Cbhi compilation formatted

Community Based Health Insurance
and Micro Health Insurance
GIZ Kenya Health Sector Programme
June 2013
Kenya Profile
Implemented by:

Compilation
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MHI:
Kenya
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© 2013
Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH
GIZ Health Sector Programme
6th Floor, ACK Garden, 1st Avenue Ngong Road
P.O Box 41607 00100 Nairobi
Kenya
Tel: + 254 20 2725684
Fax: + 254 20 2719217
Web: www.giz.de /www.gtzkenyahealth.com
List of Acronyms and Abbreviations
CBHF - Community Based Health Financing
CBHI - Community Based Health Insurance
CHF - Community Health Finance
MHI - Micro Health Insurance
MOH - Ministry of Health
NHIF - National Hospital Insurance Fund
OOP - Out of Pocket
SACCO - Savings and Credit Co-operative Society
WHO - World Health Organization

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Acknowledgement
GIZ Health Sector Programme in Kenya would like to acknowledge all the organisations, who are
implementing either the community based health insurance schemes or micro-insurance scheme or
both in Kenya, for the time and information that was provided to us for use in this document. We
appreciate these organisations effort in serving their targeted group and making a contribution
towards the community.
The programme also appreciates Ms. Alisha Rahmatulla (Intern) for compiling the examples of
various forms of health insurance in Kenya; Ms. Hellen Were (Consultant) for putting it under a
context and Ms. Atia Hossain (Head of Healthcare Financing Component) for overall guidance in
the compilation effort.
Last but not least, the Programme acknowledges Ms. Olivia Okech (Communications Officer) for
putting the document together, and Dr. Heide Richter-Airijoki (Programme Leader) for approval of
the effort.

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Table of Content
Page
Introduction ................................................................................................. 5
Background …………………………………………………………… 5
Definitions ……………………………………………………………. 5
Features ………………………………………………………………. 5
Examples ………………………………………………………………… 8
Global: East African experience …………………………………….. 8
Kenya: CBHIs and MHIs …………………………………………… 9
Kenya: Health Insurance Platform ………………………………………... 10
Conclusion ……………………………………………………………….. 11
Annex ………………………………………………………..................... 12
References ………………………………………………………............... 13

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1. INTRODUCTION
In the wake of Kenyan Government commitment
to providing free healthcare aiming the maternal
services, primary healthcare and the indigent
population, sustainable ways of funding for health
care other than traditional taxation and donor
funding need to be looked into. This paper
explores the Community based health funding as a
way of pooling resources and providing health
coverage to the low income groups in the informal
sector by reviewing literature on various countries’
experiences. The main aim of the paper is thus to
document, under one roof, the various
Community Based Health Insurance and Micro
Health Insurance schemes being practiced and
implemented in Kenya.
1.1 Background
Health financing has attracted a lot of attention in
the recent past as countries aim to provide
accessible, affordable and quality health care to all
their citizens. Health financing refers to the
collection of funds from various sources (e.g.
government, households, businesses and donors),
pooling them to share financial risks across larger
population groups, and using them to pay for
services from public and private health-care
providers (WHO, 2000). The objectives of health
financing are to make funding available, ensure
choice and purchase of cost-effective
interventions, give appropriate financial incentives
to providers, and ensure that all individuals have
access to effective health services (Carrin and
James, 2005). Kenyan health sector continues to
be predominantly financed by private sector
sources including by households’ out-of-pocket
spending (RoK, 2011). Only 18% of the
population is covered by both NHIF and private
insurance companies. The remaining majority of
population mostly poor, access health care
through out-of –pocket or fees for services that
can be a major source of impoverishment (RoK,
2011). Community Based Health Insurance and
Micro Health Insurance organizations have risen
to target this population excluded from the formal
health coverage.
1.2 Definitions
The term community-based health financing
(CBHF) has evolved into an umbrella term that
covers a wide spectrum of health financing
instruments (Hsiao 2001; Dror 1999).
The common characteristics of various forms of
CBHF are that they are run on a non-profit basis
and they apply the basic principle of risk sharing
(Jakab and Krishnan, 2001). Some schemes are
integrated with the provider while others operate
outside of the service providers. These are termed
provider-based and community-based schemes,
respectively.
Micro health insurance (MHI) is a form of
micro-insurance in which resources are pooled to
mitigate health risks and cover health care services
in full or in part. It is also referred by different
names such as community-based health insurance,
mutual health insurance, community-based health
financing, and community health insurance
(Preker et al, 2002). Services are delivered through
a variety of different channels, including small
community-based schemes, credit unions or other
types of microfinance institutions, but also by
enormous multinational insurance companies
(Churchil, 2006).
1.3 Features
There are a number of reasons behind the growth
of interest in CBHF schemes in low-income
countries, including the widespread imposition or
increase in user fees for government health care
services that occurred during the 1980s and 1990s
in many low-income countries, particularly in sub-
Saharan Africa, Kenya, Uganda and Tanzania
included the increasing recognition of the
CBHF is often loosely referred as:
v Micro insurance
v Community health funds
v Community health Insurance
v Mutual health organizations
v Rural health insurance
v Revolving drug funds
v Community involvement in user fee
management

