Perceptions of the Quality of Services Provided by the 'Improved' Community Health Fund in Tanzania: Does the Involvement of Private Health Facilities Really Matter?

Abstract

Healthcare access and quality are fundamental determinants of well-being, particularly in developing countries where community-based health insurance schemes are heavily relied upon to protect informal sector populations from catastrophic health expenditures. In Tanzania, the Community Health Fund (CHF) was established in 2001 as a flagship program for healthcare coverage. To address persistent challenges, the scheme was recently "improved" through the strategic involvement of private health facilities, aiming to broaden healthcare options and enhance service quality. However, the actual impact of this integration on members' perceptions of service quality remains largely unexamined. Anchored in the Consumer Theory of Health Insurance and Institutional Theory, this quantitative study investigates the perceptions of healthcare quality under the improved CHF in two distinct regions: Dodoma and Kilimanjaro.

Drawing on data from 668 household surveys (342 in Dodoma and 326 in Kilimanjaro) collected between 2017 and 2018, the study utilized cross-tabulations, frequencies, and chi-square tests to compare regional experiences. The findings reveal that while both regions share similarities in CHF card usage, premium affordability, and agreement that the scheme increases healthcare access, significant regional disparities exist. Notably, Dodoma exhibited higher CHF renewal rates and a significantly greater proportion of households reporting actual benefits from the scheme (81.25% in Dodoma vs. 68.89% in Kilimanjaro). Conversely, Kilimanjaro respondents reported higher satisfaction with CHF enrollment officers.

Crucially, the study uncovered systemic challenges that persist despite private facility integration. A significant majority of respondents across both regions reported perceived discrimination, noting that health professionals treated CHF cardholders worse than non-members who pay out-of-pocket. Furthermore, respondents indicated that CHF members still faced longer waiting times and continued to incur high out-of-pocket user fees at the point of care, undermining the core objective of the insurance. The study concludes that the mere inclusion of private facilities in the CHF does not automatically translate to improved perceived service quality. It recommends tailored regional interventions, stricter enforcement of equitable treatment standards, and a critical review of benefit packages and hidden costs to ensure the CHF achieves its mandate of equitable healthcare delivery in Tanzania.