilities ......................................... 25

4.4.2 Factors hindering effective adherence to NHIF standards ............................... 27

4.5 Possible improvement measures on NHIF health service provision ................... 28

4.5.1 Strategies to improve NHIF service provision ................................................. 28

4.5.2 Ways to improve NHIF performance through accredited health facilities ...... 29

4.5.3 Perception on improvement measures on NHIF health service provision ....... 30

CHAPTER FIVE ..................................................................................................... 31

SUMMARY, CONCLUSION AND POLICY IMPLICATION ......................... 32

5.1 Summary ............................................................................................................. 32

5.2 Conclusion .......................................................................................................... 32

5.3 Policy implication ............................................................................................... 33

5.4 Areas for further evaluation ................................................................................ 33

REFERENCE .......................................................................................................... 33

APPENDICES ......................................................................................................... 37

xii

LIST OF TABLES

Table 1.1: Stakeholders Matrix ................................................................................... 5

Table 3.1: Variables and its measurements ............................................................... 16

Table 4.1: Demographic characteristics of the respondents...................................... 20

Table 4.2: Responses on NHIF objectives achievement ........................................... 21

Table 4.3: Responses on NHIF objectives achievement ........................................... 21

Table 4.4 Reasons for NHIF to initiate accredited health facilities .......................... 22

Table 4.5 Benefits community gain from accredited facilities ................................. 24

Table 4.6: Attitude on NHIF services in accredited health facilities ........................ 25

Table 4.7 Challenges encountered in accredited health facilities ............................. 26

Table 4.8 Factors hindering adherence of NHIF standards....................................... 28

Table 4.9 Strategies to improve NHIF service provision .......................................... 29

Table 4.10: Ways to improve NHIF performance .................................................... 30

Table 4.11: Perception on improvement measures on NHIF .................................... 31

xiii

LIST OF FIGURES

Figure 1.1 : Logic model of NHIF program at facility level ....................................... 4

Figure 2.1: Theoretical framework of the evaluation................................................ 13

Figure 4.1: Reasons for NHIF to initiate accredited health facilities ........................ 23

Figure 4.2: Benefits gained by the community from accredited health facility ........ 24

Figure 4.3 Challenges encountered in accredited health facilities ............................ 27

Figure 4.4 Factors hindering NHIF service provision .............................................. 28

Figure 4.5: Strategies to improve NHIF service provision ....................................... 29

1

CHAPTER ONE

INTRODUCTION

1.1 Study Overview

Social Health Insurance Scheme is a health insurance which is provided by

governments to its employees (Churchill, 2006). This type of insurance maintains a

risk pooling fund account into which contributions and other incomes are deposited.

Out of this account; the scheme makes reimbursement of medical costs to accredited

health facilities in respect of medical services provided to beneficiaries (Carrin and

James, 2002). The main objectives of Social Health Insurance are: “To provide

health care that avoids large out of pocket expenditure, to increase appropriate

utilization of health services and to improve health status” (ILO, 2008). .

The first Social Health Insurance Scheme was established by the Government of

Germany between 1883 and 1889 (Wagstaff, 2009). The beneficiaries of the scheme

access health services through accredited public and private facilities whereby the

accredited health facilities are being reimbursed by the insurance scheme (Wagstaff,

2009). The scheme set the standards which all accredited health facilities must

adhere to in order for their claims to be reimbursed, failure to do so, it resulted into

rejections of the claims (Churchill, 2006). The insurance scheme of Germany was

very successful, therefore it was a good example to other countries; by 1930s Social

Health Insurance had spread to Latin America, the United States and Canada

(Wagstaff, 2009). After the end of the second World War, Social Health Insurance

was introduced in many countries in Africa, Asia and the Caribbean area (Wagstaff,

2009). Currently a number of African countries are implementing Social Health

Insurance Scheme with different approaches, including Nigeria, Rwanda, Kenya,

Ghana and Tanzania (Wagstaff, 2009).

1.1.1 Social Health Insurance Scheme in Tanzania

The National Health Insurance Fund (NHIF) is the largest social health insurance

scheme in Tanzania; it was established by the Parliament Act number 8 of 1999

2

(NHIF, 2013). This was the outcome of 1990 -1992 study on long term options for

financing health services in Tanzania (MOH, 1994). The scheme started its

operations on 1st July 2001 by members and their respective employers starting to

contribute and beneficiaries started to access medical services from 1st October 2001

(NHIF, 2013). The scheme maintains a risk pooling fund account into which such

contributions and other incomes are deposited, out of this account, the scheme makes

reimbursement for medical costs to accredited health facilities in respect of medical

services provided to beneficiaries (NHIF, 2013).

1.1.2. NHIF Accredited Health Facilities

NHIF does not provide health care services to the beneficiaries directly in the sense

of ownership of health facilities; relatively, it facilitates access of health services

through a network of accredited health facilities (NHIF, 2013). Currently there are

5,840 accredited health facilities throughout the country; accredited Health Facilities

are classified as Government, Faith Based Organizations, NGO and Private health

facilities (NHIF, 2013). Accredited health facilities are required to provide quality

services to NHIF beneficiaries because the success of NHIF depends much on how

health care providers receive and treats NHIF beneficiaries (NHIF, 2013). Therefore,

an adherence to NHIF standards is very important to ensure that the facility gets high

reimbursement rate which will lead to improvement of services to NHIF

beneficiaries. In order for the accredited health provider to be reimbursed for the

services they provided to NHIF beneficiaries, they must adhere to NHIF guidelines

and standards, failure to which may result into adjustments or rejection of the amount

claimed.

1.2. Description of Program to be evaluated

1.2.1. Expected Program effects/objectives

NHIF has the following objectives:

(i) To avail necessary guidelines as per NHIF standards to every accredited

health facility, by the end of 2014.

3

(ii) Increase accessibility and quality of services to beneficiaries and providers

by 2015

(iii) Increase accreditation of health facilities from current average of 80% to

95% by 2015

(iv) To increase reimbursement rate from 60% to 90% in each health facilities

from year 2010 to 2015.

(v) To train 10,000 health professionals (clinicians) on NHIF matters at the end

of 2014.

(vi) To conduct supervision at accredited health facilities at least 2 times in

hospitals and at least once in health centre and dispensaries per year from

the year 2010 to 2014.

1.2.2. Major strategies

(i) Early reimbursement to the accredited health facilities

(ii) Training health workers in accredited health facilities in adherence to NHIF

standards

(iii) Feedback to the accredited health facilities by providing payment advice

letter that allows an assessment of performance for the health facilities

(iv) Distribution of guidelines, benefit package, price list, and disease code to

every accredited health facility.

(v) Ensure quality of services to members as per NHIF benefits package.