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significant scale of use of private sector providers,
even in relatively poor communities, the collapse
of government health care services in certain
countries e.g DRC Congo due prolonged conflict
the difficulties faced in expanding formal health
insurance coverage to people who are outside of
formal sector employment (Preker, 2004).
Musau (1999) argues that the decentralization
process unleashed in these countries to empower
lower layers of government and the local
community further fueled their emergence. The
inefficiency in the public health care system
caused patients to avoid accessing lower level
facilities first due to the low fees charged at all
facilities (primary, secondary, tertiary). In addition,
the district or regional hospital may have been the
only health facility that was geographically
accessible to the local community and lastly,
insufficient funding for the more cost-effective
primary health care facilities lowered the quality of
service they could provide, (inadequate supply of
drugs and other commodities, inadequate staff)
which also discouraged their use (Musau, 1999).
The success of community-based microcredit
schemes may have also contributed to the
emergence of community-based health initiatives
designed to improve the access through risk and
resource sharing (Dror and Jacquier, 1999).
In Kenya, the reduction in Government subsidies
and increasing operation costs of mission
hospitals (FBOs) led to the rise of the first CBHF
scheme. It was started by Chogoria mission
hospital in partnership with Apollo insurance in
1991 (Musau, 1999). All CBHF schemes in Kenya
are community based; however, most of them
were initiated within integrated development
activities (Musau, 1999).
Assessing the overall impact of community-based
health insurance schemes is very difficult because
in most cases, community-financing arrangements
are not registered, and therefore centrally
maintained data do not exist (Jakab and Krishnan
2004). Other reasons are lack of proper legislative
framework, policies and guidelines as to how
CBHI
and
MHI
schemes
should
be
operated. This is further complicated by variations
in structures and services offered by the schemes.
Literature review suggests that Community Based
Health Insurance has several strengths; Mobilizes
resources thus improving access to health care by
low income people, improves financial protection
by reducing out of pocket payment and combats
social exclusion by extending coverage to a large
number of rural and low income populations who
would have otherwise been excluded from
collective arrangements to pay for health care. A
study conducted by Jutting (2003) in rural Senegal
(Thies region) showed that community health
financing through prepayment and risk-sharing
reduced financial barriers to health care as was
demonstrated by higher utilization and lower out
of pocket. It further showed that risk pooling no
matter how small- scaled, could improve financial
protection for the poor. Arhin (1995) in assessing
the viability of rural health insurance as an
alternative to user fees also found that the scheme
in Ghana removed a barrier to admission and led
to earlier reporting of patients and increased
utilization among the insured.
CBHI is also useful as a component of a health
financing system involving other instruments.
Community-based health insurance schemes may
complete or fill the gaps of other health financing
schemes (social health insurance or government
financing), or they may be a first step toward a
larger-scale system (Gottret and Schieber, 2006).
Community-based health insurance may be very
useful to supplement other forms of medical
Strengths of CBHF:
v “community” people is the target
v Improves access
v Reduce out-of-pocket payment
v Mobilization of insufficient fund
Difficult Assessment of CBHF:
v Non registration of schemes
v Limited data
v Variability of schemes
Growth of CBHF: Why?
v Increase in user fees
v Dysfunctional government health care
v In-effective health insurance
v Absence of mechanism to provide health
service to in-formal sector
v Decentralization

