Reuben Thomas, 29, lies motionless in Tanzania’s largest orthopaedic hospital, the Muhimbili Orthopaedic Institute (MOI). A bodaboda (motorcycle taxi) driver, he had been navigating Dar es Salaam’s chaotic traffic in pursuit of a potential passenger when he collided with a minibus. His left leg is now fractured and held together by costly intramedullary nails, as his hospital bill mounts.
With no daily income and his meagre savings swallowed by the initial costs, his future remains uncertain. He is not covered by any health insurance scheme. Some 9-10 people who have been in motorcycle crashes arrive daily at MOI for emergency treatment—and, like Thomas, 80% of them do not have any health insurance.
“I was brought to the hospital by friends, but they can’t afford to help me foot the bill. My sister has been going from family member to family member, asking for contributions,” says Thomas, whose average daily income of around £3 is what his family relies on for survival. If he can’t find a way to pay the bills, he—like many others—may be forced to forgo care. Alternatively, many in this position turn to crowdfunding to pay for treatment or end up heavily in debt.
Millions of Tanzanians like Thomas struggle to make ends meet. More than 80% of the population are on low incomes. They have minimal access to healthcare services and are outside of the country’s existing health insurance system. Only 15% of the country’s 64 million people are covered by health insurance. Currently, the available schemes are only mandatory for people in formal employment. The majority who are not covered by insurance (over 50 million people) pay out-of-pocket to access services.
“We are hoping that a definite solution will be found. As a hospital, we shoulder the burden of those who are unable to pay,” says Joel Bwemelo MOI’s head of research and training.
The solution at hand is Tanzania’s new Universal Health Insurance Law, passed on 6 December 2023 by President Samia Suluhu Hassan.
When it is finally implemented, every citizen in Tanzania will be required to have some form of health insurance, with Article 15 (2) of the law requiring everyone to have the baseline Community Health Insurance Package. Under the current policy, Tanzania only provides free healthcare services for people aged 60 and over, pregnant women, and children under 5.
But there are widespread concerns about the sustainability and impact of the new law on those on low incomes.
Details to be confirmed
“There has to be a distinction between the existing policies and what the new health insurance schemes will offer,” says Hendry Samky, the head of system strengthening at the Benjamin Mkapa Foundation, an organisation that focuses on improving healthcare in rural Tanzania. He adds that a mass awareness campaign on health insurance is essential “because there is a clear lack of awareness.”
The new law—the exact date for rollout is yet to be announced—promises to cover a broader proportion of the population than the current controversial system.
The current system isdominated by the National Health Insurance Fund (NHIF), whose dual role as both an insurance provider and price setter for healthcare services has led to friction, with private hospitals recently threatening to deny care to NHIF cardholders.
Under the new law, NHIF, which is run by the ministry of health, will be recognised as a separate “public health insurance scheme.” Like other health insurance providers, it will be regulated by the Tanzania Insurance Regulatory Authority, which will oversee the entire insurance landscape, including health services. Private health insurers have always been regulated by the authority.
Details of how the universal insurance scheme will work are scarce. The attorney general’s office in collaboration with the ministry of health are still working on regulations that will guide implementation of the law. But health minister Ummy Mwalimu said on 1 January 2024 that the regulations “will specify how much each person will contribute” in terms of premiums.
The law also guarantees a special fund for accident and emergency patients and further stipulates that a fund should be set up by the government to provide health insurance for people who are unable to pay and those with chronic diseases.
To succeed will require “strong political will,” says Samky. “The government must be ready to make hard decisions. The first is around where it will get financial resources to pay for health insurance for people who are unable to pay.” He favours a largely tax funded scheme that he believes is more sustainable when compared with user fees.
The new law also allows the government to double down on health by taxing “sin goods” like sugary drinks, gambling, and alcohol. In the context of the rising burden of non-communicable diseases in Tanzania, Samky sees it as a “double win” in curbing unhealthy behaviour.
Sustainability
The Parliamentary Social Services Committee, led by MP Stanslaus Nyong, warns of the new law’s potential burden on low income earners. “Can they truly afford the healthcare they deserve under this law?” Nyong asked in a report published on 12 February.1
He expressed concern that people with low incomes will be “forced” into having an insurance package they can’t afford, despite government support for the very poorest. Samky and other experts The BMJ spoke to emphasise the difficulty in judging levels of poverty by income. For instance, according to the National Bureau of Statistics,2 in 2018 the minimum needed to meet basic needs was 49 320 Tanzanian shillings (£15.15; €17.72; $19.34) per adult a month.
Nyong also emphasised the need for careful consideration of the services people on lower incomes will receive under universal health insurance. Under the current system, hospitals have exemption policies for the poorest patients—the hospital foots the bill for those who are found unable to pay and are eligible for assistance—but the process of evaluating who is “poor” is obtuse and inconsistent. Hospitals like MOI have also raised concerns about the rising burden of such exemption costs.
To safeguard Tanzanians from catastrophic healthcare costs,3 Ntuli Kapologwe, a researcher of primary healthcare and director of preventive services at the ministry of health, advocates an integrated approach prioritising prevention. He advocates a model that includes “health promotion, primary and secondary prevention, and basic curative services,” and is delivered by the country’s newly trained community health workers (CHWs). The CHW programme launched in January 2024 and aims to recruit 137 294 workers in 26 regions of mainland Tanzania. Its focus is to increase primary healthcare access with the aim of reaching villages, streets, and hamlets across the country.
Kapologwe believes a model using CHWs could help detect disease conditions early. “That means people can seek treatment for conditions while it is less costly, compared with when the disease is advanced,” he tells The BMJ.
George Ruhago, a senior lecturer in health economics at Muhimbili University of Health and Allied Sciences in Tanzania, stresses the need for a smooth transition that preserves the ongoing government budgetary support for healthcare provision, while introducing new insurance schemes. “The key is maintaining the balance between current government funding and the introduction of universal health insurance,” he says, cautioning against abruptly withdrawing budget support and explaining why achieving universal health insurance will require a delicate balancing act.
“The government must continue investing while building robust and self-sufficient universal health coverage mechanisms,” Ruhago says. “This must go along with improving the quality of health services provided. People might enrol in the schemes but if they don’t get good quality healthcare they might not renew their subscriptions.”
As the public waits for the official rollout of universal health insurance, Thomas—echoing the thoughts of many in Tanzania—says, “I’ll join as soon as I’m shown how. As for now, I don’t really know how to go about it.”
Footnotes
-
Commissioned, not externally peer reviewed.
-
I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.