Planning, Development and Standards Branch

For the past two decades the informal sector has grown very rapidly in Tanzania. In the early 1990s it was estimated to be contributing about 60% of the country's GDP. Some authorities even believe that this figure is an underestimate.

This sector provides a "safety net" to many women and youth in the country. Its role in providing for livelihood is becoming more important as the formal sector shrinks due to retrenchment. In some towns the sector is better organised than in others. There have also been many attempts to organise members into groups for effective operations. In some, such attempts have succeeded in establishing social security benefits of various kinds. In others, these attempts are yet to bear fruit. This sector is widely spread in both urban and rural areas.

As is the case for the rest of Tanzania, Arusha and Mbeya have no social assistance programmes. This is becoming so more and more now. For many years the Government had provided health care and education free. Now it no longer does. People must pay for them on an out of pocket payment basis. Likewise, food-subsidies have been removed and prices have been decontrolled. Those in the formal sector (itself shrinking rapidly) are better off in receiving some packages of social assistance. Those in the informal sector are on their own. The only social assistance programmes they have are those which are self-initiated.

Tax-financed social assistance has been on a very rapid decline in Tanzania. This has left many vulnerable groups in very poor conditions. These groups include pregnant women, children, low income families, the disabled, the old and widows! Their only hope remains in the informal sector. This sector, however, needs some seed money and other inputs such as a piece of land from where they can operate. Due to irregular and decreasing incomes, members of this sector have virtually fallen out of any supportive network. Self-organisation, pooling of resources, and collective approach to problems is the only solution out of the current situation.

Most of the target groups do realise the situation they have found themselves in. This explains why there was so much enthusiasm in Arusha and Mbeya when we introduced the idea of health insurance schemes. In Arusha, one old lady of 78 years of age gave us her contribution on the spot. When we declined to take it, she was very disappointed. She then insisted we tell her exactly when the schemes are going to start.

The enthusiasm with which people are discussing the idea of schemes is associated with the high costs they are now facing on an individual basis at the private health care provider units. A single visit simply costs at least five thousand Tanzanian shillings. This is 15% of the minimum wage. Many people are, therefore, going without any care at all. When they learn that by contributing twenty shillings they can regain access, they feel waiting any longer is fatal. Since these contributions will come from the people themselves, they will continue to be available. Care must be exercised, however, to ensure that the quality of services is good. Given the large numbers of private providers in town and the ensuing competition for patients, quality will be an important card for most providers. Other resources that are locally available are the experienced leaders of the groups. These leaders owe their competence to frequent training undertaken by GTZ of Germany and the co-operative offices of respective regions. These leaders have also been taught simple book keeping and accounts. These are resources which will be there for many years to come.

The experience with the ILO initiated health insurance scheme for the informal sector in Dar es Salaam shows that administrative costs can be kept to a minimum if the schemes are led by the elected committees. As much simplicity as possible must be retained. Frugality needs to be exercised. As far as care providers are concerned, we have experiences where they have charged for what they prescribed rather than what they dispensed. This often increases the bill. Also, incidences where prescriptions fall out of the Essential Drugs List have been recorded. Monitoring the providers closely is necessary. This is possible by making sure that the circulating invoices which have spaces to show all drugs prescribed are properly completed.

Five informal sector groups in Dar es Salaam have for the past one year enjoyed the benefits of a health insurance scheme. This scheme provides for all the needed primary health care needs, for the group member, his wife/husband and children. The providers are private health care practitioners operating in Dar es Salaam either solo or as a group. All participating members do contribute twenty Tanzanian shillings per day per head. It is about one US dollar per month, or twelve US dollars per year (a figure estimated by the World Development Report of 1993 by the World Bank Health as being enough to provide primary health care). By use of the money collected, they have opened a bank account controlled by the groups themselves.

A system for services users has been put in place. This identity system uses photo identity cards, a circulating invoice, a sick-sheet and the respective groups leadership. The care providers have agreed to prescribe those medications approved by the World Health Organisation in its Essential Drugs List.

In balancing their books, they have made use of a professional accounting support. This support has been paid for partly by the groups fund and partly on an administrative one time support. It is in the constitution of the groups that all of the needed administrative support will have to come from their own funds. This will enable the scheme to be self sustaining. Savings made so far indicate that there will not be any need for externally supplied finances to support the administrative infrastructure.

The success enjoyed by these groups - in coming together and staying together - in the health care schemes is based on two main attributes:

There is a serious crisis in Tanzania now as far as health care financing is concerned. The economy is still performing very poorly. The emerging private practice is yet to expand to the rural areas which carries 85% of the population. Any attempt that seeks to put in place a viable financing system is therefore readily supported by all institutions and the Government. UMASIDA has already been reported in several news papers and has been on the TV news. The co-ordinator and Mr. Frans Heijnis have been invited to present it at the Population and Health group meetings (This group consists of donors supporting the health sector in Tanzania). The Ministry of Health Tanzania has also asked the ILO for the UMASID report. As a health insurance organisation, UMASIDA is also registered with the Ministry of Home Affairs. The National Insurance Corporation has also asked to meet the co-ordinator so that they can exchange ideas on how it works.