1.2.3. Programme activities

NHIF major activities of NHIF are:

(i) To register members and employers and issue identity cards to beneficiaries;

(ii) To accredit and inspect health service providers and avail a broader network

of health facilities for improving access to health services in the country

(iii) To undertake quality assurance processes of the claims from accredited

facilities;

(iv) To collect monthly contributions from employers;

4

(v) To provide health insurance education to the public with the aim of

marketing it and enhance public relations.

1.2.4. Logic model

A logic model is a visual conceptualization of how the elements of a program are

connected together (Mtei, 2012). It lays out which inputs are necessary for the

program activities (process), expected outputs as well as short and long term

outcomes of the successful program implementation.

Figure 1.1 : Logic model of NHIF program at facility level

Input OutputActivities ImpactOutcome

Human

Resources

Trained health

workers

in NHIF quality

Assurance standards

Timely requisition of

guidelines and

other working tools

from NHIF office

Compliance to

NHIF guidelines

Claiming based on

NHIF guidelines

and manualsImprove quality

of services to NHIF

beneficiaries

Number of

claim forms

filled in line

with NHIF

standards

Number of

guidelines

and other tool

distributed as

requested

Improved clinicians

and health workers

adherence to NHIF

guidelines

Infrastructure

NHIF Manuals

and guidelines

NHIF Claim

2A&B form

Reduction out of

stock of medicine

and medical

consumables

Number of

health worker

trained working at

NHIF unit

Increased purchase

of medicine and

Medical consumables

Increased

reimbursements

rate

Reduced

adjustment

and rejections

of claims

Source: Researcher‟s Own Construct, 2015

1.2.5. Stakeholder analysis

Stakeholders are individuals, groups, or organizations having significant interest in

how well a program functions, they are decision making authority, funders,

personnel, health providers, clients or intended beneficiaries (Mtei, 2012).

Stakeholders involved in this evaluation are The Ministry of Health and Social

5

welfare, NHIF management, accredited health facilities, NHIF coordinators, and

NHIF beneficiaries. Their involvement is as described in table 1.1

Table 1.1: Stakeholders Matrix

Stakeholder Category Role in the Program Perspective on Evaluation

Findings

Ministry of

health and

social welfare

Involved on

program operation

Policies and guidelines

formulation

Identify area of improvement

NHIF Involved on

program operation

Coordinating and

organizing resources

Conduct training to

Health Workers

Information on Strength and

weakened of program

Program operation

Identify area of improvement

Accredited

Facilities (Staff)

Service provision Provision of services to

NHIF Beneficiaries as per

policy and guidelines

Information on Strengths and

weaknesses

NHIF

coordinators

Involved on

program operation

Collect resource and

distribute to health

facility

Supervise Health facilities

Information on Strength and

weakened of program

Identify area of improvement

Get base line data for future

comparison

NHIF

Beneficiaries

Served by the

program

These are beneficiaries of

the Scheme

Service utilization

Accessibility of health services

Source: Researcher‟s Own Construct, 2015

1.3 Statement of the Problem

Social health insurance scheme is a new industry in Tanzania and in most of

developing countries. Since its beginning, NHIF has been facing multiple challenges

such as resistance from members and shortage of medicine and medical consumables

at accredited health facilities. According to NHIF statistics, it shows that there has

been increased number of trainings to the health workers in accredited health

facilities thereby expecting health services to be improving (NHIF, 2013). Not only

training but also increased number of accredited health facilities thereby expecting

services offered to its beneficiaries to be improving in context of accessibility of

health care. Currently there are 5,840 accredited facilities countrywide, this

comprises the Government, FBO, NGO and Private Facilities (NHIF, 2013). The

main purpose of NHIF is to make sure that beneficiaries access better health services

which are up to date and timely (Austin, 2010).

6

However, despite all initiatives made by NHIF, beneficiaries are still complaining of

multiple problems in accredited facilities such as lack of medicine, lack of

laboratory services, inadequate accredited facilities and negative attitude of health

workers towards them at accredited facilities (NHIF, 2013).

Continuing with this current situation of multiple complains from beneficiaries in

turn inhibits the achievement of the goals of NHIF. Therefore need arises to evaluate

why despite NHIF efforts to achieve its goals towards accredited health facilities but

still there are persistent gaps. Furthermore, several studies on social health insurance

in Tanzania have been conducted in the focus of NHIF beneficiaries, therefore there

is a need to focus on health providers.

1.4 Objectives of the evaluation

1.4.1 General objective

The general objective of this study was to evaluate NHIF service provision in

accredited health facilities.

1.4.2 Specific objectives

(i) To assess service provision in NHIF accredited health facilities

(ii) To determine challenges faced by NHIF through accredited health facilities

(iii) To evaluate possible improvement measures on NHIF health service

provision

1.5 Evaluation Questions

(i) How are NHIF service provisions performed under accredited health

facilities?

(ii) What are the challenges faced by NHIF through accredited health facilities?

(iii) What are the possible improvement measures on NHIF health service

provision?

7

1.6 The Significance of the Evaluation

The justification of this process evaluation of NHIF service provision in accredited

health facilities is that, the main aim of NHIF is to increase access and quality of

service to its beneficiaries. If the reimbursement is low due to non-compliance to

NHIF standards therefore this goal will never be achieved. Therefore, findings from

this study are expected to reveal the achievement of NHIF, attitudes of health

workers towards NHIF, the challenges and measures to improve service provision in

accredited facilities. However, the findings of the evaluation may provide valuable

information to NHIF management and Ministry of Health and Social Welfare in

support of their decision making for the improving service provision in the health

facilities. Moreover, the successful completion of this study may lead to the award of

Master of Science in Health Monitoring and Evaluation of Mzumbe University.

8

CHAPTER TWO

LITERATURE REVIEW

2.1 Theoretical Literature Review

2.1.1 Program evaluation

According to Kolstad and Lindkvist (2013), evaluation is the periodic, in-depth

analysis of the programme performance by using indicators of the work plan. The

main purpose of evaluation is to assess overall achievements and performance,

therefore it helps an organization, program, project or any other intervention to

assess the progress and make decisions (Mtei, 2012).Evaluations usually focuses on

effectiveness, significance and impact, therefore it can be undertaken by programme

managers, supervisors, funders, external evaluators and beneficiaries (Mtei, 2012).

