Context

The Self-Managed Health Insurance Schemes (SMHIS) programme in Mbozi district (Tanzania) targets to improve the quality of services provided by a network of health partners in the area of activity. It is both a financial instrument and a social organization that has been implemented for 3 years in Tanzania as a pilot-project. The project is implemented within the catchment area of the Moravian Church Mbozi Hospital (MCMH), a faith based hospital, main health partner.

As planned in the agreements signed between the MCMH and the 9 operational SMHIS for the year 2004/2005, and eventually as agreed between the SMHIS network, the MCMH and the CIDR programme manager, an independent physician (Dr.Itrosi Sanga M.D), was appointed to conduct a medical auditing in the MCMH on the treatments of members who have been attending the hospital through the use of their SMHIS procedures in a period of 1 year.
Two different objectives were assigned to the medical audit : to evaluate the contract between the SMHIS and MCMH and to asses the costs of HIV members for the SMHIS.

Contribution

This medical audit report presents the methodology employed and results for each point evaluated. It also provides recommendations.
It is a good and complete example of basic medical audit report which can be used by health insurance schemes network’ counsellor and/or doctor.

Executive summary

The evaluation concerns :
 The control of the number of recourses and the amount invoiced by the MCMH to the SMHIS and the evaluation of the lump sums negotiated between the MCMH and SMHIS ;
 The evaluation of the cost of planned recourse ;
 The evaluation of the possible adverse selection and the risks of over/ under prescription ;
 The evaluation of the role of gate keepers ;
 The evaluation of the financial impact of HIV/ AIDS.