Institutional support has also been readily forthcoming in the two regions where the feasibility studies were done. In Mbeya, the Regional Commissioner, Mr. Basil Mramba, gave the researchers full audience and promised to give all support that may be required in the future. The Regional Medical officer and the Medical Officer of the Municipality were extremely supportive and promised to do all they can in the future.

This feasibility study aimed at assessing how and under what conditions the outputs produced and the activities deployed by the ILO project on social security for the informal sector will contribute to the establishment of a social security system in the two areas. The main emphasis for this study was the establishment of health insurance schemes in the identified areas, i.e., Mbeya and Arusha.

This research was by and large guided by the ILO/INTERDEP project results in Dar es Salaam. The INTERDEP project was implemented in Dar es Salaam to improve social security in the informal sector in an urban setting. It succeeded to establish a functioning health insurance scheme for five informal sector groups. Since the Dar es Salaam field experiences were used as a guide in the fieldwork in Arusha and Mbeya, a summary will be provided of some of the lessons learnt about establishing social security - health insurance schemes - for the informal sector.

In essence, this is an exploratory study. It seeks to investigate whether the schemes (health insurance schemes) being proposed would be able to take in the regions chosen as pilot areas. The rationale for choosing these regions will be dealt with later. To be able to achieve the objectives laid out above, various methods were used.

The formal and informal interviews facilitated an in-depth understanding of the social security schemes in the area under question. This arrangement provided an interactive milieu for deeper probing on responses given. Details of the findings of the interviews will be presented below. Actual visit to work/operational sites yielded first-hand information on the realities of the informal sector workplace and group dynamics. It also enabled the researchers to talk to the operators on a one-to-one basis and experience some of their organisational arrangements.

There are no health insurance schemes in Mbeya and Arusha. For the past 35 years, health care services were provided by the Government and missionaries. As already mentioned, private health care services were banned in 1977 and unbanned in 1993. In between, the country's economic situation deteriorated seriously and the Government had to largely withdraw from the social sector - including health care. This left behind a big vacuum that needs to be filled. There is, so to speak, a palpable crisis in health sector financing in the country. So far, there are no plans to fill this vacuum. The INTERDEP attempt with the consequent success in Dar es Salaam appears to offer some light at the end of the tunnel.

As it were, therefore, the Mbeya and Arusha planned pilots already had a precedent. The INTERDEP Dar es Salaam experiences had already established a field experience to be tapped for the studies. However, since Dar es Salaam is so much of an urban area and as it is not representative of the real situation in Tanzania, it was necessary to move upcountry and study areas which are more representative of Tanzania.

Mbeya and Arusha were chosen because they are deeper in the country. They are much smaller than Dar es Salaam and have areas which come very close to Tanzania's rural set-up. Both towns have typical urban, and periurban areas. The periurban zones merge into typical rural areas. They are both supported by an agricultural economy typical of the rest of Tanzania. A large portion of their inhabitants live in rural areas. Whatever succeeds in Arusha and Mbeya, therefore, would be easier to replicate elsewhere in Tanzania. Arusha, in particular, presents with a good balance of project participants. Some of the groups visited are situated in the urban area while some are situated in the rural areas. Mbeya, similarly, but not to as great an extent as Arusha.

Informal sector worker associations need to have (some of) the following characteristics to be viable carriers of health insurance

The group size. The Dar es Salaam experience has shown that a critical number of members is around 400. Smaller groups cannot absorb the slippages of risk pooling. With this number of members, the savings made to meeting the administrative costs are good. With increasing numbers savings are bigger, but they begin to level off at 2000 due to increasing administrative costs. At that level another cell needs to be created. Geographical proximity can be used to coalesce smaller groups to reach the critical number. Care needs to be exercised in resolving leadership problems in this approach.

Gender sensitivity. The majority of the disadvantaged, impoverished and marginalized in the developing countries are women. If a social security oriented scheme is to be of any impact, selected groups must reflect this composition. Deliberate measures need to be taken to involve women in the leadership and as members. The top leadership of the Dar es Salaam groups has taken account of this sensitivity and it has contributed in strengthening it.

Financial stability. Viable groups are those which have already established a common bank account and have some savings. Those with minimal accounting problems do better than those with these problems. A common fund is a powerful unifier. If this fund exists, it saves the group leadership from collecting contributions from individual members daily. Once the idea has been accepted by the group, contributions will come from the common fund.

Strong and stable leadership. A group with strong, stable and accepted leadership does extremely well in mobilising members for almost any issue. This quality played a major role in mobilising members in the INTERDEP project in Dar es Salaam.

Life history of the group. How the group has fared in the past, indicates how it will do in the future. If it has had occurrences of splitting up or confrontations, or member misunderstandings, its performance will be poor. This information is readily available from community development offices. Occasionally, some group members will volunteer such information.