According to Bultman et al, (2012) there are three main designs of evaluation:

i. Goal based evaluation; Is the evaluation which takes place to determine the

actual outcome of a programme when compared to the goals/objectives of the

original plan (Bultman et al, 2012). Objectives are usually determined by the

people responsible for the funding or implementation of the programme

(Mtei, 2012).Therefore, this design of evaluation assists the organization to

further develop a successful process and either take out or reconfigure

unsuccessful goals.

ii. Process based evaluation; Is the evaluation which takes place while the

programme or project activities are in progress (Bultman et al, 2012).These

activities are assessed to date against the planned input and output, often

emphasizes on checking the progress of activity and applied to examine

reasons for the discrepancy of outputs of plans and suggest corrective

measures (Bultman et al, 2012). Therefore, this design of evaluation

examines operations of the programme and identifies strength, weakness and

areas that need improvement.

iii. Outcome based evaluation; Is the evaluation which takes place to assess

what occurred in the programme and whether the programme objectives has

9

been achieved (Bultman et al, 2012). It is used to assess the outcome of the

stated short-term, intermediate and long term programme objectives(Bultman

et al, 2012).Therefore, this design should be conducted when the programme

is matured enough to produce the intended outcome.

2.1.2 Health Insurance System in Tanzania

The Social Health Insurance in Tanzania is still at an infantry stage as compared to

other countries (NHIF, 2013). Up to 1990s the provision of health services was free

to all citizens and was financed by the government (NHIF, 2013). However, the

National Insurance Corporation (NIC) was providing voluntary Health Insurance

cover, very few people mainly businessmen and few others with fair income

managed to buy such premiums (NHIF, 2013). In the light of these factors, the

government made a health sector reform which initiated insurance schemes in the

country (NHIF, 2013). In 1997 the National Insurance Company established a health

insurance scheme known as Medicare for its members (Risha, 2002). In 1998 Igunga

Community Health Fund (ICHF) was established by the government in Tabora

(Risha, 2002). In 1999 NHIF was established by the government for formal sector

employees and CHF was established by parliamentary law no 8 in 2001 for informal

sector (NHIF, 2013).

2.1.3 Types of Health Insurance

There are three major types of health insurance which include: Social Health

Insurance; Private Health Insurance and Community Based Health Insurance (NHIF,

2013). Social Health Insurance is set by the government with clear benefits in return

for payment (NHIF, 2013). The main feature of this type of social insurance is that, it

is compulsory and mostly limited to those with salary stable wage earning

employment, normally referred in Tanzania as National Health Insurance (Ibrahim,

2001). Private health insurance normally covers groups or individuals through a

third party payer institution operating in the private sector (Ibrahim, 2001).

Community Based Health Insurance is normally voluntary and does not cover the

full cost of health care, contributions are collected when cash incomes are highest

10

and this helps to guarantee that the contributors have ongoing access to health care

(Ibrahim, 2001).

2.1.4. National Health Insurance Fund

The National Health Insurance Fund is a social health insurance scheme in Tanzania;

it was established by the Act number 8 of 1999 of Parliament (NHIF, 2013). This

was the outcome of 1990 -1992 study on long term options for financing health

services in Tanzania. The scheme started its operations on 1st July 2001 by members

and their respective employers starting to contribute and beneficiaries started to

access medical services from 1st October 2001 (NHIF, 2013). The scheme maintains

a risk pooling fund account into which such contributions and other incomes are

deposited, Out of this account, the scheme makes reimbursement for medical costs to

accredited health facilities in respect of medical services provided to beneficiaries

(NHIF, 2013).

2.2 Empirical Literature Review

Ghana National Health Insurance Scheme (NHIS) was established under the National

Health Insurance Act of 2003 and is based on District-wide Mutual Health Insurance

Schemes (DMHIS) which operate in all districts in the country (Slavea et al, 2009).

At the end of 2008, 61% of the population of Ghana was covered by the NHIS

(Slaves et al 2009). In 2009 an evaluation was conducted to evaluate the effects of

NHIS to service provider and beneficiaries of the scheme, data was collected using

closed and open ended questionnaires. The evaluation findings was that; there was

delays in insurance cards to beneficiaries, lack of motivation of DMHIS staff, lack

of understanding of the need for health insurance by community members and delays

in the reimbursement accredited health facilities (Slaves et al 2009). The authors

argued that delays in reimbursement soured relationship among service providers in

the district, who in some cases threatened to stop accepting insurance patients. The

study concluded that NHIS faced challenges which require Ghana Government to

use the findings of the study to improve the performance of NHIS by making

necessary reforms. However authors didn‟t point out the factors which contributed to

11

mentioned challenges especially the delays in the reimbursement process, therefore

this evaluation will look in the same scenario as Ghana but specifically on service

provision in accredited health facilities

In 2008 Mohammed et al, conducted an evaluation of NHIS in Zaria-Nigeria to

determine the enrolee‟s satisfaction with health service provision under a health

insurance scheme and the factors which influence the satisfaction. Mohammed et al

(2008) showed that Length of employment, salary income, hospital visits and

duration of enrolment slightly influenced satisfaction. Similarly, in 2012 Onyedibe et

al conducted a study to evaluate the level of enrolment of member to NHIS, the

results showed that the enrolment was very poor; authors pointed out that, the poor

enrolment was mainly contributed by dissatisfaction of health services offered to

NHIS beneficiaries. The authors concluded that the quality of the services was the

most important factor which influenced the enrolment of members to any insurance

scheme; therefore the Nigerian Government should use the evaluation findings to

improve the services in order to increase the enrolment. However, authors didn‟t

point out anything concerning the performance of the scheme in compliance with the

accredited health facilities, therefore this evaluation will evaluate the insurance

scheme in Tanzania but specifically on accredited health facilities.

According to Obonyo 1996, the Kenya National Health Insurance Fund (NHIF) has

been successful in implementing the scheme since 1966 to date, whereby the

coverage is 25% for the whole nation‟s population. The reason for their success is

that they have set a fee for services which is reasonable; hence health providers are

able to provide high quality health services (Obonyo, 1996.) Beneficiaries are

satisfied with the services and are fully utilizing them and have attracted even those

who are not compulsorily liable to join the scheme, such as self-employed people

and part-time workers who have joined the scheme as voluntary members (Obonyo,

1996). The second reason for Kenya‟s NHIF success is that it has the fund‟s

inspectorate unit, which inspects health providers regularly; they inspect their quality

of services and grade the providers according to score, they inspect drugs and

medical equipment availability and grade the facilities based on compliance with the

guidelines and standards. Thus, the author (Obonyo, 1996) presented utilization of

12

health insurance in Kenya and the factors that influence the utilization and how the

insurance inspects and grades the health providers. The author concluded that

inspection to the health providers is the key for improving the quality of NHIF

services. This evaluation will look on the same scenario but specifically for NHIF

accredited health facilities in the context of Tanzania.