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coverage. Community-based schemes cannot
provide medical coverage to the whole population,
but can help meet the needs of specific categories
of people, such as the rural middle class and
informal workers (Bennett, Kelley, and Silvers
2004). For this reason, in many countries
governments try to launch community-based
health insurance schemes (as in Rwanda) or use
existing ones to extend health coverage to certain
populations. In Tanzania, for instance, the
Community Health Fund targets informal
workers, while workers in the formal sector are
covered through a new social health insurance
scheme (Bennett, Kelley, and Silvers 2004).
Musau (1999) in his study of Community Based Health
Insurance Schemes in East Africa; 3 in Tanzania, 2 in
Uganda and 1 in Kenya, attributes long-term
sustainability of the schemes to their design and
management.
He further says that the problems experienced by the
schemes was not a failure of the concept of health insurance
and its applicability to low-income communities, but were
due to difficulties encountered in their design and
implementation.
CBHI has weaknesses: Limited protection for
members, sustainability, limited ability benefit for
the poorer part of the population and limited
effect on delivery of care (Gottret and Schieber,
2006). Eckman (2004) in his systematic review of
36 papers and 178 schemes of CBHI found little
convincing evidence that voluntary CBHI could
be a viable option for sustainable financing of
primary health care in low-income countries. They
were found to mobilize insufficient amounts of
resources. However, the study found evidence
that CBHI provided financial protection by
reducing OOP spending and by increasing access
to health care, as seen by increased rates of
utilization of care. The very low and diminishing
population coverage rates, however, put the
implications of this finding in doubt (Eckman,
2004).
An extensive WHO study was made in 82 non-
profit health insurance schemes for people outside
formal sector employment in developing countries
(Bennett et al. 1998). It was observed that very
few of these schemes covered large populations or
even covered high proportions of the eligible
population unless government or others facilitated
their membership through subsidies (Bennett et al.
1998).
CBHF: seen from a different glass
v Complement social health insurance or
government financing
v Supplement medical coverage
Sustainability of CBHF can be attributed to the
design and management, not on the failure of the
concept of health insurance.
Weaknesses of CBHI:
v Limited member protection
v Sustainability
v Limited benefit
v Less control on service provision

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2. Examples
2.1 Global: East African Experience of CBHI
Tanzania
Through its health sector reform initiative, the
Tanzanian government introduced the
Community Health Fund (CHF) in 1995 as a new
element in the country’s health financing strategy.
The CHF is a district-level voluntary prepayment
scheme, introduced in parallel with user fees at
public health facilities, that targets the 85% of the
population living in rural areas and/or employed
in the informal sector. It was introduced in
Tanzania as part of the Ministry of Health’s
(MOH) endeavor to make health care affordable
and available to the rural population and the
informal sector. The scheme started in 1996 with
Igunga acting as a pilot district, and was later
expanded to other districts (MOH, 1999).
Several studies have shown an improvement in the
provision of and access to health care services
after the introduction of CHF. For example, Shaw
(2002) shows that the CHF fund helped to
purchase microscopes, reduce drug stock-out, and
improved the availability of or introduced other
important equipment and supplies in various
hospitals. Other studies have also shown an
increase in health service utilization for CHF
members (Msuya, Jutting et al. 2004; Musau 2004).
However, CHF is faced with low enrolment and
coverage (MOH- Tanzania, 2003). The barriers to
enrolment identified by evaluations are: a
widespread inability to pay membership
contributions, the poor quality of available
services, a failure among communities to see the
rationale for protecting against the risk of illness,
and a lack of trust in CHF managers (Mwendo
2001; MOH- Tanzania, 2003).
Rwanda
Rwandan experience is arguably one of the most
dramatic recent experiences of CBHI-based
National Health Insurance in sub-Saharan Africa
today, at least in terms of population coverage.
After successfully initiating pilot schemes in 1999,
the Government decided to go to scale in a rapid
fashion. As of October 2007, it is reported that
the schemes had enrolled about 75% of the total
population. By 2009, the schemes coverage had
exceeded 86%, reduced out-of-pocket spending
for health from 28% to 12% of total health
expenditure, and increased service use to 1·8
contacts per year. Over the last decade in Rwanda,
deaths from HIV, TB, and malaria dropped by 80
percent, maternal mortality dropped by 60
percent, life expectancy doubled -- all at an
average health care cost of $55 per person per
year, which could be attributed to the success of
the CBHI scheme (MOH- Rwanda, 2010)
To support the growth of the schemes, the Government of
Rwanda has created a special solidarity or risk-pooling fund,
into which transfers from the Ministry of Finance via the
Ministry of Health are made to cover the costs of indigents
and people living with HIV/AIDS. The Global Fund to
fight AIDS, Tuberculosis and Malaria is providing financial
support for five years to cover the Government subsidy.
Tanzanian CBF: key features and results
v Government initiative
v Voluntary pre-payment scheme
v Parallel to user fees
v Target: rural areas, informal sector
v Started as pilot, later rolled out
v Marked improvement in service provision,
utilization
v Low enrollment, coverage
v Inability to pay membership contributions
v Poor service quality
v Lack of understanding the rationale for
protecting against risks of illness
v Lack of trust
Rwandan CBHI: key features and results
v Government initiative
v Started as pilot, later rapid rolled out
v Marked improvement in utilization, enrollment
v Reduction in out-of-pocket spending
v Average health care cost: 55USD per annum
v Government subsidy for HIV/AIDS, Malaria
continued