Dynamism of the group. How dynamic a group is, is important in generating income, and venturing into new activities, i.e., diversifying. These qualities ensure economic security for its members. It also means that can absorb without problems sudden increases of costs.

Group stability. This means the ability of a group to take on new measures or plans to secure its members. It is also characterised by leadership terms that reach maturity. Frequent leadership changes means instability in the groups.

Security of tenure. This is a very important quality of a group as far as social security schemes are concerned. The group needs to have legal control over the land/area on which they are operating. If the local authorities do not recognise the groups ownership of the area of operation, it will remove them. This often causes groups to disintegrate and so the collapse of schemes.

Engagement viability. This has a bearing on group turnover. If there is no continuous demand on group activities, they will not be able to generate income to sustain social security scheme contributions. This element must be considered in group selection for participation in social security schemes of any kind.

Interest in ensuring availability of reliable health care services. The Dar es Salaam groups benefited much from this quality point. This project came to Dar es Salaam at the right time because the Government was withdrawing from health care services. There was a big vacuum waiting to be filled. People were, therefore, happy to organise themselves for health care. A similar vacuum is now all over the country. This may help in organising people in the other areas.

Availability of providers. The last strong lesson in establishing health insurance schemes is the availability of willing health care providers. Dar es Salaam has about 400 such providers. Such large numbers create competition for patients and occasionally works in their favour. Patients can choose and the costs are not so high as they would be in the event of a monopoly.

The second set of lessons filtering in from the Dar es Salaam experiences, and which can be used in Mbeya and Arusha - on the health insurance schemes - is the availability of willing, competent and quality private health care providers. We have learnt that, in an urban set up, there is a large mixture of care providers. Despite being licensed by the Government, some of the private care provider units are of low quality. We also learned that often lesser qualified people are left in charge, despite the operating license showing that a qualified medical doctor is the owner. Due to these problems, we have also developed a screening criteria for good provider units. These criteria have proved of great help in Arusha and Mbeya, and include the following:

Availability of a qualified medical officer all the time at the unit. This is important to ensure provision of quality care to the clients. It also serves cost that could originate from unnecessary investigations, short-run prescriptions, and delayed diagnoses and so effective treatment.

Service availability. This means the total hours out of a day that the care providing unit is open. The longer the hours, the better. This ensures availability of care to clients. The more the hours, the better a unit did in the scheme.

Availability of specific health care services for women and children. If a unit was providing maternal and child health services, it worked better for the scheme. It could provide a balanced family care package. Choice of such units and their inclusion in the scheme saved much needed family time - because all needed care could be provided under one roof. This freed time for income generating activities.

Delivery services. Extra credit was given to those units that could carry out deliveries of expecting mothers. Some of the members could still deliver at government health care units. Some support for cost-sharing fees came from the scheme.

Competent laboratories. Well equipped laboratories were an added advantage to the units which participated in the scheme. An acceptable laboratory in our context was one which could do routine tests for common diseases in Tanzania. The ability to do 5 tests was necessary for a laboratory to be acceptable. These tests included blood slide for malaria parasites; haemoglobin check; stool examination for intestinal parasites like hookworm and ascaries; routine urine examination for sugar, albumin, blood, ova; and full blood picture examination.

Locational proximity to group's area of operation. The closer to the group's area of work a care provider was, the better. This saved time, bus fares and work absenteeism. DASICO in Dar es Salaam reports increased income for the co-operative due to saved bus fares, saved time and reduced work absenteeism.

Qualified nurses. The more qualified the nurses were, the more preventive care (information) they provided. This enables patients to take better care of themselves and so fall sick less often. This reduced the incidences of illness. In the long run, it will cut down on costs for care. At Mwananyamala and DASICO, these measures have had real results.

Record keeping. Proper record keeping was a desirable quality of participating care providers. This made it possible for the project to analyse case histories and come up with main health problems. Preventive measures were taken. This did cut visits to the care providers and so reduce costs. It was also possible to cross check on what care was given when bills were doubted.

Dispensing facilities. Those units with their own dispensing facilities were most suitable. They saved patient's time. Medicines could be dispensed at the same place rather than going elsewhere to look for them.

Observation room and administration of intravenous drips. Some patients with high temperatures or diarrhoea needed to be observed for hours before they were released. This was possible only if the care providers had observation units.

Acceptance of care provider to participate in the schemes and to be paid at the end of the month. In those instances whereby the care providers did not accept scheduled payments, participation was withdrawn. Daily payments would increase administrative costs.

Cost of care. In Dar es Salaam, it was evident that the cost of care even for similar illnesses varied significantly between providers. Consultancy fees also varied. In choosing participating providers, this issue was also considered. These criteria will also influence the choice of scheme participants in Arusha and Mbeya .

This group is located in the rural areas of Arusha, and includes both men and women. Altogether, there are about 700 members, of which about 35 per cent are women and 65 per cent men. Their main activity is to crush stones into gravel by using hand hammers. They have been at this site for the past ten years.