In 2012 Musau et al conducted an evaluation on the health system of Tanzania,

specifically the National Health Insurance Fund. Data was collected using closed and

open ended questionnaires to NHIF beneficiaries and health workers in the

accredited health facilities. Authors pointed out that despite the significant effort in

developing insurance options; only13% of the population in Tanzania is currently

covered by health insurances (7.3%covered by NHIF). The study findings showed

that there was low member enrolment which was contributed by the health facilities

staff attitudes in treating NHIF patients, weakenesses of the public facilities

financially thus affects the services in terms of quality and availability. The authors

concluded that difficult reimbursement procedures done by NHIF is one of the factor

which led to poor services on accredited health facilities, therefore the Government

under MOHSW needs to review them in order to improve the performance of the

facilities. Therefore, this evaluation will specifically evaluate on service provision in

accredited health facilities.

2.3. Theoretical framework of the evaluation

The conceptual framework for this study assumes that NHIF health provision in

accredited health facilities (as a dependent variable) is determined by the following

(independent variables): knowledge of health workers, attitude of health workers

and compliance. Figure 2 shows conceptual framework for the roles played by health

workers in improving the service provision

13

Figure 2.1: Theoretical framework of the evaluation

Source: Researcher‟s Own Construct, 2015

Attitude of Health

workers on NHIF.

Knowledge of Health

workers on NHIF

services.

Compliance with NHIF

standards .

Improve NHIF

services provision

14

CHAPTER THREE

EVALUATION METHODOLOGY

3.1 Evaluation Approach

According to Patton (2012), formative evaluation is carried out in order to

understand what is going on with the implementation of the program, to find ways

and make recommendations on improving the program outcome. A formative

evaluation was conducted to assess the ongoing NHIF activities in order to provide

information that could be used for improvement.

3.2 Evaluation Design

An evaluation design is the arrangement of conditions for collection and analysis of

data in a manner that aims to combine relevance to the research purpose with

economy procedure (Kothari, 2010). There are several types of research designs such

as case study, survey and experimental. For the purpose of this study, facility based

multiple case studies of both quantitative and qualitative nature was carried out to

evaluate NHIF service provision in accredited health facilities.

3.3 Evaluation Period

The evaluation was conducted in four months. The work started on 1st February

2015 and it was completed on 31st May, 2015.

3.4. Description of the Study Area

Temeke Municipal

The process evaluation was conducted in Temeke Municipality, located in the south

of Dar es Salaam region, Tanzania. The municipality has estimated total population

of 1,368,881 whereby 669,056 are males and 699,825 are females with an estimated

area of 786.5 km2 and growth rate of 6.6% per year of (NBS, 2012). Temeke district,

is the largest of the three Dar es Salaam districts, to the north, it is bordered by Ilala

district: to the east by the Indian Ocean and to the South and West by the Coast

15

Region. It has an average temperature of 35OC and 1000mm of rainfall per year. The

district is administratively divided into three divisions with 24 wards. The

Municipality has an estimation of 4680 NHIF beneficiaries, there are 34 accredited

NHIF health facilities in the Municipality whereby 28 are public health facilities

(82.4%) while 6 facilities (17.6%) are private ones (NHIF, 2013).

3.5. Study Population

The population for this evaluation involved facility in-charges, doctors, nurses and

pharmacists working with NHIF accredited health facilities in the district. Facility in-

charges were intrviewed because of their roles as planners, decision makers and at

the same times are the most informed about health insurance operations. Also the

evaluator interviewed doctors, nurses and pharmacists since they are the ones who

attend NHIF beneficiaries.

3.6. Units of analysis

For the purpose of this assessment , the unit of analysis involved 80 respondents

from ten selected health facilities in Temeke Municial .

3.7. Variables and their measurements

In this evaluation study, a number of variables were involved as indicated in Table

3.1

16

Table 3.1: Variables and their measurements

Variable Measurements Source of Data

NHIF

performance What are the specific objectives of NHIF?

Have NHIF objectives been achieved?

What were the reasons for NHIF to initiate

accredited health facilities?

Interview with

health workers

Challenges What are the general problems have you been

encountering in your daily operations?

What do you think hinders effective adherence of

NHIF standards in your facility?

Interview with

health workers

Improvement

measures What are the strategies to improve NHIF service

provision?

Do you think the mentioned challenges on NHIF

performance can be eliminated?

What do you think should be done to improve the

NHIF performance through accredited health

facilities?

Interview with

health workers

Source: Researcher‟s Own Construct, 2015

3.8. Sample size and sampling technique

Sampling is the act, process or technique of selecting suitable samples or a

representative part of a population for the purpose of determining parameter or

characteristics of the whole population ( Kothari, 2010). An optimal sample is the

one which fullfills the requirements of representativeness, reliability and flexibility.

The sample size depends on the population parameter of interest in a study, costs

and budgetary constraints. According to Kothari (2010), the rule of 10% of the

entire population can be used to calculate a sample size.The estimated sample size

for this study was 100 respondents which was equal to 10% of the expected

population, the expected population was the health workers of Temeke Municipal

Council. This sample has been reached on the ground that the evaluator is a student

who cannot afford a larger sample due to lack of financial resources. It was

determined by using purposive sampling methods whereby it comprised 80

respondents from ten Temeke Municipality health facilities and 20 management level

staff 2 from each centre. Each of chosen centre was randomly selected by a simple

random technique, from each centre respondents were randomly selected with

consideration that half of the interviewees were clinicians and the remaining half

included nurses, pharmacists and laboratory technicians.

17

3.9. Types and sources of data

Data are information, both qualitative and quantitative in nature, data for research

can be obtained through various sources. In this study the evaluator used both

primary and secondary sources. Primary data are those ones collected by the

researcher herself from the field, they are firsthand information and secondary data

are those which have been collected by other people or institutions but relevant to

your research. In this study, primary data were collected by administering

questionnaires to respondents. This method was used in order to gather the necessary

data and also to provide profound insight into the topic. The secondary data was

collected from different websites, reports, books, journals, and newspapers.

3.10. Data collection methods

Structured questionnaire with open and closed questions was used as data collection

tool in this study. The questinnaires was administered to individual respondents

through face to face interview. Data correctness was ensured by doing a data editing

and validation.

3.11. Validity issues

Validity refers to the quality that a procedure or an instrument used in the research is

accurate, true, meaningful and right (David, 2002). A measurement is valid when it

measures what is supposed be measure. The validity of data generated for this study

was ensured through comprehensive scrutiny of NHIF data by the evaluator.

Analysing the data descriptive statistical methods like tabulation, percentages and

frequencies were used.

3.12. Data management and analysis methods

The data has been analyzed by using both quantitative and qualitative methods with

assistance of SPSS software and microsofit word excel. After the completion of

questionnaires, data were coded, examined, compared and categorized based on the

18

evaluation questions. Throughout the analyzing process, comparison has been done

to find differences, similarities and meaning.