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2.2 Kenya: CBHIs and MHIs
The information was collected through telephone interviews with providers and also from their websites
(when available). (Please refer to Annex for details)
Name of scheme Target population Starting Date Premiums per annum Cover Limits Partners
MICRO HEALTH INSURANCE SCHEMES
Faulu Afya Kenyans in the informal
sector unable to afford
NHIF and private
insurance Premiums
Operated 3
micro-insurance
programs since
2005
• Financed
through a loan
kshs 7000
• Kshs 200 co-
payment
• Unlimited outpatient
• Kshs 200,000 inpatient limit
• Kshs 10,000 marriage benefit
• Kshs 20,000 chronic illness cover per
illness per year
• Kshs principle life benefit
• Kshs. 20,000 last funeral expense
British American insurance
–administers and processes
claims
Northstar alliance Truck drivers
Sex workers
Roadside corridor
community members
2005 TNT Express
World Food program
Pharm access Foundation
International Transport
workers federation
UNAIDS
Bima ya Jamii SACCO members
MFI clients
Jua Kali(open air) artisans
People in rural areas and
informal sector
2008 Kshs. 3650 per year • Kshs 15,000 co-payment for surgery
• Inpatient care- no monetary limit.
Maximum cumulative 180
hospitalization days
• Kshs 30,000 last funeral expense
• Kshs 100,000 accidental cover
• Kshs. 100,000 disability Insurance
cover
• Kshs 2000 per week for the duration
member hospitalised
Co-operative Insurance
NHIF
MFIs
SACCOs
Swedish cooperation Centre
Kenya Women
Finance Trust
(KWFT)
Cooperative Insurance
NHIF
Kenya Ecumenical
Church Loan Fund
(ECLOF)
COMMUNITY BASED HEALTH INSURANCE SCHEMES
Support for Tropical
Initiatives in Poverty
Alleviation (STIPA)
Low /middle income
earners(informal sector)
Living with HIV/AIDS
2006 Product A- Kshs 2000
per year
Product B- Kshs 2400
per year
Product C- Kshs 2700
per year
Kshs 5000 outpatient cover limit per year STIPA and health providers
ACK development
services((ADS)
Nyanza
Members of rural
community; nyanza
1997 Product A- Kshs 600
Product B- Kshs 960
Product C- Kshs 1200
Outpatient cover only at dispensaries and
health centres.
Product A- Kshs 8000 limit
Product B- Kshs 8000 limit
Product C- Kshs 10,000 limit
Afya Yetu Initiative
(AYI)
Residents of Nyeri and
Kirinyaga counties
2009 Kshs 2300 Total
NHIF= kshs 1920
CBHF=kshs 380
Inpatient cover at NHIF accredited
hospitals.
20,000 per visit per beneficiary
NHIF
NETWORK
Western Region
Christian community
service (WRCCS)
Rural communities in
western Region
1997 Product A-600
Product B- 600
Product C- 800
Outpatient cover only
Jamii Bora SACCO The poorest of the poor
who cannot access primary
quality health care in our
poor set-ups/slums.
2001 In-patient cover –
Kshs.5,200
In & Out patient cover
– Kshs.12,500
ACK Christian
Community services
Eldoret region
(ELRECO)
Subsistence farmers in
Eldoret Region
2005 Kshs, 1200 Outpatient cover only MOH
VI agro forestry
Good Neighbours
Min. of Livestock and
Fisheries
AMPATH
Constituency AIDs Control
Council

