CBHF and addressing HIV/AIDS
The HIV/AIDS epidemic is present in many of the countries in Africa where Community-based Health Financing (CBHF) schemes have taken hold. The epidemic poses many problems for these communities and schemes due to the dynamic nature and pattern of transmission, the complexity of the treatment regimens, the challenges of prevention, and the costs of delivering HIV/AIDS services. PHRplus has been providing technical assistance to a number of CBHF schemes in sub-Saharan Africa over the past several years in areas such as financial management, social mobilization, and risk management. A recent PHRplus paper examines what these existing CBHF schemes in sub-Saharan Africa have done to address HIV/AIDS in terms of providing prevention and/or care and support services in the benefits package through either implicit or explicit mechanisms.
PHRplus has plans for future research including expanding CBHF mechanisms for HIV/AIDS related service delivery, incorporating HIV services into benefits packages (especially home-based care and voluntary counseling and testing), and exploring the impact of inclusion of HIV services on seropositive member behavior.
CBHF and impact on Maternal and Child Health
PHRplus plans to examine CBHF scheme impact on Maternal and Child Health Services. PHRplus will:
- Develop the methodology and tools for gathering baseline information on how USAID priority services are included and/or promoted in CBHF scheme benefits packages
- Conduct fieldwork and implement data gathering activities using the above methodology and tools
- Produce a report that summarizes the findings from the survey and makes recommendations for possible technical assistance and follow on activities concerning the use of priority services by CBHF scheme members.
MHOs in Ghana
Since 1985, Ghana has sought to finance health care delivery through several different methods. These include different kinds of geographically based Mutual Health Organizations (MHOs), social health insurance for the formal sector, and private health insurance. Within these three categories, the Ghanaian government estimates that private health insurance and social health insurance cover only 15% of the population. Policy makers are proposing that MHOs cover the remaining 85% of the population.
In order for MHOs to expand rapidly to cover a larger percentage of the population, the technical assistance provided by PHRplus will be crucial. PHRplus experience demonstrates that well designed MHOs have much greater chances for success and growth. PHRplus is conducting costing studies, feasibility studies, and trainings to facilitate MHO's expansion throughout the country. PHRplus is also explaining the MHO concept to policy makers and media practitioners and disseminating findings of the health care financing study completed in September 2001.
In the Ashanti region of Ghana, PHRplus is not only helping MHOs get started, but is working with the Ashanti king to design a regional fund that would provide ongoing technical assistance to MHOs and potentially subsidize membership for the poorest and/or expand members' access to tertiary care.
MHOs in Mali
The concept of community-level MHOs in Mali is relatively new. In cooperation with the government, PHRplus has provided assistance to launch four MHOs in two locations. The objectives of MHOs in Mali are to increase access to health care and the utilization of health services, as well as to improve the quality of health care available. PHRplus plans to not only help groups organize themselves into MHOs in Mali, but also to document the processes through which MHOs are implemented, to evaluate the impact of MHOs on the utilization of health services, and to assist the government to improve health policy using the results of MHO experience.
The origins of PHRplus work in Mali are baseline provider and household surveys in Bla (rural setting) and Sikasso (urban setting) that identified the causes of low utilization of health services. Based on the results of these surveys, PHRplus worked with local stakeholders to identify priority problems and strategies to address these problems.
MHOs were selected as a strategy to improve access to health services. PHRplus worked with these communities to create MHO planning committees in the two test sites, to educate the population about MHOs, to conduct feasibility studies for the four MHOs to be started, and to discuss their results with the community. As a result, 4 new MHOs are now operational in these two sites. PHRplus plans to monitor the initial activities and provide technical support to the MHOs as needed. After one year of service provision to members, PHRplus will carry out evaluation surveys to measure the impact these MHOs have on the utilization of key health services.
MHOs in Senegal
For the last 5 years under the previous project, PHR technical assistance addressed MHO design flaws, lack of insurance and managerial skills, and low population coverage rates in Senegal. PHR supported innovations to the MHO movement in Senegal such as the decentralization of MHO management, improved marketing of MHOs and models for MHO design and training.
As the number of MHOs in Senegal grows, PHRplus understands there is a high cost incurred by multiple feasibility studies. More and more communities are setting up MHOs and it is impractical to do feasibility studies for each one. The team created a new type of feasibility study to address this issue. The new feasibility study is based on the past experiences of all MHOs in the region and uses generic regional feasibility study techniques. This should reduce both the cost and the time it takes to launch well designed new MHOs.
The PHRplus team also is concerned about the small size of pools of insured that may undermine long-term viability of the MHOs. Low contribution rates yield limited benefits packages. Exposure to external risks like hyperinflation, macro-economic shocks, and higher than expected morbidity also incurs additional risk to MHOs. As a result, the PHRplus team is exploring reinsurance as a way to cushion MHOs from these additional challenges.
Community Health Fund in Tanzania
The Community Health Fund (CHF) began as a pilot program in December of 1995 as a key component of the Tanzanian health financing strategy. In 1998, the CHF was expanded to 10 districts. The CHF Act was passed in April 2001, and aims to establish the CHF in all rural districts by the end of 2003. According to the Tanzanian CHF Act of 2001, "CHF is … a voluntary community based financing scheme whereby households pay contributions to finance part of their basic health care services to complement the Government health care financing efforts." In practice, the CHF is used to refer to both user fees and the pre-payment program, since user fees at the health center and dispensary level are introduced concurrent with the establishment of the CHF in each district.
PHRplus conducted an assessment of the Hanang district in December of 2001 to identify strengths and weaknesses of the existing CHF program there. PHRplus worked with the District Health Management Team to develop a plan of activities to be implemented over the next year to address key issues identified in the assessment. Over the next year, PHRplus will provide technical assistance to improve the performance of CHF in Hanang District and to evaluate the impact of changes implemented.
By compiling and disseminating tools and lessons learned that can be replicated throughout Tanzania, the experience in Hanang district will be used to strengthen the CHF in other districts. This activity aims to contribute to regional knowledge on how to implement community based financing schemes.