3.13 Ethical issues

Permission to conduct evaluation was obtained from the Director General of NHIF

and Temeke District Medical Officer (DMO). Each respondent was fully and clearly

informed about the aim of the evaluation and the confidentiality of the information.

Data security was ensured first and foremost by the principle for confidentiality. Data

collection instruments for the purpose of this evaluation were not constitute

personnel identifiers such as respondent‟s name.

19

CHAPTER FOUR

PRESENTATION AND DISCUSSION OF EVALUATION FINDINGS

4.1 Introduction

This chapter discusses the finding from the evaluation objectives. These were

understanding of the NHIF services provision in accredited health facilities,

determining challenges faced by NHIF through accredited health facilities, and

evaluation of possible improvement measures on NHIF health service provision.

Furthermore, the chapter puts into consideration the demographic information of the

respondents like their characteristics on sex,age and work experience.

4.2 Sample and its characteristics

The study comprises of a sample of 80 respondents of whom 71.2% were male and

28.8% were female. Intentionally the evaluator cosidered sex categories in this study

in order to assess views from both sexes. In addition the aim was to get

representative from both males to females. Through out the study, it can be said that

it was easier to come into contact with male respondents than it was for the females.

Findings shows that 67% of the selected respondents had diploma education, 23%

had first degree and above. From these findings, it can be concluded that,

respondents interviewed had good education capable to assess services provided by

accredited health facilities. With regard to the working experience of the

respondents, data reveal that fourty five percent (45%) of the selected respondents

had an experience in working with NHIF and its accredited facilities for more than

ten years. The remaining fifty five percent (55%) had an experience of 1-5 years in

service. It can be concluded that the combination of the respondents‟ education and

working experience was vital for this study, this produced respondents with justfiable

experience in NHIF.

20

Table 4.1: Demographic characteristics of the respondents

Sn Variable Frequency Percentage

1 Sex of respondents

Male

Female

57

23

71.2%

28.8%

2 Education level Secondary

Certificate

Diploma

Degree and above

2

5

54

19

2.5%

6.3%

67.5%

23.8%

3 Working experience

Less than 1 year

1 to 5 years

6 to 10 years

More than 10 years

4

33

7

36

5.0%

41.3%

8.7%

45.0%

4 Age distribution

18-25 years

26-35 years

36-45years

46-55 years

56-60 years

11

24

16

15

14

13.8%

30.0%

20.0%

18.8%

17.5%

Source: Field data, 2015

4.3 NHIF service provision in accredited health facilities

4.3.1 Responses on NHIF objectives achievement

Before proceeding with other questions set for this evaluation, the evaluator started

interrogated the respondents on if at all the objectives of NHIF in the accredited

facilities were achieved. Answers from respondents were either agreeing or

disagreeing. As illustrated in table 4.2, it was noted that more than half of the

respondents (62%) agreed that there is an availability of guidelines required by

NHIF. On increase of the accessibility of services to beneficiaries 59% of the

respondents agreed. Also, the majority of the respondents (78%) strongly agreed that

there is an increase of accredited health facilities. Contrary to those reported

achievements majority of the respondents (90%) strongly disagree that there was an

increase in reimbursement rate from NHIF. Finally the majority of them (69%)

strongly disagree to have attend NHIF trainings whereby 82% strongly diagreed that

NHIF staff conducted supervision at least once a year. The NHIF performance in

health facilities depends much on the achievement of its objectives. These findings

give an implication that the objectives achieved are only distribution of guidelines

and increased number of accredited health facilities. Therefore, more effort is still

needed especially on training of health workers, supportive supervision to the

21

facilities and increase of reimbursement rates in order for NHIF to achieve its

objectives as well as to improve service provision.

Table 4.2: Responses on NHIF objectives achievement

Statement Strongly

agree

Agree Uncertain Disagree Strongly

disagree

Availability of guidelines as per NHIF

standards in the facility

13.0% 62.0% 6.0% 13.0% 6.0%

There is increase of accessibility and

quality services to beneficiaries

10.0% 59.0% 15.0% 14.0% 2.0%

There is increase of accredited health

facilities

78.0% 20.0% 0.0% 1.0% 1.0%

There is increase of reimbursement in

facility from NHIF

0.0% 0.0% 5.0% 5.0% 90.0%

Attended training on NHIF matters 2.0% 18.0% 0.0% 11.0% 69.0%

Supervision conducted by NHIF at

least once per year

1.0% 0.0% 4.0% 13.0% 82.0%

Source: Field data, 2015

4.3.2 Responses on overall achievement of NHIF objectives

To check the overall achievement of NHIF, respondents were asked to agree or

disagree if at all the objectives of NHIF initiating accredited health facilities were

achieved. Table 4.3 shows that there are some achievements of NHIF objectives.

This is because only 51.3% of the respondents agreed that the objectives were

achieved. These results imply that respondents are aware of NHIF performances in

their health facilities.

Table 4.3: Responses on NHIF objectives achievement

Response Frequency Percent

Yes 41 51.3

No 8 10.0

Don‟t know 31 38.8

Total 80 100.0

Source: Field data, 2015

22

4.3.3 Reasons for NHIF to initiate accredited health facilities

In order to comply with NHIF in provision of services, health workers should be

aware of the reasons for NHIF to accredit health facilities. A question contained a list

of items that required each respondent to choose one. Table 4.3, shows that 32.5% of

the respondents said that it was primarily initiated to improve health services, while

others mentioned to speed up service provision (22.5%), These findings suggest that

health providers are aware of reasons of NHIF iniatiating accredited facilities. This

implies that NHIF has positively influenced health seeking behaviour and utilization

of healthcare services. Prepaid scheme has a potentiality of reducing out of pocket

payment for health services. Other respondents (21.3%) reported the reason was to

enable many people to get health services. In this report therefore NHIF should be

sustained to increase the affordability and access to heath services.This will improve

the performance and at the sametime promote universal coverage for the people of

Tanzania.

Table 4.4: Reasons for NHIF to initiate accredited health facilities

Reason Frequency Percent

To speed up service provision 18 22.5

To improve health service 26 32.5

To enable many people attend the service 17 21.3

To cover large areas 13 16.3

Not sure 6 7.5

Total 80 100.0

Source: Field data, 2015

23

Figure 4.1: Reasons for NHIF to initiate accredited health facilities

Source: Field data, 2015

4.3.4 Benefits Gained by the Community.

Study findings has proved that accreditted health facilities are very important to

NHIF beneficiaries as well as to the community. During the study respondents were

asked to choose one benefit from the list, see figure 4.2, 38.8% of the respondents

stated that Primary Health Care (PHC) were more beneficial to communities. PHC

refers to essential health care that is based on scientifically sound and socially

acceptable methods and technology, which make universal health care, universally

accessible to individuals and families in a community (WHO, 2004). Therefore

NHIF needs to take a critical look in expanding primary health care geographically.