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3. Kenya: Health Insurance Platform
In the Vision 2030 under the social pillar, Kenya’s
vision for health is to provide “equitable and
affordable healthcare at the highest affordable
standard” to its citizens. The key areas of focus
are: (a) access including actual availability of
services and financial access - targeting
affordability, (b) equity, (c) quality, (d) capacity,
and (e) institutional capacity (RoK, 2010). The
current President of Kenya in his speech during
the official opening of 11th parliament stated that
his government would progressively roll out its
commitment to provide free primary healthcare to
every Kenyan by 2020, starting with children,
persons with disability, pregnant women and
breastfeeding mothers. Free medical care implies
more financial resources to invest in human
resource for health, medical and non- medical
supplies, health infrastructure and equipment.
Given the limitation in financing through taxes,
the Government needs to explore and invest in
alternative methods of mobilizing resources.
Free medical care has also put demand on the
urgency for universal health coverage in Kenya.
Health Care finance strategy (RoK, 2009)
recognizes that no single healthcare financing
system can work and that several mix of solutions
need to be applied in order increase health
financing and also ensure access to quality health
care by all Kenyans.
It recommends the following;
• Improving efficiency, transparency and accountability in the current health systems at NHIF and
MOH.
• Strengthening revenue collection by; 1) establishing a new revenue collection agency to collect and
manage the overall pool of Health care financing. 2) review the case for ear marked taxes and 3)
explore health bonds and other financing instruments
• More effective risk-pooling; 1) through transformation of NHIF to National Health services trust
that would oversee overall health care financing system.2) establishment of community health funds
to be insured under National Health services trust above.
• Harnessing the informal sector financing potential; supporting reforms in NHIF to penetrate
informal sector and increasing coverage from 24% to 70%.
• Broadening the benefits package; NHIF to broaden package to cover both inpatient and outpatient
• Strengthening provider incentives;
• Protecting the poor and vulnerable groups by; 1) better Identification of poor that are to be
registered for social health insurance, 2) strengthening of service provision to the poor, 3) elimination
of user fees for the poor and, 4) covering the cost of providing health to the poor through social
health insurance approach.
• Improving aid effectiveness; by ensuring Donors make more use of country mechanisms
• Ensuring sustainability through continuous review and long-term planning horizons
From the above, the strategy has placed much of
the health financing responsibility on MOH and
NHIF. NHIF is to provide cover for those in the
formal sector (together with private insurance),
informal sector (expected to increase coverage
from 24% to 70%) and also to the poor through
Social Health Insurance. Given the governance
and structural reforms that are warranted for
NHIF to perform as per the members’
expectations, it may be extremely ambitious to
expect that NHIF would be able to implement all
the above roles in the immediate future. In
addition, the challenges of arriving at a national
consensus for a scheme’s structure; income
inequalities; weak oversight capacity, and poor
infrastructure may limit the facilitation of
collections, re-imbursements and monitoring.
Given these difficulties, CBHI and MHI schemes
could be probably options for extending insurance
coverage in Kenya and particularly among the
rural and informal sectors of the society.

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4. Conclusion
Kenyan health policy makers need to recognize
the potential of CBHIs and MHIs in contributing
towards the health coverage of the informal
sector, and thereby may consider to provide for
their establishment, space, and legal framework
for growth and efficiency gain.
The Government can consider supporting them
through subsidies following the examples of
Tanzania, Rwanda and Ghana where CBHIs
formed the base for the National Health
Insurance. This made National health Insurance
to expand coverage much easily as it has used the
already existing structures in CBHIs.
CBHIs and MHIs therefore, may have the
potential to be complementary towards the
Government’s aim of achieving universal coverage
in Kenya.

