title: Risk distribution across multiple health insurance funds in rural Tanzania.
abstract: BACKGROUND
  Multiple insurance funds serving different population groups may compromise equity due to differential revenue raising capacity and an unequal distribution of high risk members among the funds. This occurs when the funds exist without mechanisms in place to promote income and risk cross-subsidisation across the funds. This paper analyses whether the risk distribution varies across the Community Health Fund (CHF) and National Health Insurance Fund (NHIF) in two districts in Tanzania. Specifically we aim to 1) identify risk factors associated with increased utilisation of health services and 2) compare the distribution of identified risk factors among the CHF, NHIF and non-member households.
  
  
  METHODS
  Data was collected from a survey of 695 households. A multivariate logisitic regression model was used to identify risk factors for increased health care utilisation. Chi-square tests were performed to test whether the distribution of identified risk factors varied across the CHF, NHIF and non-member households.
  
  
  RESULTS
  There was a higher concentration of identified risk factors among CHF households compared to those of the NHIF. Non-member households have a similar wealth status to CHF households, but a lower concentration of identified risk factors.
  
  
  CONCLUSIONS
  Mechanisms for broader risk spreading and cross-subsidisation across the funds are necessary for the promotion of equity. These include risk equalisation to adjust for differential risk distribution and revenue raising capacity of the funds. Expansion of CHF coverage is equally important, by addressing non-financial barriers to CHF enrolment to encourage wealthy non-members to join, as well as subsidised membership for the poorest.
authors.affiliation: Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania ; Aarhus University, Aarhus, Denmark.
authors.forename: Eunice Nahyuha
authors.initials: EN
authors.lastname: Chomi
authors.affiliation: Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Phares Gamba
authors.initials: PG
authors.lastname: Mujinja
authors.affiliation: Aarhus University, Aarhus, Denmark.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Enemark
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Kristian
authors.initials: K
authors.lastname: Hansen
authors.affiliation: Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Angwara Dennis
authors.initials: AD
authors.lastname: Kiwara
mesh_terms: D003625:Data Collection; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D016015:Logistic Models; D015999:Multivariate Analysis; D009313:National Health Programs / Q000191:economics*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012306:Risk; D012307:Risk Factors; D012424:Rural Population; D012959:Socioeconomic Factors; D013636:Tanzania
keywords: Health insurance; cross-subsidisation; risk distribution; risk pool fragmentation; risk stratification