This group has many health problems. Some are occupational, some are non-occupational. The main occupational problems we see here are "crush wounds": many of the members here no longer have nails on their fingers, and they also have lacerations. Coughing is also evident, most probably due to dust originating from the stones they are crushing. They have also complained that they cannot see a distant object any more. They most probably have developed short sightedness because of the many hours they spend with their eyes adjusted at an arm's length. Stone splinters keep hitting their eyes and they often develop conjunctivitis. They have also developed varicose veins, probably because of the long hours of squatting and exposure to the sun. A few admitted they have haemorrhoids, probably these are also caused by continuous squatting.

Hearing loss was a common complaint. This probably originates from the silica dust and the constant noise. Almost all of them complained of backache and much fatigue that are most likely due to extended squatting positions and lifting heavy rocks. Dermatitis was evident, and may be a result of excessive exposure to the sun and silica dust. Occasional nasal bleeding was reported by the women which could be caused by the excessive heat. Several children seen on site accompanying their mothers were malnourished.

Non-occupational health problems reported included malaria, pneumonia, tuberculosis, dysentery and venereal diseases.

Their average income is about 15,000 Tshs per month. It remains lower than the minimum national salary. Most have large families, and children who do not go to school. Some of the children were seen at the site accompanying their parents.

They received the idea of a health insurance scheme with applause. They felt it will serve them in their problems of inaccessibility to health care services. This group featured very high up on the 10 point criteria for a group's potential to join the scheme.

This co-operative consists of approximately 2000 people. Slightly more than half of all members of this group are women. The rest are men. Their main activity is to sell cereals, vegetables, meat, fruits, potatoes, clothing and other household items.

It is notable that hygiene in this market is inadequate. Ventilation and lighting is poor in some of the areas. These are possible sources of health problems for them. Work-related health problems originate from load lifting. Huge sacks weighing more than 100 kgs. are carried from the off-loading point by one person. Hernias were commonly reported as were occasional fractures and pulled muscles. Backache was reported by all involved in the off-loading activity. Episodes of diarrhoea and vomiting were also reported. Probably, these were due to low hygiene.

Incomes do vary greatly here. The majority have an income of between 25 and 30 thousands Tanzanian shillings per month. With increasing costs of health care, many have resorted to herbs and over-the-counter prescriptions. The idea of joining a health insurance scheme was received very well.

This is an umbrella organisation of youth engaged in a variety of income generating activities which mainly include food selling, metal works, agriculture, handicrafts making, brick making, sewing and painting. The majority of the members are young men and about 25% are young women. The main general health problems are malaria, pneumonia, dysentery and skin diseases. This group has poor access to health care services. Cost for health care are high, while incomes are low. A few of them have young families. It is becoming clearer to them that new arrangements are necessary to improve availability of health care services.

The idea of a health insurance scheme was very well received. Incomes also vary. Most, however, are within the national minimum income.

This group is located in periurban Arusha. It has about 500 members. The main activities are selling fruits, cereals, vegetables, meat and clothes.

In terms of composition, about 30% are women and 70% are men. Main health problems are related to weight lifting and poor hygiene. Hernias are a frequent complaint. So, also, are dislocations and backache. The other health problems are general health problems as seen in the other groups, i.e., dysentery, venereal diseases, tuberculosis, AIDS, malaria and pneumonia. The majority of the members here are middle aged. The problem of quality health care and decreasing availability is acutely felt in this group. The idea of health care insurance schemes was therefore received with much support. Full mobilisation is yet to be done.

This group is also located in periurban Arusha. It has fewer members than the other groups already presented. Its gender sensitivity is low because it has fewer numbers of women. It has a total of 200 members. Their main activities are selling household items. They also make wheelbarrows. Main health problems include general health problems like malaria, pneumonia, dysentery, etc. They also suffer crush injuries from wheelbarrow making.

Their incomes are between 15 to 20,000 Tshs per month. Most of these members have families. The question of good and accessible health care, therefore, is important. Like the other four groups, the question of health insurance schemes was well received.

Name of care provider	Qualifying criteria
	A	B	C	D	E	F	G	H	I	J	K
Dr. Peter Mhando Hospital	+	14 hrs	+	+	+	++	+	+	+	+	+
Dr. G. Mardai Hospital	+	24 hrs	++	+	+	+	+	+	++	+	++
Itnashari Charitable Hospital	+	24 hrs	+++	+++	++	++	+++	+	+++	+	+++
Dr. Wanjara Women's and Children's Hospital	+	24 hrs	++++	+++	+	+	++	+	++	+	++
FM Clinic	+	18 hrs	+	+	+	+	+	+	+	+	++
UPONE Hospital	+	24 hrs	++	++	+	-	+	+	++	+	++

NB: For the first ten criteria, i.e., A to J: the more crosses one has, the better the quality. For criteria No. K, the more crosses a unit has, the lower the cost and so the greater its potential to participate in the scheme. Qualifying criteria A = Availability of a qualified Doctor of Medicine B = Service availability over 24 hours C = Availability of specific health care services for women and children D = Delivery services available E = Competent laboratories F = Qualified nurses G = Record keeping H = Dispensing facilities I = Observation room J = Acceptance of care provider to participate in the scheme K = Cost of care.

