1
A public private health care providing and financing partnership between a cocoa
company, a faith-based hospital, and public authorities, promoted by an NGO (CIDR)
1- History of the Public Private Partnership
The setting up of a social health insurance scheme in Kyela district initially came into existence
thanks to four actors:
 Biolands Ltd, a cocoa trading company in Kyela since 1999, willing to support the farmers;
 Matema Lutheran Hospital, a Faith-Based Hospital, willing to set up a micro health insurance
mechanism around the hospital to help the population accessing the services;
 Centre for International Development and Research (CIDR), Implementing the Self Managed
Health Insurance Scheme (SMHIS) Program in Mbozi district since 2002;
 Kyela District Council, asking CIDR to carry out a survey to boost the CHF in the district.
After a feasibility study, this partnership has led to a Memorandum of Understanding between Kyela
District Council, Biolands International, Matema Lutheran Hospital, CIDR, GIZ and USAID, for the
implementation of a common strategy to boost the CHF in the whole Kyela District. This innovative
approach which focuses on the setting up of a Community Health Insurance Fund (CHIF) Association
in charge of the CHF premium management is also supported by the German NGO “EED”, the French
cooperation (AFD) and the Elton John AIDS Foundation (EJAF).
2- Reformed management of the CHF: The CHIF Concept
The Council, through the Council Health Service Board, is responsible for the CHF as per CHF bylaws, but has delegated the management of the premiums to the CHIF Association. Together they
are co-managing the CHF. Contrary to the CHF, based on community, the CHIF Association is
member-based. The CHIF members are the owners of their premiums and govern the association via
their elected leaders. It assures real participative governance and ownership. In addition the
scheme is built on professional insurance management principles and on a contracting approach
between public and private health providers and CHIF Association. This has made the product more
attractive particularly by including access to a faith-based hospital and to private pharmacies; but
also via the low price of the premium (2,000 per head above 5 per year) through a premium subsidy
by Biolands for cocoa producers and by the Council for non cocoa producers (3,000); as well as with
the coverage of health expenditures related to HIV/AIDS (opportunistic infections) via a HIV/AIDS
reinsurance system; and thanks to a private ambulance system management. At last the CHIF aims
at linking the CHIF enrollment with quality health services. Through a Co-management of the
Matching Fund with the CHSB, the funds are allocated efficiently to improve the services where
needed. It is also planned to distribute allowances to contracted health providers on a pay for
performance basis.
3- The results after one year of operation
The first result is the ownership by all the stakeholders, which has been possible through a longterm process of negotiation (more than 1 year), as well as through a strategy designed and
implemented in common from the beginning. This strategy being based on a co-financing
mechanism presents another result. The CHIF actually benefits from a subsidy of the premiums by
Biolands and the District Council. The Matching Fund is invested in improvement of quality health
services, but is also used for covering budget for services overrun. In addition the high HIV/AIDS risk
in Kyela is transferred to a HIV/AIDS reinsurance fund. This co-financing allows a unique guarantee
for the whole district and a free access to public and private faith-based health providers. The family
members above 5 years old only pay 1 euro per year per head.
Compared to the CHF membership in 2008 (800), the CHIF concept has allowed in only one year a
significant increase of the membership reaching more than 16,000 beneficiaries.
2
Indicator
Beneficiaries (insured people)
Penetration rate
Position of the district in the region in terms of coverage
Results
16,203 (800 before starting)
16%
1st (Last before starting)
Concerning the financial situation, the below table shows the results for 2011.
