Social health insurance schemes in Africa leave out the poor

In many sub-Saharan African countries, evidence shows that the poor bear the highest burden of diseases and experience high levels of catastrophic health expenditures.1 Social health insurance (SHI) is considered a key mechanism for achieving universal healthcare by providing financial protection.2 Social health insurance programmes are expected to protect people from catastrophic healthcare costs by pooling funds to allow cross-subsidization between the rich and poor and between the healthy and the sick. Some African countries, grappling with dissatisfaction from the public over exorbitant fees charged by health sector providers, have introduced social health insurance schemes as a way to ensure access to all income groups, especially the poor.3 However, relatively little is known about the experience of how countries that have adopted this health financing strategy have tackled the issue of ensuring coverage of the poor. A comparative study of five African countries sought to help fill this gap by looking at how social health insurance schemes have been able to cover the poor or not, as the case may be. Selected countries have either national or community-based insurance schemes with the intent of providing health insurance for all citizens (more than 10 million inhabitants). The selected countries are Ghana, Tanzania, Kenya, Rwanda and Ethiopia. Ghana, Tanzania and Kenya have similar social health programmes, although their target groups differ.4–8 Ghana’s National Health Insurance Scheme (NHIS), covers every citizen by law, with exemption entitlement to some segments of the population. Tanzania and Kenya have separate insurance schemes for the formal and informal sectors. Rwanda and Ethiopia operate a Community-Based Health Insurance (CBHI) programme, but Rwanda’s CBHI system (CBHIS) is mandatory (Table 1). Structure of health financing reforms in five sub-Saharan countries 72% taxes 20% SSNIT contributions 4% investment income 3% premiums 1% other sources 66% household premiums 14% government 10% global fund 10% other sources 34% government 29% OOP 19% NPISH financing schemes 11% (NHIF) 1.3% (CBHI) 9% voluntary health insurance schemes 5% social health insurance schemes 4% others 70% household premiums 25% government contribution 5% others 72% taxes 20% SSNIT contributions 4% investment income 3% premiums 1% other sources 66% household premiums 14% government 10% global fund 10% other sources 34% government 29% OOP 19% NPISH financing schemes 11% (NHIF) 1.3% (CBHI) 9% voluntary health insurance schemes 5% social health insurance schemes 4% others 70% household premiums 25% government contribution 5% others CBHI: Community Based Health Insurance; CBHIS: Community Based Health Insurance Scheme; CHF: Community Health Fund; NHIF: National Health Insurance Fund; SHIB: Social Health Insurance Benefit; SSNIT: Social Security and National Insurance Trust; TIKA: Tiba kwa Kadi. Structure of health financing reforms in five sub-Saharan countries 72% taxes 20% SSNIT contributions 4% investment income 3% premiums 1% other sources 66% household premiums 14% government 10% global fund 10% other sources 34% government 29% OOP 19% NPISH financing schemes 11% (NHIF) 1.3% (CBHI) 9% voluntary health insurance schemes 5% social health insurance schemes 4% others 70% household premiums 25% government contribution 5% others 72% taxes 20% SSNIT contributions 4% investment income 3% premiums 1% other sources 66% household premiums 14% government 10% global fund 10% other sources 34% government 29% OOP 19% NPISH financing schemes 11% (NHIF) 1.3% (CBHI) 9% voluntary health insurance schemes 5% social health insurance schemes 4% others 70% household premiums 25% government contribution 5% others CBHI: Community Based Health Insurance; CBHIS: Community Based Health Insurance Scheme; CHF: Community Health Fund; NHIF: National Health Insurance Fund; SHIB: Social Health Insurance Benefit; SSNIT: Social Security and National Insurance Trust; TIKA: Tiba kwa Kadi. Countries have used different methods to expand coverage for health services for some vulnerable groups. Some countries, such Ghana, Rwanda and Ethiopia, have exemption schemes within the health financing framework that target poor and vulnerable groups. However, many of these targeted services are not within the reach of the poor and, as a result, many are not covered by health insurance schemes.9 Of the selected countries, Rwanda is the only one with wide coverage of the poor.8 Rwanda’s Ubudehe programme provides an effective mechanism to identify those most in need of exemptions under the CBHI. Ubudehe follows a concept rooted in Rwanda’s culture whereby assistance is provided within communities to members that are in need and have no form of assistance. These are often orphans, widows and the elderly. Rwanda has invested in a stratification process that has systematically identified poor groups to enable them to access all social programmes in the country, not just health insurance. The schemes in Ghana and Ethiopia cover less than 2% of the poor even though they have exemption schemes. Tanzania and Kenya have no specific exemption schemes for the poor, but some waivers are given to patients in Tanzania who are assessed to be too poor to pay their bills. To assess the performance of these schemes, the study examines the proportion of women who delivered with the assistance of a skilled health professional in relation to their wealth status, relying on the