2.5 Viable groups and care providers in Mbeya

Uwando This is a marketing co-operative. Its main actives are buying and selling vegetables, cereals, fruits and clothing. It has a total membership of more than 5000. Women constitute about 80 per cent of the group's membership. They have very good leadership. They also have a common fund. They readily accepted the idea of establishing self financed health insurance schemes.

The majority of these members have families. Main health problems are malaria, gastro-intestinal diseases, skin diseases, elevated blood pressure and malnutrition. Backache due to lifting heavy sacks is a problem encountered often.

Wateco Group This is a group whose main activity is furniture making. It consists of about 50 people. It has no female members. They suffer general health problems. These include gastro-intestinal disorders and tuberculosis. They also suffer work related health problems like cut wounds, and crush wounds. Coughing was also reported. Probably, this is caused by the wood dust originating from working on wood. They were supportive of the idea of establishing health insurance schemes.

Ruvegesco This is a group whose main activity is selling vegetables. It has 800 members. Its member composition is well balanced about 45% the members are women. Most of their health problems are of general nature. They do not have obvious work related health problems. They, like the other groups, have happily accepted the idea of self-financed health insurance schemes.

Mpavumbe This is a group of metal workers. Total membership is 30. It has no women members. They suffer general health problems like pneumonia, gastro-intestinal problems, skin disorders, and malaria. They however, have work related problems like cut wounds, lacerations and are using welding torches without any protective measures. Hearing here is also a problem due to constant noise originating from working on metal. They have obvious interest to join the health insurance schemes.

Gayote Porters Association This is a group of porters. It is very well organised and has 48 members. Its main activity is to off load potatoes and cereals bags from lorries. They also do loading of the same. It has no women members.

This group suffers work related health problems. These include hernias, dislocations, and chronic backache. They also suffer the general health problems found in Mbeya. They have shown a strong interest to participate in the health insurance schemes.

Table 3: A summary of viable groups in Mbeya

	Group name and level of compliance
	Uwando	Wateso	Ruvegeso	Mpavumbe	Gayote
Group size	++++ 5000	-	++++ 8000	-	-
Gender sensitivity	+++	-	++	-	-
Financial stability	+++	++	++	++	++
Stable leadership	+++	++	++	++	+++
Life history	+++	+++	++	++	++
Dynamism	++	++	++	++	+
Group stability	+++	++	+++	+++	++
Engagement viability	++	++	+++	++	+
Interest to participate in the scheme	++++	++++	++++	++++	++++

3. Assessing the feasibility of the pilot projects

3.1 Existing social schemes and the participation of women

The idea of contributing to social schemes has some foundations with the groups in both areas. Most of the groups (85%) visited already have a common fund to which each member contributes. This fund is used to pay for things like funeral costs, give out small credits, and even pay for prolonged illness costs. All the selected groups are willing to pay for systematised health insurance schemes. They are also appreciative of the fact that such a systematic approach will ensure the continuous availability of health care services.

What was more encouraging is the fact that all the selected groups have a gender sensitive organisational set up that has functioned well for many years. There are functioning committees in these groups with women representatives at all levels. The question of gender sensitivity in these schemes cannot be overemphasised because of the peculiar position of women in the informal sector. The majority of participants in this sector in both towns are women. They are the ones who oversee family health, and use health care services more often. If they are not ill themselves, they have a child who is ill or they are seeking immunisations. If a health insurance scheme is going to work at all, it is necessary that women are there throughout its design and execution. Caution has been taken to ensure that all the larger groups chosen in Arusha and Mbeya have between 40-50% women members. The Dar es Salaam experience has shown that, to cut down on administrative overheads, it is necessary to involve the groups as much as possible in administering the schemes. This has worked very well with Mwananyamala (in Dar es Salaam). The proposed co-ordinator in Arusha is a woman and all the committees of the identified groups have women members. In Mbeya, the treasurer of the largest group is a women. The plans are that, when the supervising committee is composed, it must be as representative as possible. This will ensure gender sensitivity.

3.2 Funding and financial administration

All the funds for these schemes will originate from the groups themselves. It has been made very clear right from the beginning that no externally supplied funds will be available. All the groups have accepted this proposal and are confident that they will manage it. The Dar es Salaam experience shows that this is the best approach. The possibility of members or groups failing to contribute is virtually none there because the contributions per head are so small: 20 Tanzanian shillings per member per day. In both Arusha and Mbeya, group members indicated willingness to double this amount during our exploratory visits.

The need for funds from outside will be there from the beginning. Before the schemes mature, there is a need for financial support for the co-ordinators, for the holding of training seminars for the providers and groups (because this is very new arrangement in Tanzania), for some start up administrative costs (e.g., buying ledger books, communication costs, travel for the co-ordinator, and preparing the constitution for the umbrella group). As the scheme matures and savings start accumulating as they did with the INTERDEP project in Dar es Salaam, the administrative costs will be covered by group funds.

