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Scaling-up health insurance through communitybased health insurance schemes in rural subSaharan African communities

by Ufuoma John Ejughemre

Posted on Sunday 8th of February 2015 09:15:59 PM


Context: The knotty and monumental problem of health inequality and the high burden of diseases in sub-Saharan Africa bothers on the poor state of health of many of its citizens particularly in rural communities. These issues are further exacerbated by the harrowing conditions of health care delivery and the poor financing of health services in many of these communities. Against these backdrops, health policy makers in the region are not just concerned with improving peoples’ health but with protecting them against the financial costs of illness. What is important is the need to support more robust strategies for healthcare financing in these communities in sub-Saharan Africa.

Objective: This review assesses the evidence of the extent to which community-based health insurance (CBHI) is a more viable option for health care financing amongst other health insurance schemes in rural communities in sub-Saharan Africa.

Patterns of health insurance in sub-Saharan Africa: Theoretically, the basis for health insurance is that it allows for risk pooling and therefore ensures that resources follow sick individuals to seek health care when needed. As it were, there are different models such as social, private and CBHI schemes which could come to bear in different settings in the region. However, not all insurance schemes will come to bear in rural settings in the region.

Community based health insurance: CBHI is now recognized as a community-initiative that is community friendly and has a wide reach in the informal sector especially if well designed. Experience from Rwanda, parts of Nigeria and other settings in the region indicate high acceptability but the challenge is that these schemes are still very new in the region.

Recommendations and conclusion: Governments and international development partners in the region should collectively develop CBHI as it will help in strengthening health systems and efforts geared towards achieving the millennium development goals. This is because it is inextricably linked to the health care needs of the poor.

Key words Sub-Saharan Africa, Health insurance, Pre-payment, Community-based health insurance 1


Healthcare delivery and overall health system performance are neatly knitted to health care financing. However, the situation in sub-Saharan Africa shows that in spite of the efforts made to improve healthcare financing, the knotty and Journal of Hospital Administration, 2014, Vol. 3, No. 1 Published by Sciedu Press 15 monumental problem of health inequality and the high burden of diseases in sub-Saharan Africa still bothers on the poor state of health of many of its citizens particularly in rural communities [1]. These issues are further exacerbated by the harrowing conditions of health care delivery and the poor financing of health services in many of these communities [1-3]. As it were, in a region where many of the citizens live in rural communities, it is therefore not surprising that many of the people especially women and children and in particular the poorest of the poor die from avoidable health problems such as preventable infectious diseases, malnutrition, as well as complications of pregnancy and child birth. Consequently, this has translated into a perpetually low life expectancy for many in the region. Statistical evidence show that on the average life expectancy slide by approximately two years to 47.1 between 1990 to 2005 [4]. Current life expectancy range level is about 50 years, from a high of 72 years in Mauritius to a low of 37 years in Zimbabwe with trends clearly negative in many countries in the region [4]. Increasing adult mortality from HIV/AIDS has led to a decline in overall life expectancy in the region. Equally, estimates of maternal mortality show that rates as high as 500 deaths per 100,000 live births are still recorded in many settings in sub-Saharan Africa [5]. Additionally, substantial evidence from the United Nations Children Fund (UNICEF) has it that there are records of infant and child mortality rates as high as 46 and 102 deaths per 1,000 live births respectively as well as a low index of 0.7 annual rate reduction for under five mortality recorded between 1999-2004 in many parts of sub-Saharan Africa [6]. The situation is further compounded by poor maternal delivery services as evidence reveals that in many settings approximately sixty percent of the births are not attended to by a skilled health professional [7, 8]. More so, a child born in sub-Saharan Africa is about four times more likely not to achieve full immunezation when compared to children in developed countries of the World [9].

  As it were, the poor health care delivery performance is very clearly shown from its unsalutary health systems funding with particular attention to government budgetary allocation as a percentage of total gross domestic product as illustrated in Table below. For instance, following the Abuja declaration by African Heads of State and Government in 2001 to allocate at least 15% of their annual budget to the health sector, only about six countries in the region spend about 15% of their national budget on health: Rwanda, 18.8%, Botswana, 17.8%, Niger, 17.8%, Malawi, 17.1%, Zambia, 16.4% and Burkina Faso, 15.8%, while many others are yet to implement this in their budgetary allocation to health [10]. Additionally, out-of-pocket payment for health care delivery now constitutes over fifty percent of healthcare financing in most settings in the region, driving millions of people every year into poverty and their untimely death due to catastrophic health expenditure [11-14].The result is a persistently high disease burden that has a risk of propagating a sickly and unproductive labor force, and this continues to present formidable challenges to governments, academicians and policy experts [15, 16].

  Against these backdrops, health policy makers are therefore not just concerned with improving peoples’ health but with protecting them against the financial costs of illness [17]. What is now cardinal in the region is the need to rapidly scale-up health financing through sustainable alternatives. Of critical consideration are the different models of health insurance (private and social insurance or general taxation), as health financing through general taxation and other pre-payment schemes are viable alternatives to easing the existing burden of payments for health services [18]. Substantial evidence now show that these insurance systems tend to respond to equity in financing, in that beneficiaries are asked to pay according to their means while guaranteeing them the right to health services according to need [19, 20]. However, some of these financing schemes have inherent drawbacks that will impede their full realization in a region that is characteristically rural and where most of its citizens are not employed in the formal sector [21-23]. Accordingly, there is now the need to scale-up sustainable pre-payment schemes through community-based health insurance (CBHI) in the region.

