Financing Eye Health in Tanzania

Introduction to Sightsavers’ Seeing is Believing project in Tanzania

Sightsavers’ Maono Project has been working with the Singida Regional Authority since April 2016 to support and strengthen the regional referral hospital and district health facilities to increase demand for eye care and enable eye health treatment to be brought closer to the communities.

Since the inception of the project, the number of people who received cataract surgery per year has increased from 530 in 2015 to 2,600 in 2018. Moreover, the number of districts offering eye care services has increased from one in 2015 to four by June 2019.

The advocacy component of the project aimed to influence the Government of Tanzania (through the regional health management team) to increase their commitment to eye health services across all seven districts of Singida region. While we have seen a significant increase in the budget allocation for eye health, the amount allocated is still insufficient to meet the current eye care demands in the region. The government allocated 37,916 USD for consumables and surgical outreaches in Singida’s 2018/2019 regional plan, compared with 104,022.56 USD allocated through the SiB project. It is with this background that the project supported the development of an Eye Health Financing Mechanism to enable the regional authority to increase their revenue through cost recovery from eye care service delivery across the seven districts.

Eye Health Financing Mechanism

In 2017, with support of a consultant, the project explored financing options that would provide a practical financing framework with the ultimate goal of increasing access to sustainable quality eye care services funded from a domestic source with the intention of minimizing dependence on donor funding while ensuring the continuity of services (currently funded by donors). Click here to read the full report.

Singida Regional Authority, through the Regional Health Management Team (RHMT) and seven Council Health Management Teams (CHMTs), were involved in the design of the Singida region eye care financing mechanism. Key stakeholders such as the National Health Insurance Fund (NHIF) and the Ministry of Health Community Development Gender Elderly and Children were consulted to share their experiences and learning during the design of the financing framework.

Working with the National Health Insurance Fund and the improved Community Health Fund

The NHIF is an alternative financing option in the Tanzanian health sector, which is a result of the Government of Tanzania’s decision to implement health sector reforms. The aim of the Fund is to bring quality health services closer to its members and support medical providers. The Fund currently caters for government employees, including their spouses and up to four children and/or legal dependents (i.e. up to six people in a family).

The improved Community Health Fund (iCHF) was launched in November 2014 with the aim of increasing access to quality healthcare for people in the informal sector, mostly rural and low-income groups. It is a voluntary, public-private health insurance scheme, built on a strong partnership between the NHIF, the district councils (local government), public and private healthcare facilities and PharmAccess. It offers an extensive benefits package, covering primary care and referral for inpatient care for up to five-days of admission. The premium is currently set at 30,000/= Tanzania shillings (less than USD 14) per household per year.

The project explored the opportunities available within the NHIF to identify possible areas where Singida Regional Authority can ensure a more sustained way of financing eye care in the region. The following opportunities were identified:

Availability of trained Eye Health staff: Four Cataract Surgeons and 16 Ophthalmic Assistants, who were trained through the SiB project, now qualify to offer eye care services, as per NHIF guidelines. NHIF have, therefore, agreed to provide eye health charging codes in all seven councils (which were not previously available). Eye patients with NHIF cards had to travel to Singida Regional Referral Hospital for eye care services such as refraction and dispensing of spectacles. These services are now available at the district level eye clinics.
Availability of Ophthalmic Equipment: Through the SiB project three districts (Iramba, Manyoni and Mkalama) were provided with equipment to support cataract surgeries and refractive error services, therefore they now qualify for NHIF charging codes and are able to access the online NHIF patient registration database, so that they can generate revenue from NHIF.
Presence of outreach services: NHIF will pay for eye treatments to their members during the ongoing outreach services. NHIF members at lower level facilities, especially members who demand refractive error services, within districts that do not have enough eye care equipment will be reached during outreach services.
Trained Health Management teams (i.e. CHMTs) who will support the integration of eye care services with NHIF while ensuring the quality of services. They will ensure that training is done by NHIF staff aimed at ensuring that health staff understand the NHIF eye care products catalogue so that they can use them to increase eye care revenue across the region.