Since all groups have a bank account, the question of collecting contributions from individual members is reduced. What is needed here is a collective decision by the group members that they wish to participate in the schemes. Once such an agreement has been obtained, then contributions can be given on a group basis by the group treasurer. These contributions are then deposited in the account created specifically for the health insurance scheme. This account will then be used to settle the monthly bills sent in by the care providers. For proper bookkeeping, an accountant will be needed - on a part-time basis to begin with- to balance their books. Initially, this accountant will need to be supported by externally supplied funds. As the schemes mature, the accountant costs will be absorbed by the group common fund. This is the only administrative position that will have to be created. Whoever does the accounts will also be the administrator (an accountant cum administrator). This position will need to be provided with some record keeping equipment. These can be provided on a one-time support basis. Replacement and maintenance of this equipment will come from within.

All the groups in Mbeya and Arusha have some experience with financial management. For the purposes of regular collections and payments to a third party, their experiences are inadequate. It is planned, therefore, to enlist the help of a part-time accounts assistant. This trained professional will train a member from the group on simple accounts. The trained member will then be responsible for the group's finances. Periodical checks, however, will be done by an outside accountant.

3.3 Benefits and benefit administration

Before the scheme begins meetings are held between the providers and the groups to agree on benefits to be received. What has worked so far is an agreement specifying that all required primary-health care needs will be provided to a member, the member's spouse and children.

During the earlier phases of the INTERDEP project, we learnt that you simply cannot rely solely on trust, i.e., that everyone will be responsible and use the scheme as agreed. There was some abuse of the system by members. The system of administering benefits was still inadequate. A system to cut down on abuse was therefore developed, consisting of :

a photo identity card given to each member; a circulating invoice and, a sick sheet.

Whenever the need for care arises, the respective member sees a group leader (who keeps the sick sheets and circulating invoices) who issues a sick sheet and two circulating invoices to the needy member. The member then proceeds to the care provider with his/her photo identity card and the sick sheet and circulating invoices. The care provider, after attending to the member, signs the sick sheet and indicates the total cost on the circulating invoices. One circulating invoice remains with the care provider, whereas the second one is returned to the group office. These will be used to check on the correctness of bills sent later by the provider.

To control reproduction of the sick sheets and circulating invoices through forgery, each one of them is numbered and has an embossed seal/water mark that makes it impossible to replicate. The administration of benefits, therefore, begins in the groups where each member is known. This has cut down on possible abuses. This system has so far worked well. We hope it will do the same in Arusha and Mbeya.

It is necessary to have a check and control system to regulate use. This will also ensure that benefits are given to deserving recipients only. Groups in the studied areas have accepted to use photo identity cards, sick sheets and circulating invoices. These control measures have been found to be effective in the UMASIDA fund in Dar es Salaam.

The aspect of administrative costs was well dealt with in the UMASIDA project. Most of the administrative demands such as issuing sick sheets, provision of identity cards, communicating to providers/members, were taken care of by group committees. To start with, however, the local co-ordinator will help with setting up the system and getting it going. She/he will then phase out gradually. As she/he phases out, the group leadership and committees will incorporate the schemes demands in their daily office duties.

3.4 Interaction between the groups and the future project.

Despite the obvious need for these schemes in the country, effective mobilisation will be needed. In Dar es Salaam it began with the leaders of the groups. They in turn went into the groups and mobilised them. To be able to do this mobilisation well, those who have worked on the Dar es Salaam project will hold initiation seminars with groups in Arusha and Mbeya. The expertise they have accumulated for the twelve months will be very useful. The leaders of the five groups in Dar es Salaam will participate in mobilising their colleagues in Arusha and Mbeya. A "person-to-person" approach is effective. The message will sink in deeper if it is "grass-root to grass-root" rather than from the project coordinator. Some of the more technical aspects will be taken care of by local co-ordinators. These have already been identified.

A trusted leadership is necessary in the mobilisation and collection of financial contributions. If a group does not trust its leaders, delays and interruptions are likely to occur in individual financial contributions. Groups in both areas (Arusha and Mbeya) have a system in place that can maximise the chances of getting good leaders. They have a democratic system of electing leaders. There is also a provision of removing leaders before their term is over. They also have a constitution which defines very clearly the responsibilities of each member.

The role of the national and local co-ordinators is to introduce the idea to the various groups. The groups will then discuss it until they, on their own, accept or reject it. The groups will also form a scheme committee which will be responsible for day-to-day guidance of the scheme. This committee will be supported by an advisory group of professionals in health care. Groups of professionals have been identified in Arusha and Mbeya, but they need orientation and training to be able to understand the schemes and their role.

3.5 Sustainability

Learning from abundant bitter experiences in Tanzania, the issue of sustainability has assumed a prime role in these schemes. The exclusive use of locally generated funds in the schemes is the best guarantee for sustainability. So also is the use of as much local expertise as possible. Insistence is on keeping to the lowest possible level of resources from outside in funding the schemes. Even in the instances whereby some equipment is needed, the instances these must be restricted to one-time supplies only.

