Abstract
BackgroundThe National Health Insurance Fund (NHIF), a compulsory formal sector scheme took over the management of the Community Health Fund (CHF), a voluntary informal sector scheme, in 2009. This study assesses the origins of the reform, its effect on management and reporting structures, financial flow adequacy, reform communication and acceptability to key stakeholders, and initial progress towards universal coverage.MethodsThe study relied on national data sources and an in-depth collective case study of a rural and an urban district to assess awareness and acceptability of the reform, and fund availability and use relative to need in a sample of facilities.ResultsThe reform was driven by a national desire to expand coverage and increase access to services. Despite initial delays, the CHF has been embedded within the NHIF organisational structure, bringing more intensive and qualified supervision closer to the district. National CHF membership has more than doubled. However, awareness of the reform was limited below the district level due to the reform’s top-down nature. The reform was generally acceptable to key stakeholders, who expected that benefits between schemes would be harmonised.The reform was unable to institute changes to the CHF design or district management structures because it has so far been unable to change CHF legislation which also limits facility capacity to use CHF revenue. Further, revenue generated is currently insufficient to offset treatment and administration costs, and the reform did not improve the revenue to cost ratio. Administrative costs are also likely to have increased as a result of the reform.ConclusionInformal sector schemes can benefit from merger with formal sector schemes through improved data systems, supervision, and management support. However, effects will be maximised if legal frameworks can be harmonised early on and a reduction in administrative costs is not guaranteed.
Highlights
The National Health Insurance Fund (NHIF), a compulsory formal sector scheme took over the management of the Community Health Fund (CHF), a voluntary informal sector scheme, in 2009
The objectives of this paper are to ascertain to what extent the initial motivation for the reform was driven by a desire for progress towards universal coverage; assess the impact of the reform on management and reporting structures; assess the responsiveness of and adequacy of financial flows; describe how the reform has been communicated to key stakeholders and assess its acceptability; examine if the reform has made any initial progress towards universal coverage in terms of pooling and purchasing
A donor funded workshop in 2007 highlighted weaknesses in CHF management and constraints to coverage expansion [24,25] resulting in the commissioning of a ten year health sector evaluation, which recommended synchronizing the NHIF and CHF [26]; which was formalized in a Cabinet directive to the
Summary
The National Health Insurance Fund (NHIF), a compulsory formal sector scheme took over the management of the Community Health Fund (CHF), a voluntary informal sector scheme, in 2009. The two largest health insurance schemes are the National Health Insurance Fund (NHIF), a mandatory scheme offering comprehensive benefits to the formal sector, and the Community Health Fund (CHF), a voluntary scheme for the informal sector in rural areas, offering limited benefits in public lower level facilities. While NHIF coverage has been gradually increasing since its introduction, CHF coverage has remained low due to weak management, poor understanding of the concept of risk pooling [2], and a limited benefit package [3]. Evidence from Asia and Latin America indicate this can present challenges including the need for benefit package convergence, dealing with adverse selection and ensuring financial sustainability [12,13]
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