Table 7 Factors influencing heterogeneity in implementation outcome of the CHF Iliyoboreshwa

Organizational factors

Reward system: the reward system adopted by a given district to its workforce had impact to motivation and turnover of the workforce

“Commission is paid per number of households enrolled, whereby in this district the EO gets 10% commission … ….”

Accountability in the system: the redesigned CHF workforce being mainly part-time and had other duties (main job)

“we decided to replace teachers by local people because teachers were underperforming due to heavy workload

Availability of resources: Availability of human workforce, materials for enrolment and management of the CHF procedures, financial capacity

The scarcity of health workers and health facilities is the biggest challenge. In this district, we have only four health centres and twenty nine dispensaries instead of having twenty health centres and one hundred and three dispensaries.

Leadership engagement and team work: some districts displayed good team work spirit from top leadership to village level actors

If all leaders in the district speak the same language (cooperate) in ensuring the community members enrol in the scheme and get health services, the performance of the scheme will improve

Facilitation strategies: The variation in facilitation strategies per district, mainly rely on resource capacity, innovations and commitment

We use “gulio la afya” [open market for health services] strategy to promote the redesigned CHF

Effective communication channels: The speed and effectiveness of communication between leadership and implementation teams

For example, we use WhatsApp group for communication with CHF officer and enrolment officers but also receive, feedback from CHF members through mobile phone short messages

Number of stakeholders involved in implementation: Engagement of wider stakeholders based on their experiences with the community environment and processes, such as civil society organizations, community based leaders and influential community members

D7 has gone up until the eighth and ninth month, after the coming-projects of TASAF, where they have started the implementation of their activities. For instance we have observed that enrolment in D6 has improved very quickly because the citizens are empowered by TASAF projects

Socioeconomic and political factors

Budget gaps in local governments: Variation of sources of financing, especially, the district own source collections. Some districts are better than others

Some districts use the collected money/ own funds to buy CHF cards for the poor people who cannot afford to buy CHF cards.

Political leaders engagement: Engagement of district commissioners, regional commissioners, members of parliaments and councillors

Political will is required to make CHF a success, the previous CHF only focused on technocrats. Political leaders are close to the community and are listened by the community. In my district, CHF is a permanent agenda.

Cognitive factors

Knowledge: knowledge about insurance concepts and the operations of the scheme among the community members as well as implementers

“We have decided to recruit volunteers to support the district CHF officers to enter and manage data in the IMIS because of inadequate computer literacy which delays timely collection of the data”

Attitudes: Attitudes to the scheme by community members, leaders and implementation teams

“We have not so far claimed any funds from the nearby districts whose clients have been attended by us because we do think that we all belong to the government and we should not claim funds from the other government facilities

Motivation: Motivated leaders and implementers as key to success of the scheme operations

We implement the redesigned CHF in district level by making sure that DC,DED and District Council Chairperson contribute and motivate the heads of departments to collaborate with CHF manager and the team though the response of these government leaders is low. (manager CHF)

Perceptions: Perceptions related to usefulness of the scheme and the related services by the community members, the leaders and the implementation teams

People still have perceptions of the old CHF. All these people should be reached using village level sensitization teams (Fiona)

Coping behaviours of implementers: implementers coping behaviours and innovations to successful implement the scheme procedures in adverse conditions