This will help to achieve universal health coverage. Also other 27.6% of respondents

mentioned large coverage was another benefit which the community gained from

these facilities. This implies that the beneficiaries have choice where to go for

services .i.e. Government, FBO or private for profit health facilities. The findings

generaly disclose that NHIF, has a significant influence on the use of health services

whereby beneficiaries are free to choose where to go for services, this is because

services are driven by quality consideration rather than cost and distance.

24

Table 4.5: Benefits community gain from accredited facilities

Benefit Frequency Percent

Primary Health Care 31 38.8

Access to medicines 9 11.3

Advice 7 8.8

Readily available health services 8 10.0

Large coverage 22 27.6

No benefits 3 3.8

Total 80 100.0

Source: Field data, 2015

Figure 4.2: Benefits gained by the community from accredited health facility

38.8

11.3

8.8

10

27.6

3.8

0 10 20 30 40 50 60 70 80 90 100

Primary care

Access to medicines

Advice

Readily available health services

Large coverage

No benefits

Percentages

Ben

efi

ts

Percent

Source: Field data, 2015

4.3.5 Attitude on NHIF services in Accredited Health Facilities

Attitudes is a mental position, which influence a person in regard to his/her feeling

or emotion toward the fact. Knowing health workers attitude toward NHIF, was of

great important in this assessment because workers attitude may affect the

organizational performance. A number of attitudinal statements were subjected, to

test the respondents‟ attitude on the performance of accredited health facilities under

NHIF. The information contained in table 4.5 shows that 42.0 % of respondents

25

agreed with the statement that „there is a real need for health insurance. This could be

due to the fact that NHIF, has improved the accessibility of the registered

beneficiaries through the accredited health facilities. This was also, supported by the

statement that „private employees should be covered by health insurance, which was

agreed by 46% of the respondents. This suggests that the respondents had positive

attitudes with NHIF due to services provided by accredited health facilities. Despite

the fact that 64.0% of the respondents strongly revealed that „health insurance is not

well organized‟ and at the same time about half of the respondents (48%) believe that

health insurance is bad, unfair and can not be trusted. These findings suggest that

despite the achievement of NHIF objectives, there are some shortfalls which need to

be addressed so as to achieve the intended outcomes. Generally, from these findings

of this assessment, respondents are aware of the achivements of NHIF and its

shortfalls.

Table 4.6: Attitude on NHIF services in accredited health facilities

Statement Strongly

agree

Agree Uncertain Disagree Strongly

disagree

There is a real need for health

insurance

33.0% 42.0% 12.0% 10.0% 3.0%

Health insurance services is not well

organized

64.0% 34.0% 0.0% 1.0% 1.0%

Private employees should be covered

by health insurance

33.0% 46.0% 0.0% 9.0% 12.0%

Health insurance is bad and unfair 37.0% 48.0% 3.0% 7.0% 5.0%

All medicines should be included in

benefit package

82.0% 13.0% 0.0% 4.0% 1.0%

Health insurance fund is worthy to be

trusted

24.0% 17.0% 0.0% 28.0% 31.0%

Exempted diseases are not taken care

of

49.0% 38.0% 2.0% 5.0% 6.0%

Health insurance should benefit

employees only (and not the families)

5.0% 8.0% 4.0% 37.0% 46.0%

Contributions are too big for NHIF

services (3% of basic salary)

25.0% 49.0% 13.0% 9.0% 4.0%

Source: Field data, 2015

4.4 Challenges faced by NHIF through accredited health facilities

4.4.1 General challenges encountered in health facilities

Challenge is the situation of difficulty in job or something else that need a special

effort to overcome it. In Tanzania health services provision focus a number of

26

challenges that need to be addressed. This would enable the program or organization

to improve the operating environments. In this regard, evaluation involved

determining the challenges encountered in NHIF accredited health facilities. Number

of challenges were noted from respondents point of view. 41.3% (figure 4.3 and

table 4.7) mentioned that low Government budget in health facilities is the leading

challenge in the facilities, followed by lack of modern technology (17.4%) and lack

of community awareness 16.3%. Other remaining problems are as shown in figure

4.3. These results suggest that NHIF performance in health facilities will be low and

the objective will never be achieved if the facilities will continue to face the

mentioned challenges. In conclusion NHIF in collaboration with other stakeholders

should increase public awareness and early reimbursement to health facilities in

order to increase performance in health delivery.

Table 4.7: Challenges encountered in accredited health facilities

Challenge Frequency Percent

Low government budget 33 41.3

Lack of community awareness 13 16.3

Lack of modern technology 14 17.5

Frail financial flow 12 15.0

Acceptance by the community 8 10.0

Total 80 100.0

Source: Field data, 2015

27

Figure 4.3: Challenges encountered in accredited health facilities

Source: Field data, 2015

4.4.2 Factors for less adherence to NHIF standards

In regard to the operationalization of NHIF which has been in service for more than

ten years, the investigator felt it prudent to get an eyesight on reasons behind

unsatisfactory performance of NHIF. Analysing factors hindering NHIF service

provision, Most of respondents reported that (36.3%) it was due to lack of active

monitoring mechanism of NHIF funds (table 4.8). This is followed by respondents

(26%) who reported that overflow of attending NHIF clinics be a factor of poor

performance. Other factors are poor laboratory services (18%) and poor supply of

working tools(11.3%). View of this evaluation, NHIF, could achieve better

performance through effective monitoring claims and reimbursed funds. Referring to

a study conducted by Mtei (2012) pointed out that effective monitoring of claims and

funds improved the performance of private health insurance schemes in Tanzania.

Therefore, MOHSW and NHIF management should put more attention on the basic

requirements of the facilities to provide good working conditions for health workers.

This will motivate them to work hard as a result will promote the performance of

NHIF in health facilities.

28

Table 4.8: Factors hindering NHIF service provision

Factor Frequency Percent

Poor working tools 9 11.3

Poor laboratory services 15 18.8

Too many patients to attend 21 26.3

Lack of active monitoring mechanism 29 36.3

Lack of NHIF training 4 5.0

Total 80 100.0

Source: Field data, 2015

Figure 4.4: Factors hindering NHIF service provision

Source: Field data, 2015

4.5 Possible improvement measures on NHIF health service provision

4.5.1 Strategies to improve NHIF service provision

Strategies are arranged plans of an organization, very useful in achieving

organizational objectives. It is known that in most cases health service are

overwhelmed by many problems. The evaluator wanted to know the possibilities to

averse such a situation. During evaluation respondents were given an option to

mention one strategy that could help to solve existing problems. 20.0% of the

respondents (see table 4.9) pointed out that, stakeholders‟ involvement in decision

making as one of the strategies. This implies that there is a need to establish

permanent and functional structure of health insurance to constantly engage the

29

NHIF management, health providers, donors and beneficiaries to improve NHIF

service delivery.