Economically, socially and politically, these schemes are a most opportune event. The Government, as already indicated, is now unable to provide health care services. Also, on an individual basis, procurement of care has become an impossible task. Costs for care have gone up and will continue to increase. Given decreasing incomes, there is no other way to ensure accessibility to care. These schemes moreover will enhance a long standing culture of the country - a culture of mutual support.

3.6 Extension to new areas

Initially activities will be focused on establishing schemes for the groups in which studies have begun. The purpose of starting with a few groups is to gain experience in the locality. Within the first six months as the first groups are getting consolidated, surveys for more groups in the same towns will be going on. Extension will also be planned for towns of similar size elsewhere in the country. For Tanzania, the next areas to be given priority are the north-west e.g. Mwanza and Shinyanga and the north-east, i.e., Tanga. These are areas that are as highly populated as Arusha and Mbeya.

As it has been stated already, so far these schemes have been occupation based. As it were most areas are mainly urban. This means some of the lessons will not be applicable to the rural areas which form the majority of the country. To make the project suitable for the rest of the country, an area based component has been chosen in Arusha. This area uses a ten-cell organisational system. Through the ten-cell system, it is possible to locate members for meetings or collective decision making in a rural set-up. This component is important because it will show how operational the scheme is for the rest of the country. It has been noted, however, that in the rural areas and the area chosen, there are no private health care providers. It is planned that, existing government health care facilities be used. The collected funds will be used to buy supplies or required inputs for these units. In the event that there is no government health care unit, a mission health care unit will be used.

The support of the local government is necessary. Its support is needed in mobilising people, opening bank accounts and even in holding meetings. To-date, this level of government has been very supportive to the idea of schemes and the study.

The Ministry of Health in Tanzania is fully informed of the studies and what has been going on in Dar es Salaam, i.e., UMASIDA. Results are eagerly awaited because of the health care financing crisis in the country. In the event a breakthrough is made, it will be a great relief for the Government.

The Ministry of Labour as well as the National Provident Fund (NPF) have planned to establish a social security fund. Its current thrust is in the formal sector. It has also welcomed interested individuals and groups in the informal sector to join.