Demographic and Health Survey (DHS). For women of reproductive age, Rwanda’s poor groups have almost the same level of access to a doctor/midwife as compared with richer groups (Figure 1). On the other hand, Ghana, which has premium exemptions for pregnant women under the NHIS, has huge gaps in access. In Ghana, less than 50% of women in the poorest quintile deliver with the assistance of a skilled professional, compared with 97% in the richest quintile. Proportion of women, ages 15–49 years, who delivered with the assistance of a skilled health professional by selected African country, DHS data (%). Source: Ghana (DHS 2014), Kenya (DHS 2014), Rwanda (DHS 2014), Ethiopia (DHS 2011) and Tanzania (DHS 2015). In spite of provisions made to cover the poor, SHI programmes have faced challenges in enrolling this group. Defining who the poor are is a task that policymakers have grappled with. Many terms have been used to identify the poor—ultrapoor, very poor, indigent and vulnerable, to name a few. Coining these terms and explaining what they mean and who qualifies to be categorized as such has become not only burdensome but costly—and political.10 The findings from this research suggest that setting down policies or programmes does not guarantee reaching the poor. Many have questioned whether African countries have been too eager to adopt Western-style policies that are not necessarily appropriate to their fiscal context. The selected countries are characterized by large informal sectors, making it difficult for the rolling out of health insurance scheme models that depend on this group. After almost 12 years of introducing national health insurance in Ghana, less than 40% of the population are covered by the scheme. The role of governance and political interests cannot be overlooked. The fact that many of the schemes were introduced with the backing of strong political interests has resulted in the inconsistencies we have seen among the selected countries. Ghana’s insurance scheme has been a political pawn since its creation. The two leading political parties—the New Patriotic Party (NPP) and the National Democratic Congress (NDC)—have often disagreed over the manner in which the scheme should be run. The scheme was introduced by the NPP in 2005 to fulfil its promise to improve access to healthcare. The NDC, after winning the elections in 2008, failed to implement the one-term premium promise it made during the 2008 election campaign. A national review that took place just before the most recent election in 2016 pointed out several flaws, such as delays in reimbursing providers, false claims from some providers, difficulties with registration into the scheme and poor quality of care at health facilities, that needed to be addressed. However, with the NPP back in power, these recommendations (owned by the opposition) have been largely ignored. Meanwhile, the scheme is in crisis and many millions of Ghanaians are without access to health services. Efforts by the Tanzanian government to cross-subsidize and widen the insurance pool has faced much opposition in Parliament in recent years. Like Tanzania, Kenya has several insurance schemes targeting various groups of people. Sadly, the attempt to pool these schemes and ensure coverage for the large number of people in the informal sector has proven futile. Although Rwanda’s national health insurance scheme is heavily donor funded, it has proven that where there is strong political will and good governance structures, policies can be implemented successfully. Multi-country studies like this one allow for some validation and knowledge building, as we are able to test the common goals of these processes within the various country case studies and draw some key conclusions, including: Poor and vulnerable groups are left out of schemes because of difficulties in the identification process, even where there are legal requirements for doing so. Poverty is a dynamic process and therefore categorizing poor and vulnerable people into rigid categories may lead some into financial impoverishment as a result of health shocks. Fragmented risk pools discourage income cross-subsidization among the pools, making them unsustainable in the long term. Have we been too optimistic in thinking that our national health insurance schemes can cover the poor? Which system of health financing will work better in the African context? Is it time for reforms? For many African countries, it is time to look at reforming the health sector. Political leaders have a penchant for using their power to cripple the very policies they set up amidst a flurry of activities to garner more votes for the next election. As we advocate for the poor, we must not forget our politicians, who have the power to drive the success of our social health programme. Will health insurance schemes cover the poor? Let us speak to our politicians. Integrating the poor into SHI will require the strengthening of institutions and an increase in the political will to effectively implement exemption policies across all sectors of the economy. Authors' contributions: APF, RY, and RT conceived and designed the study. APF, RY, and RT did data acquisition. APF analyzed the data. APF wrote the manuscript. RY and RT did critical review of the manuscript and revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements: The authors are grateful for comments received in conferences where this paper was presented. Funding: None. Competing interests: None declared. Ethical approval: Not required