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Annex
..DropboxGIZ-HSP VideosCBHI and MicroinsuranceCBHI Programs in Kenya-desk
review-July31,2012.xls
..DropboxGIZ-HSP VideosCBHI and MicroinsuranceMHI Programs in Kenya -desk
review-July31,2012.xlsx

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References
1. Arhin DC. 1995. Rural Health Insurance: A Viable Alternative to User Fees. London School of Hygiene and
Tropical Medicine.
2. Atim C (1999) Social movements and health insurance: a critical evaluation of voluntary, non-
profit insurance schemes with case studies from Ghana and Cameroon. Social Science and
Medicine 48, 881–886.
3. Bennett, S., A. G. Kelley, and B. Silvers. 2004. 21 Questions on CBHF: An Overview of
Community-Based Health Financing. Bethesda, Md.: Abt Associates, Inc., Partnerships for
Health Reform Project.
4. Carrin G, James C, Social health insurance: Key factors affecting the transition towards universal
coverage, International Social Security Review, 58(1): 45–64, 2005.
5. Churchill C. (ed.) (2006). Protecting the Poor: A Microinsurance Compendium. Geneva: ILO
6. Dror, D., & Jacquier, C. (1999). Micro-insurance: extending health insurance to the excluded.
International Social Security Review, 52(1), 71–98.
7. Eckman, Bjorn. (2004). ‘Community based health Insurance in low income countries; systematic
Review of the evidence. Health Policy and Planning 19 (5). Oxford University Press.
8. Gottret and Schieber (2006).’ Health Financing Revisited; A practitioners Guide’, World Bank.
9. Hsiao,W. 2001.“Unmet Health Needs of Two Billion: Is Community Financing a Solution?”
Health, Nutrition, and Population Discussion Paper,World Bank,Washington, D.C.
10. Jakab M. and C. Krishnan (2001), 'Community Involvement in Health Care financing; A Survey
of the Literature on the Impacts, Strengths, and Weaknesses’, Health
Nutrition and Population (HNP), Discussion Paper, Commission on Macro Economics
on Health, The World Bank, Washington DC
11. Jakab, M., and C. Krishnan. 2004. “Review of the Strengths and Weaknesses of Community
Financing.” In A. Preker and G. Carrin, eds., Health Financing for Poor People: Resource
Mobilization and Risk Sharing.World Bank,Washington, D.C.
12. Jutting, P. (2003). Do Community Based health Insurance Schemes improve poor people’s
Access to HealthCare? Evidence from rural Senegal. World Development Vol.32, No.2, pp.273-
288.
13. MOH (1999). Community Health Fund (CHF) Operations Guidelines, URT.
14. MOH (1999). Community Health Fund (CHF): Design, URT.
15. MOH (2010). Rwanda Community Based Health Insurance Policy. RoR
16. Msuya, J. M., J. P. Jutting, et al. (2004). Impacts of Community Health Insuance Schemes on
Health Care Provision in Rural Tanzania. ZEF.
17. Musango, L, J.D Butera, H. Inyarubuga, B. Dujardin (2006) “Rwanda's Health System and
Sickness Insurance Schemes” , International Social Security Review, Vol. 59, No. 1, pp. 93-103,
January 2006
18. Musau, S., (1999). Community-based health insurance: experience and lessons learned from East
Africa. Technical Report No. 34. Partnerships for Health Reform Project. Bethesda, MD: Abt
Associates Inc.
19. Musau S. 2004. The Community Health Fund: Assessing implementation of new management
procedures in Hanang District, Tanzania. Technical Report No.34. Bethesda, MD: Partnerships
for Health Reform (PHR), Abt Associates Inc.
20. Preker, A. (2004). Health financing for poor people: resource mobilization and risk sharing.
Washington DC: The World Bank.

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21. Preker, et al (2002). "Effectiveness of community health financing in meeting the cost of
illness". Bulletin of the World Health Organisation (Geneva: WHO) 80 (2): 143–150.
22. Republic of Kenya, 2009. Health Financing Strategy. Ministry of Medical Services, and Ministry
of Public health and Sanitation.
23. Republic of Kenya, 2010. Vision 2030. Ministry of Planning and National Development.
24. Republic of Kenya, 2011.National Health Accounts, 2009/10. Ministry of Medical Services and
Ministry of Public health & Sanitation.
25. Shaw P. 2002. Tanzania’s Community Health Fund: prepayment as an alternative to user fees.
Washington, DC: World Bank Institute unpublished.
26. United Republic of Tanzania (URT). 2003. Assessment of Community Health Fund in Tanzania:
factors affecting enrolment and coverage. Dar es Salaam: Ministry of Health.
27. WHO, The world health report 2000: Health systems: improving performance, Geneva, World
Health Organization, 2000

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