Cost recovery mechanisms

NHIF pays 350,000/= Tanzania shillings (equivalent to 152.2 USD) for each eye surgery at the regional referral hospital and 150,000/= Tzs (65.2 USD) when surgeries are done at the district hospital or other lower level facilities. For refractive error, NHIF pay 2.2 USD for all patients to have their visual acuity tested and 8.7 USD for reading glasses (for principle members only).

Sightsavers’ eye health financing mechanism calls for the recovery of eye care costs, through utilisation of NHIF and iCHF and the use of dedicated bank accounts for eye care in all districts (and at the regional referral hospital). It also calls for the sensitisation of the community to encourage individuals to pay for health insurance, where possible. Following the dissemination of the eye health financing mechanism, the key achievements are:

Integration of NHIF with eye care service delivery: previously, none of the districts in Singida had any NHIF charging codes for eye health services. Eye patients with NHIF cards had to travel to Singida Regional Referral Hospital to get spectacles or other eye treatment. Trained eye care staff (i.e. Cataract Surgeons and Ophthalmic Assistants) as well as outreach services have helped to provide refractive error services at district level. For example, the Ikungi District Eye Coordinator report of May 2019 indicates that the district generated 1,319,500/= Tanzania shillings from NHIF after selling spectacles. This amount will be re-invested by the district to sustain refractive error services at Ikungi Health Centre.
Direct “out of pocket” payment from patients[1]: Singida Regional Authority have prepared a cost for each eye care service (based on estimates provided by the districts and regional hospital), at all levels. Patients who receive eye care are encouraged to pay for (or contribute) to ensure the continuity of eye services. For example in May 2019, Manyoni and Ikungi districts generated 980,000/= Tanzania shillings from consultation fees. This demonstrates that if the region continues to raise awareness on cost sharing the community will continue to pay for services directly, which in turn will contribute to the cost improve the quality of eye health services and expand coverage.
Establishing income-tracking mechanisms at eye departments: Eye care staff were oriented on how to record and track funds collected in eye care units. The project team and the Regional Economist continue to conduct periodic supportive supervision to ensure that District and Regional Eye Coordinators record all revenue collected in eye units. Recording of income collection will provide evidence for the ongoing advocacy work and helps to influence districts to allocate staff to eye care clinics.

Advocacy for eye health financing.

District and Regional Level Advocacy: The project team continue to conduct advocacy meetings with community leaders to generate buy in towards self-sustainability through the eye health financing mechanism. This advocacy focuses on:

Ensuring that hospital plans, council health plans, and health facility plans include eye care components (such as medicines, medical devices and consumables).
Encouraging districts to decrease the number of exemptions for eye care and increase enrollment in iCHF and NHIF especially for vulnerable groups, so that they can generate more resources from eye care service delivery.
Build the capacity of managers in financial control, efficiency and fair allocation of funds most.

National Level Advocacy: Sightsavers Tanzania ensured that lessons learned from the implementation of the eye health financing mechanism are integrated into the newly launched National Eye Care Strategic Plan 2018/2022. On page 15, the Ministry of Health calls for the integration of eye health in national insurance schemes (iCHF and NHIF), and the introduction of the cost recovery model.

Challenges in implementing the eye health financing.

The eye health financing mechanism requires integration with health insurance schemes however; some eye care services are not covered by NHIF/iCHF.

NHIF provides spectacle for the principle member only (dependants are excluded). This have been raised by Singida Regional Authority at the national level- Sightsavers is planning to undertake a national level advocacy meeting to ensure that the NHIF guideline is revised to accommodate these challenges.
iCHF does not cover the cost of surgeries and spectacles. As the majority of beneficiaries fall under iCHF, these creates a barrier to the full implementation of the developed Eye Health Financing Mechanism. The project team and Singida Regional Authority continue to engage and advocate for changes to the newly developed iCHF guidelines.
Most community members (beneficiaries) fail to pay for health insurance either due to lack of awareness or inability to pay for health insurance. Singida Regional Authority will continue to create awareness on the importance of health insurance to encourage more people to prioritise health insurance.

The eye health financing mechanism calls for Sightsavers, the Ministry of Health Community Development Gender Elderly and Children and the Singida Regional Authority to ensure the sustainability of project outcomes, however it requires separate financial resources for effective follow up and periodic training to eye care staffs and health management teams. Therefore, it is critical that future interventions invest resources into the implementation of sustainable eye health financing mechanisms.