Total expected collection
Contributions (2,000)
Biolands subsidy
Council subsidy
Total expenses (Health + Transport)
Claim ratio
Tsh
74,250,000
29,700,000
24,002,000
10,000,000
33,043,000
USD
47 903
19 161
15 485
6 452
21 318
67%
Through its payment center, the CHIF Association controls the use of funds paid to the health
providers. That’s why the share of the resources used for the payment of the bills is only 2/3 of the
budget. In addition the CHIF participates in the allocation of funds for quality of care improvement
4- Innovation
The CHIF concept is a new approach in the CHF landscape in Tanzania, particularly through the comanagement of the CHF with a member-based CHIF Association. This “privatization” of the
governance has led to the involvement of Biolands, ready to co-finance the premium if it was
managed by an independent organization. This has encouraged the District Council to subsidize the
others and avoid any disparity. On top of that the professional and transparent management has
brought confidence and attracted other partners, like Mango Tree paying the premium of 1,300
Orphans and Vulnerable Children (OVC), or like the EJAF contributing with USAID into the HIV/AIDS
reinsurance fund. The CHIF structure presents in fact a potential for managing equity funds targeting
specific categories of populations like (indigents, OVCs, pregnant mothers, etc)
In addition, the contracting approach between the CHIF Association and the health providers relies
on a separation of the provider and the purchaser of health care and allows the health facilities to
be paid according to the services delivered. This was possible only with the setting up of a CHIF
Association, which has created new partnership relations between the Council and an organization
of the civil society, making people deeply involved in the health sector. After one year of operation,
other districts and private companies are interested in such a mechanism. The later is appreciated
by the National Health Insurance Fund (NHIF) and the Mbeya Regional Medical Officer. Therefore
CIDR will design a strategy in order to propose the other districts of the region to replicate.
5- Role of Biolands in the CHIF design and implementation
During the feasibility study, emphasis has been put on Biolands because it was an initiator of the
study, but also due to its important share in the district cocoa trading business and its pioneer role
in the Kyela cocoa valorization.
In the setting up, Biolands played a major role by laying down the condition for the subsidy to be
managed by an independent private structure. It also pushed to lower the premium for the whole
district. In addition Biolands is involved in the promotion through the Biolands Village Coordinators
(VC) located in each village (123), and in the collection since 80% of the premiums are transferred to
the CHF account by Biolands. At last, the setting up of a micro health insurance scheme in a new
location requires time to build confidence with the communities. This was even more challenging
because of the bad reputation of the CHF since it failed to deliver services to the CHF members. In
fact the confidence in the company which has been transferred to the program and CHIF Association
was a major factor of the fast enrollment.
3
Structure of the CHIF Association
Council Health Service Board Supervision
CMC
GOVERNANCE
MANAGEMENT
CHIF General Assembly
Board – Executive Committee
Electoral
group of
Wards
Electoral
group of
Groups
Technical Unit
Representatives
Program
Coordinator
Representatives
Biolands
Field
Supervisors
Ward
sections
Representatives
Village
sections
Village
sections
M
Village
sections
BBP
Representatives
G
r
o
u
p
s
M
Village
sections
BBP
Representatives
HFGC
G
r
o
u
p
s
M
G
r
o
u
p
s
Representatives
BBP
M
Ward
sections
M
M
G
r
o
u
p
s
G
r
o
u
p
s
Coordination
Risk
management
Medical and
Financial
Audits
CHIF Agents
Team
Field
Officers
HFGC
G
r
o
u
p
s
M
M
CIDR
Technical
support
CHIF
Promoters
Team
8
BBP = Biolands Buying Posts; CMC = Co-Management Committee
Financial transactions
Matching Fund
=B
CHIF Premiums
=A
CHF Account
(Council – CHIF)
By installments
(services + RC)
CHIF
Account
Quality
investment
Health
Facilities
13
4
Services delivered per type of providers:
Health facilities
Private Hospital (FBO)
Public Hospital
Ipinda Health Center
Faith Based Dispensaries
Public Dispensaries
Transport
Private pharmacies
GRAND TOTAL
Nr
1,381
1,109
169
1,169
643
66
255
4,537
Cost
12,843,500
8,310,000
527,000
5,970,000
961,500
1,807,000
2,624,000
30,419,000
Frequency
8.52%
6.84%
1.04%
7.21%
3.97%
0.41%
1.57%
28.00%
Average cost
9,300
7,493
3,118
5,107
1,495
27,379
10,290
6,705
Categories of services delivered:
Health facilities
OPD
SIMPLE DELIVERY
IPD
SURGERY
CHIF AMBULANCE
MLH AMBULANCE
IPINDA HC AMBULANCE
OTHER TRANSPORT
PRIVATE PHARMACIES
GRAND TOTAL
Nr
4,218
6
226
14
23
4
1
45
255
4,792
Cost
Frequency Average cost
21,868,500
26.03%
5,185
0.04%
5,803,500
1.39%
25,679
760,000
0.09%
54,286
630,000
0.14%
27,391
120,000
0.02%
30,000
0.01%
1,237,000
0.28%
27,489
2,624,000
1.57%
10,290
33,043,000
29.57%
6,705