Table 4.9: Strategies to improve NHIF service provision

Strategy Frequency Percent

Stakeholder involvement 16 20.0

Restructuring health sector 14 17.5

Creating service awareness 7 8.8

Cooperation with other sectors 13 16.3

No strategy 18 22.5

Don‟t know 12 15.0

Total 80 100.0

Source: Field data, 2015

Figure 4.5: Strategies to improve NHIF service provision

0 10 20 30 40 50 60 70 80 90 100

Stakeholder involvement

Restructuring health sector

Creating service awareness

Cooperation with other sectors

No strategy

Don’t know

20

17.5

8.8

16.3

22.5

15

Percentages

Strategy

Percent

Source: Field data, 2015

4.5.2 Ways to improve NHIF performance in accredited health facilities

To improve the quality of services delivered by the accredited health facililties is of

great important because NHIF facilitate access of health care services to its

beneficiaries by meeting health care cost. To improve NHIF services, a number of

measures need to be taken to reflect the respondents views. This is because about

quarter (27.5%) of the respondents ( see table 4.10) reported that Government should

increase the budget to meet health facilitiy requirements. This is true because with

good budget it implies that all health requirements will be meet. On the other hand,

30

16.3% of respondents suggested an improvement on health facilities by providing

essential medicines, medical supplies and enough staff.

Table 4.10: Ways to improve NHIF performance

Solution Frequency Percent

Improve accredited health facilities in all levels 13 16.3

Reviewing quarterly reports 8 10.0

Develop NHIF in charges at facility level 11 13.8

Train NHIF coordinators 10 12.5

Facilitate Head of departments 12 15.0

Increase health budget 22 27.5

Not applicable 4 5.0

Total 80 100.0

Source: Field data, 2015

4.5.3 Perception to improve health service provision.

Perceptions are mental image, concepts, physical sensation interpreted in the light of

experience. In order to determine the perception from the respondents on NHIF

health service provision improvement, the evaluator suggested perception options

which were used by respondents to rank levels of perception.Table 4.11 shows that

factors influencing poor quality services. Respondents strongly agreed with the

statements „Too many patients to attend (Over worked)‟ (29%), „Too much paper

work to attend NHIF patients‟ (37%). These imply that if health workers are

overworked and there is too much paper work the NHIF compliance and

performance will be low. Contrary to these agreed statements, respondents strongly

disagree with the statements „Aware on using generic names when prescribing

medicine‟ (61%), „Comfortable with reimbursement procedures by NHIF‟(49%),

„Get feedback of supportive supervision done by NHIF‟(47%) and „Attended training

concerning NHIF in the past two years‟ (56%). It could have been expected that

respondents were comfortable with reimbursement procedures by NHIF, get

feedback of supportive supervision and attended NHIF trainings, however the data

proves on contrary which implies that respondents are overworked, too much paper

work , not comfortable with reimbursement procedures and don‟t get feedback of

31

supportive supervisions which creats gap between NHIF and health facilities. It

could be concluded that NHIF is judged to be ineffective but there is still room for

improvement, hence it should not be untrusted as mentioned by some of the

respondents. Therefore, NHIF must reduce paper work, review reimbursement

procedures, regular facility inspection and provide feedback of supportive

supervision to the facilities in order to improve performance in these facilities.

Table 4.11: Perception to improve health Service Provision.

Statements Strongly

agree Agree

Uncertai

n Disagree

Strongly

disagree

Too many patients to attend (Over

worked)

29.0% 16.0% 34.0% 12.0% 9.0%

Availability of different types of

medicine in Hospital

15.0% 14.0% 41.0% 19.0% 11.0%

Aware on using generic names when

prescribing medicine

18.0% 8.0% 3.0% 10.0% 61.0%

Aware on filling of NHIF claim forms 16.0% 19.0% 5.0% 17.0% 43.0%

Have a copy of NHIF Standard

Treatment Guide Line and Essential

Medicine list

12.0% 13.0% 0.0% 33.0% 42.0%

Given opportunity by the Hospital

management to advise on the use of

NHIF acquired fund

44.0% 46.0% 0.0% 9.0% 1.0%

I feel strongly involved in the utilization

of fund acquired from NHIF

16.0% 19.0% 3.0% 22.0% 40.0%

I feel not well recognized by the

Hospital Management

41.0% 25.0% 0.0% 17.0% 17.0%

I have no trust to the hospital

Management Team with regards to how

they use NHIF fund

9.0% 9.0% 0.0% 48.0% 34.0%

I do need motivation to provide service

easily to NHIF beneficiaries

6.0% 4.0% 69.0% 13.0% 8.0%

Government play important role in

health financing

39.0% 52.0% 3.0% 4.0% 2.0%

Too much paper work to attend NHIF

patients

37.0% 47.0% 2.0% 6.0% 8.0%

Comfortable with reimbursement

procedures by National health insurance

7.0% 10.0% 18.0% 16.0% 49.0%

Get feedback of the service provided to

your Patients/Client

15.0% 19.0% 0.0% 21.0% 45.0%

Get feedback of supportive supervision

done by NHIF

Attended training concerning NHIF in

the past two years

17.0%

4.0%

10.0%

12.0%

4.0%

0.0%

22.0%

28.0%

47.0%

56.0%

Source: Field data, 2015

32

CHAPTER FIVE

SUMMARY, CONCLUSION AND POLICY IMPLICATION

5.1 Summary

This study evaluates NHIF service provision in accredited health facilities,.

Challenges encountered need a clear measures for improvement of health services.

This is because findings have revealed that NHIF objectives are not fully achieved

due to various factors. Also the evaluation noted a number of challenges facing

accredited health facilities.These challenges are manageable through good plan and

Government commitments.

5.2 Conclusion

NHIF facilitates access of health care services to her beneficiaries through a network

of accredited health facilities. Therefore, accredited health facilities are required to

provide quality services to NHIF beneficiaries. The success of NHIF depend on how

health care providers treat its client. The evaluation noted that, there are challenges

facing accredited health facilities in the country. The challenges encountered

included small health budget, poor financial flows, lack of community awareness,

lack of modern technology and low acceptance by the community. Also, other

factors are lack of active monitoring mechanism of NHIF and claims, poor laboratory

services, poor working tools, too many patients to attend and lack of training of

health facility staffs. The evaluation suggest that more effort is needed to improve

health services in accredited health facilies. These challenges need to be addressed in

order to promote performance as well as for the achievement of the objectives.

