Abstract:
Background: In 2001, Tanzania started implementing a National Health Insurance Fund
(NHIF) Scheme. Through the NHIF Claims Process, services rendered by providers could be
reimbursed by the Scheme. In 2012 NHIF established an electronic claims processing system
ensure an effective implementation of claims process. Despite such efforts, there is limited
information about the service providers’ compliance with claims preparation procedures at the
health facility level. Essentially, there is little documentation on the implementation of the
NHIF claims process management, especially at regional referral hospitals in Tanzania.
Objective: To assess the implementation of the National Health Insurance Fund claims process
management in Temeke Regional Referral Hospital.
Materials and Methods: This study employed qualitative case study design to assess the
implementation of the NHIF claims process in Temeke regional referral hospital. A purposive
sampling method was used to select participants in this study following the principle of
saturation level of the information collection. NVivo 12 software was used to code the data
into themes for thematic analysis.
Results: This study found that the NHIF claims process management is implemented according
to NHIF guideline and service providers were aware of the claims mangment. However, there
were several critical challenges that hinder effective implementation of the claims process
management. They include noncompliance to claims and submission process, electronic claims
system challenges and a discrepancy between NHIF treatment manuals and the national
standard treatment guideline.
Conclusion: Although service providers are aware of the NHIF claims preparation and
submission procedures. The noncompliance to claims management is the challenge, which
negatively affects the provision of high-quality health services to clients insured under the
NHIF.
Recommendation: The noncompliance practices to the NHIF claims management among
health service providers has a negative impact on the provision of quality health services to
NHIF clients and performance of the NHIF scheme. Thus, an effective collaboration among
key stakeholders is necessary in order to address the noncompliance practices in the context of
collective improvement of health service delivery.