Annex 1: A summary of critical factors in the feasibility study

FACTOR	Dar es Salaam	ARUSHA	MBEYA
1. Criteria for selecting Mbeya and Arusha	Selected by the INTERDEP project. One of three cities in the world as a pilot. Only city in Africa. The country's past policies on informal sector a decisive factor in its selection. Health insurance schemes in five groups have succeeded in this city.	A town in the northern part of the country. Has both urban and rural groups. Approximates better than Dar es Salaam to the rest of Tanzania. Lessons from this town better for the rest of the country. Private practice situation closer to realities of the rest of Tanzania than what it is in Dar es Salaam.	A town much smaller than Arusha in the Southwestern part of the country. More typical of Tanzanian towns than Arusha and Dar. Has rural elements.
2. Urban-rural balance	Poor	Good	Fair
3. Benefits to be purchased	All needed primary health care needs Used health as an entry point to create a fund that is also used for other social security needs.	All groups wish to purchase primary health care services Want to use fund for other social security schemes as it happened in Dar es Salaam. Groups have accepted the scheme as discussed.	All groups wish to purchase primary health care services. Plans to use created fund for other social security schemes following on Dar es Salaam example. Group has accepted scheme as discussed.
4. Female participation in design and operation of schemes.	In the five groups. Top leadership has 40% women. They have participated in all decision making. Treasurer to the UMASIDA scheme in Dar es Salaam scheme is a woman.	Identified project coordinator for Arusha is a woman. All groups have 45% women in top leadership.	The largest group UWANDO has 60% female membership. Two leaders out of five are women.
5. Contributions from groups	All contributions came from group members themselves. External support for coordinator, seminars, and workshops.	Groups have accepted that all funds for the schemes will be contributed by members individually or by members through their group funds.	Groups have accepted that all funds for the schemes will be contributed by members individually, or by members through their group funds.
6. Other sources of funding	Kept to lowest possible levels. External funds for coordinator, seminars and workshops.	Will be kept to the minimum level possible. Support to coordinators (national and local), seminars, and workshops only.	Will be kept to the minimum level possible. Support to coordinators (national and local), and seminars and workshops only.
7. Organizational capacity of groups	All groups were well organized	Selection of groups according to stability and degree of organization. Continued workshops will enhance organizational capacity	Good organization has been used as a criteria in selecting groups. Seminars and workshops to enhance organizational capacity.
8. Leader Trustworthiness	All leaders elected democratically On "one man-one vote" secret ballot. Have a limited term renewable if needed. Leaders can be terminated midterm.	System of electing leaders is democratic. Able to remove leaders if need be. Leadership guided by a constitution.	Constitution determines leadership election process. Removal of leader allowed. Committees advice the leader.
9. Contributions Collections	All groups had experiences in collecting contributions for common funds. Most had bank accounts. Daily contributions were collected and registered.	Groups in Arusha have traditions of contributing daily to a common fund. Demands for this scheme will not be new.	Existence of a common fund has simplified this task. It will be matter of expanding on what is in place already.
10. Financial administration	Was done by a part time accountant Accountant from the groups remuneration shouldered by the schemes fund.	The services of an accountant are necessary. After a limited time, external support groups will take over all costs.	Initially, professional help is necessary. After a prescribed time, groups will take over all costs.
11. Administering benefits	A group based control system was used. - Photo - ID - Sick sheet - Circulating invoices signed by group leaders. This arrangement has worked well as a control system.	Dar es Salaam control system will be adopted.	Dar es Salaam control system will be adopted.
12. Mobilization and coordination	This was very important It was group based. Workshops to re-orient leaders were very useful. Coordination supported from outside the groups.	All leaders are already mobilized. They will need some reorientation workshops. Idea has been accepted. Will carry out mobilization from within. Will initially require coordination from outside groups.	Leadership already mobilized. In collaboration with the identified local coordinator group mobilization is going on now. Need for outside coordination outstanding.
13. Sustainability	All funds came from the groups themselves. Outside funds kept to a minimum - and phased out over a prescribed time. Scheme had all economic and political support because of the crisis - in health sector financing in the country.	Groups have accepted that all funds will come from their contributions Any support from outside sources will be minimal and limited in time. Scheme has all political and cultural support.	Right from the beginning groups know they will raise all funds themselves. Government financing of health care is in a crisis. It has all political support.
14. Beneficiaries	Self-organized Informal Sector Group members. Most are the poorest of the poor in society. This group has some of the poorest women, children, the disabled and widows.	Informal sector groups selected. Composition similar to Dar es Salaam groups. These however are poorer than their counterparts in Dar es Salaam.	Choice of groups targeted the informal sector groups. Composition similar to Arusha. These are even poorer given the smaller size of the town.
15. Internalization of the schemes	After the first discussions. All the groups took up the initiative to ensure success of the schemes. They discussed it in their meetings until everyone supported the idea.	A similar process has been initiated in Arusha. Support has readily been given by group leaders and group members.	A similar process has been initiated in Mbeya. Support is very high.
16. Resources	All resources: manpower, finances, administrative inputs are group based. Initially there was one-time support for these as 'seed-support'. Professional support like accounting was needed from outside. Costs for this input gradually phased over to group as savings accumulated.	Groups have so far planned that all resources will come from within. Exceptions are some professional support in accounts. Costs will be phased in gradually.	Resources to be mobilized from within. Costs for professional support to be phased in.
17. Administrative costs	The simplicity of the schemes allowed groups to take on most of the administrative functions. This has kept costs low. It is necessary that the schemes are kept as simple as possible.	Administrative costs to be kept low by use of groups skills in meeting administrative demands. Most groups have good administrative structures that can be used.	Groups administrative structures to be used to cut costs in administration. All the identification aspects can be done by groups.
18. Extension to new areas	Dar es Salaam is a poor example. No other area is like Dar es Salaam in Tanzania.	Better example. If it works here, there are many other areas to where it can be extended without too many modifications.	Is even more representative of Tanzania as a whole.
19. Local government support	It has been very good in Dar es Salaam. All the district government hospitals have accepted to participate.	Support received during the study was excellent. Community development officers were very supportive.	Support during study was excellent. The Regional Commissioner gave the team an audience.
20. Policy level: Government commitment	The Ministry of Labour and Health as well as the NPF are supportive of the idea, and are following with keen interest.	All regional leadership supports the idea.	All top regional leadership including the Regional Commissioner and Regional Medical Officer are supportive and look forward to its start.
21. Project feed back and consequences	Initial results very inspiring. Many more informal sector groups are asking to join the schemes.	Any success will inspire extension to a bigger population of the town.	More people will most likely ask to join if success is accorded.
22. Replication conditions	Willingness of other groups to join. Enough private providers. Adequate support to orient groups to scheme.	To other cities and nearby rural areas.	To other towns and nearby rural areas.
23. Government policies on the informal sector	Favourable and getting better	Favourable being improved.	Favourable. Being improved.
24. Capacity for training workshops	Good	Good	Good.

Annex 2: Project activities

Remark: Not all the tables referred to in the text have been included in this Web document. In order to obtain a copy of the complete document, kindly contact the Social Security Department.

Annex 3: Project time frame (in trimesters)

Remark: Not all the tables and graphs referred to in the text have been included in this Web document. In order to obtain a copy of the complete document, kindly contact the Social Security Department.

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The ILO believes that the worldwide service for a better design and management of social protection is a permanent process which can only be advanced by a frank exchange of ideas. This series is thought to be a contribution to the process of publicizing new ideas or new objectives. It thus, contributes to the promotion of social security which is one of the ILO constitutional core mandates.

Footnotes:

1. ¹ Las estimaciones del ISSS de la PEA para 1995 son de 1.872 millones de trabajadores. Las encuesta de hogares la estiman en 2.136 millones. El diferente denominador trae como consecuencia una diferencia en la estimación de la cobertura.