Tanzania: NHIF Drama Intensifies As Private Hospitals and Government at Odds Over Healthcare Reforms.

By Adonis Byemelwa

In a seismic shift within Tanzania's healthcare landscape, a deadlock between private hospitals and the government over transformative NHIF (National Health Insurance Fund) reforms has unfolded, introducing a riveting twist in the nation's pursuit of a fair and resilient healthcare system.

Influential private hospitals, including TMJ, suspended services in protest of proposed NHIF reforms, citing concerns over lower reimbursement rates that could impact healthcare quality.

The conflict reached a positive turn as some private facilities, such as TMJ Hospital, decided to welcome NHIF cardholders, providing much-needed relief to beneficiaries.

The heart of the dispute lies in the proposed NHIF healthcare packages, featuring reduced prices for essential services but increased rates for less frequently used ones.

 For instance, the reimbursement for a Caesarean section (C-section) delivery has been significantly slashed, raising concerns about private facilities covering operational costs.

The Private Hospitals Advisory Board (PHAB) intervened, stressing the legal obligation of private healthcare facilities to provide medical services to all emergency patients, irrespective of their insurance status.

While some private hospitals have resumed services after discussions with the Ministry of Health, others, including Bochi, have opted to reject NHIF members from March 1, 2024, citing disagreements over proposed rates.

The lack of private hospital involvement in the NHIF review committee, coupled with NHIF's role as the judge in its case, raises concerns about the fairness of the process.

Adding to the complexity is the government's provision of free services to the elderly without compensating costs, contributing to the financial struggles of NHIF. The centralization of health insurance services for public servants, mandated by President Magufuli, has strained NHIF, creating customized VIP packages that burden the fund further.

Last week, private hospitals collectively announced their refusal to accept NHIF patients, prompting expectations for government engagement to find a solution. However, instead of dialogue, the government issued threats to specific hospitals, including Agha Khan, Kairuki, and Regency, employing a "divide and rule" strategy to force compliance by intimidating influential hospitals.

The potential threats and sabotage tactics against private hospitals reveal a concerning pattern, reflecting a last-resort tactic used by autocratic governments. The ongoing conflict underscores the imperative for a united and strategic approach in Tanzania's pursuit of a fair and resilient healthcare system.

In the labyrinth of Tanzania's healthcare intricacies, shining examples from other African nations stand as guiding lights, showcasing the triumphs of comprehensive health insurance coverage. Rwanda, with an impressive 78.7% coverage, leads the pack, followed by Ghana at 58.2%, Gabon at 40.8%, and Burundi at 22.0%. These nations serve as compelling benchmarks, demonstrating the efficacy of robust health insurance frameworks in ensuring widespread access to quality healthcare services.

PHAB reiterated its legal prerogative outlined in Section 15, Regulation 32 of the Private Hospital (Regulation) Act 151, emphasizing the obligation of private hospitals to provide medical services to emergency patients and those already admitted. This underscores the notion that healthcare is a fundamental right that should not be compromised, regardless of insurance status.

The proposed NHIF healthcare packages, with reduced prices for essential services and increased prices for certain less frequently used services, continue to be a focal point of contention. The example of a C-section delivery cost reduction from 300,000 TZS to 130,000 TZS highlights the financial strain that private facilities may face in delivering crucial services at the proposed rates.

The intricacies of medical procedures, such as C-sections, involve a team of at least six or more people, including an OBGYN specialist, assistant surgeon, anesthetist, surgical technologist, delivery nurse, and supporting staff. With a reimbursement of 130,000 TZS, private facilities express concerns about their ability to cover operational costs, including salaries, electricity, water, and other necessary expenses.

The last review of NHIF package prices occurred in 2016, implying that eight years have passed without an adjustment to reflect the changing costs of living and medical expenses. The discrepancy between the 2016 reimbursement rate of 300,000 TZS for a C-section and the proposed rate of 130,000 TZS raises questions about the basis for lowering the reimbursement.

The conflict also extends to other medical services, with some fees being increased (e.g., consultation with a specialist) while many others have seen reduced reimbursement rates. For example, the reimbursement for a cast in the case of a broken leg is set at 12,000 TZS, leaving patients to cover a substantial amount out of pocket.

The government's attempt to implement these package changes in December of the previous year faced strong opposition from stakeholders, leading to a boycott initiated by private healthcare sector entities in late 2023. The Parliamentary Committee on Health and HIV/AIDS intervened, instructing the formation of a committee to review the proposed packages, involving the Ministry, NHIF, and service providers from both public and private hospitals.

However, the exclusion of private hospitals from the committee and the composition of the secretariat primarily with NHIF members have raised questions about the fairness and objectivity of the review process. Despite the intervention, NHIF returned with largely unchanged prices, exacerbating the conflict between private hospitals and the government.

The misuse of NHIF funds, as revealed in the CAG report for the year 2022, further adds a layer of complexity to the ongoing crisis. The report discloses that NHIF employees borrowed more than TZS 41 billion among themselves, constituting contributions from members, essentially transforming the fund into a lending pool without interest.

The situation bears similarities to issues observed in social security funds, where government borrowings for social amenities have led to challenges for retirees in receiving their due benefits.

In response, the government has considered disbursing only 25% of retirees' benefits, with the remaining amount to be reimbursed gradually. This approach has faced opposition from civil servants, who advocate for receiving their full funds, similar to the treatment given to Tanzania Defense Force military officers.

Additionally, the report highlights the government's policy of providing free healthcare to the elderly without compensating costs. While the initiative is commendable, the lack of reimbursement to NHIF for these services, coupled with outstanding government debts, contributes to the financial struggles faced by the fund. The report underscores the need for a comprehensive and sustainable financial model to ensure the continued viability of NHIF in providing essential healthcare services.

The centralization of health insurance services for public servants, enforced by President Magufuli, has added to the challenges faced by NHIF. While the move compelled all public servants to use NHIF, creating customized VIP packages to match their accustomed services placed an additional burden on the fund. The financial strain resulting from this centralization has further fueled the ongoing conflict between private hospitals and the government.

As the conflict intensifies, there is a growing need for a nuanced and sustainable resolution that considers the interests of all stakeholders – the government, private hospitals, NHIF, and, most importantly, the citizens reliant on healthcare services.

A collaborative approach, inclusive of all parties in the review and decision-making processes, can pave the way for a healthcare system that prioritizes quality, accessibility, and fairness.

The ongoing crisis in Tanzania's healthcare sector highlights not only the immediate challenges faced by private hospitals but also the broader systemic issues within NHIF and the government's approach to healthcare reform.

A transparent and inclusive dialogue is crucial for crafting a solution that addresses the financial sustainability of NHIF, ensures fair compensation for private hospitals, and ultimately safeguards the well-being of Tanzanian citizens.

The clash between private hospitals and the government over NHIF reforms in Tanzania represents a critical juncture in the nation's healthcare system. The multifaceted nature of the conflict, involving reimbursement rates, governance issues within NHIF, financial mismanagement, and coercive government tactics, demands a comprehensive and strategic resolution.

 A united and transparent approach that incorporates the perspectives of all stakeholders is essential for navigating the intricacies of this healthcare crisis and securing a resilient and equitable future for Tanzanian healthcare.