Measures to be taken include; improvement of accredited health facilities at all

levels, reviewing quarterly reports, Train all health facility incharges, train NHIF

coordinators and increase budget for health. Also NHIF can benefit from improved

data systems, supervision, and management support.

33

5.3 Policy implication

The essence of this study was to evaluate the health services in accredited health

facilities by the NHIF.The purpose of introducing NHIF is to support the government

in enhancing quality health service provision to the population of Tanzania. This

evaluation sought to provide a roadmap for optimizing health sector inputs within the

context of the overall health systems. The information contained in this evaluation is

intended to create opportunities for multi-sectoral dialogue, to enhance collaborative

planning efforts, and ultimately to facilitate partnerships that will lead to an

improved health systems. Tanzania has achieved much in this area, with support of

stakeholders from both public and private sectors. This has been possible due to

good policies toward public-private collaboration.

5.4 Areas for further evaluation

This evaluation study was not exhaustive since it covered few specific areas due to

financial limitations, specificity and many others. In this regard, further evaluation

could be considered to the following areas:

Financial contribution of the accredited health facilities to the National level

Contribution of accredited health facilities to the rural communities

The sustainability of accredited health facilities.

34

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37

APPENDICES

Appendix 1: Questionnaire

A: Evaluator’s introduction

Dear Sir/Madam

I would like to introduce myself to you and the purpose for this study. I am a student

from Mzumbe University pursuing Master of Science in Health Monitoring and

Evaluation. My research title is „Evaluation of service provision in accredited health

facilities‟. I am conducting this study for academic purpose only and I will maintain

the confidentiality of the data which I am requesting from you all the time. Kindly I,

request your cooperation to fill this questionnaire, thanks in advance.

Thanks in advance

………………………… ………………..

Rose Anthony Ntundu Date

B: Socio- Demographic information of the respondents

1. Age

(a) 18-25 years

(b) 26-35 years

(c) 36-45 years

(d) 46-55 years ( )

(e) 56-60 years

2. Sex category

(a) Male

(b) Female ( )

38

3. Education level

(a) Secondary education ( )

(b) certificate

(c) Diploma

(d) Degree and above

4. Marital status

(a) Married

(b) Single

(c) Single parent ( )

(d) Widower

(e) Divorced

5. Working experience

(a) Less than 1 year

(b) 1 year to 5 years ( )

(c) 6 years to 10 years

(d) More than 10 years

C: To assess NHIF performance in compliance with accredited health facilities

6. What are the specific objectives of NHIF?

(a) Availability of guidelines as per NHIF standards in the facility

(b) There is an increase of accessibility and quality services to beneficiaries

(c) There is an increase of accredited health facilities [ ]

(d) There is an increase of reimbursement in facility from NHIF

(e) Attended training on NHIF matters

(f) Supervision conducted by NHIF at least once per year

7. Have the NHIF objectives been achieved?

(a) Yes

(b) No

(c) I Don‟t know [ ]

39

8. What were the reasons for NHIF to initiate accredited health facilities?

(a) To speed up service provision

(b) To improve health service

( c) To enable many people attend the service [ ]

(d) To cover large area

(e) Not sure

9. Indicate your attitude on the following statement pertaining to the accredited

health facilities

No Statement Strongly

agree Agree Uncertain Disagree

Strongly

disagree

1 There is a real need for health insurance

2 Expect good services with health insurance

3 NHIF is not well organized

4 Private employees should be covered by

health insurance

5 Health insurance is bad and unfair

6 All medicine should be included in benefit

package

7 Health insurance is worthy to be trusted

8 Exempted diseases are not taken care of

9 Health insurance should benefit employees

only (and not the families)

10 Contributions are too big for NHIF services

(3% of basic salary)

10. What benefits does the community gain from accredited health facility?

(a) Primary care

(b) Access to medicine

(c) Advice

(d) Readily available health services

(e) Large coverage

(f) No benefit [ ]

40

D: To determine challenges faced by NHIF through accredited health facilities

11. . Mention one challenge faced by NHIF service provision in accredited health

facilities

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

12. What do you think hinders effective NHIF service provision in your facility?

(a) Poor working tools

(b) Poor laboratory services

(c) Too many patients to attend [ ]

(d) Lack of active monitoring mechanism

(e) Lack of NHIF training

13. Please, put a tick where you think appropriate answer for the given statements.

Use; strongly agree=5, Agree= 4, Neutral=3, Disagree=2, strongly disagree=1.

No

Statements

Str

on

gly

ag

ree

Ag

ree

Neu

tra

l

Dis

ag

ree

Str

on

gly

dis

ag

ree

1 Satisfied with health insurance services in Tanzania

2 Satisfied with the treatment package provided by NHIF

3 Too many patients to attend (Over worked)

4 Understands well NHIF Standard Treatment Guide Line

and Essential Medicine list

5 Availability of different types of medicine in Hospital

6 Aware on using Generic names when prescribing medicine

7 Aware on using the disease codes provided by NHIF

8 Aware on filling of NHIF claim forms

9 Have a copy of NHIF Standard Treatment Guide Line and

Essential Medicine list

10 Given opportunity by the Hospital management to advise

on the use of NHIF acquired fund

11 I feel strongly involved in the utilization of fund acquired

from NHIF

12 I feel not well recognized by the Hospital Management

13 I have no trust to the hospital Management Team with

regards to how they use NHIF fund

14 I do need motivation to provide service easily to NHIF

beneficiaries

15 Government plays an important role in health financing

16 Too much paper work to attend NHIF patients

17 Comfortable with reimbursement procedures by NHIF

18 Get feedback of the service provided to your Patients/Client

19 Get feedback of supportive supervision done by NHIF

20 Attended training concerning NHIF in the past two years

41

E: To evaluate possible improvement measures on NHIF health service

provision

14. Mention one strategy to improve NHIF service provision in accredited health

facilities.

…………………………………………………………………………………..

…………………………………………………………………………………..

…………………………………………………………………………………..

15. Do you think the challenges mentioned on NHIF performance can be

eliminated?

(a) Yes

(b) No [ ]

16. What do you think should be done to improve NHIF performance through

accredited health facilities?

(a) Improve accredited health facilities in all levels

(b) Reviewing quarterly reports

(c) Develop NHIF in charges at facility level

(d) Train NHIF coordinators

(e) Facilitate Head of departments [ ]

(f) Increase health budget

(g) Not applicable