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by Dan Kaseje, MD, PhD Professor of Public Health & Vice Chancellor Great Lakes University of Kisumu

Posted on Sunday 8th of February 2015 09:09:46 PM


1.1 A Paradigm Shift in Order to Reverse the Trends in Health and Development

An appropriate, robust, and sustainable model for improvement in health system performance is essential in order to reverse the declining trends in health and development status and break the vicious cycle of poverty and ill-health in Africa. Given the diversity of the health systems across Africa, improvement would be contingent upon the convergence of commitment, expertise, and resources throughout the system. A robust model for improvement would embrace all the dimensions that are critical to health by addressing not only the risk factors of disease but also cross-cutting issues and linkages between health and employment, food security, nutrition, and financing for health. Such an approach would be better attuned to issues unique to the African continent, with enhanced responsiveness to the needs and capacities of the people.

This paper suggests a model for sustainable improvement of health system performance which takes into consideration historical lessons, and current opportunities and challenges facing Africans. The essential elements of the suggested model include decentralized governing structures linking the health system to communities; identification of an essential care package for health (ECPH) based on peoples’ priorities; an improved information system to provide evidence of improvement in service access, delivery, and outcomes; and regular dialogue among stakeholders to enhance informed demand, responsibility, and accountability. The model attempts to pay due regard to the people's own beliefs, knowledge, customs, experiences, practices, systems, and structures that give meaning to the ECPH and mitigate the discontinuity between people’s perceptions and the health intervention package through regular dialogue.

 1.2 Context

Improved health status leads to increased productivity, educational performance, life expectancy, savings and investments, and decreased debts and expenditure on health care. Ultimately this would lead to greater equity, economic return, and social and political stability. Therefore, improved health is a key factor for human development. However, many policy analysts have expressed fears that at the current rates of progress, sub-Saharan Africa (SSA) will not be able to provide satisfactory health care to its inhabitants by 2020, and will not achieve any of the United Nations millennium development goals due to increasing poverty. Health must be seen as a central element of productivity, rather than as an unproductive consumer of public budgets.

1.2.1 Unacceptable Disparity and Inequity

Globally, more advances in health, science, and technology have been made in the last 50 years than in the 500 years before the 20th Century (World Health Organization, 2002). Health infrastructure has been expanded and education, incomes, and opportunities have improved. Public health interventions and socioeconomic development have reduced mortality and raised life expectancy. Unfortunately, these gains have by no means been universal. The health gaps within and between countries have widened, perhaps due to inequality in the absorption of new technology as well as unequal distribution of new and re-emerging health problems (VonSchirnding, 2002). Disparity has increased, with a third of the global population wallowing in absolute poverty (Taylor and Taylor 2002). Each year, we are losing more than 11 million children to preventable diseases as a result of inequalities in health and development and problems are worst where resources are least available; those who need more care have the least access (Gwatkin et al., 2000).

 1.2.2 National Government Resource Scarcity in the Health Sector

Most SSA countries are constrained by resource scarcity; undermining the implementation of decentralized public services. In competing with other public services for scarce resources, the health sector is often ranked relatively low among national development priorities. In 2001, the heads of states in the African Union committed themselves to allocate 15 percent of their national budget to health in the Abuja Declaration. However, this commitment has not been realized by the majority of the countries. The average expenditure in the health sector in SSA rarely exceeds 5 percent of GDP with most African countries spending less than US $10 per person per year on healthcare when at least US $27 is needed.

More than 50% of African populations do not have access to modern health facilities and 40% have no access to safe drinking water and sanitation. High levels of maternal, child, and infant mortality and low rates of immunization, are symptomatic of the gross neglect of Africa’s rural communities (Figure 1).

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The Emerging Movement of Community Based Health Insurance in Sub-Saharan Africa: Experiences and Lessons Learned

by Doris Wiesmann / Johannes J├╝tting

Posted on Sunday 8th of February 2015 09:04:08 PM

 A country’s economic development is closely interrelated with the health status of its population. An efficient and equitable health care system is an important instrument to break up the vicious circle of poverty and ill health. Sub-Saharan African countries have tried different modes of health care financing since independence. Due to low and unstable tax revenues and cutbacks in public budgets, the initial goal to provide „free health care for all“ was never achieved. In the eighties, government resources dried up in many countries and a deterioration in the quality of existing services was the result, with poorly paid and less motivated staff and shortage of drugs and medical equipment. Under the pressure to mobilise additional resources for health care provision, public facilities and NGOrun hospitals resorted to formal or informal cost recovery strategies by collecting fees at the point of use (Criel 1998a). User fees have been heavily criticised for several reasons:

 · negative impact on equity and access: user fees can lead to access problems or even exclusion of the poor from health care utilisation, in case they cannot afford to pay the charges (Gilson 1998). The effect of poverty on access to health care may be aggravated by seasonal income variation in rural areas, as the striking of illness does not necessarily coincide with the availability of cash income (Creese and Bennett 1997), and by the fact that poor people mainly rely on their labour productivity for income generation, which is likely to be affected in the event of illness. Inequity related to user fees also exists within households with respect to children whose access to health care may be decreased because they cannot dispose of own income (Sauerborn et al. 1994).

 · negative impact on health care utilisation and public health: access problems cause a drop in utilisation rates and eventually delays in seeking care – people do not show up at a health facility unless they are severely ill (Waddington 1989, Asenso-Okyere et al. 1998). When admitted to a hospital, people often turn up only after several days – they need time to organise the money from relatives or out of other sources. Diminished health care utilisation, especially by vulnerable, disease-prone groups like children and the poor, and delays in seeking care result in adverse effects on public health1 (Booth et al. 1995, Sauerborn et al. 1994).

  · negative impact on cost-effectiveness of the health care system: delays in seeking care can result in prolonged and more expensive curative treatment in order to restore health status. Moreover, underutilisation of health facilities will reduce the running costs of these facilities less than proportionately due to the high share of fixed costs for salaries (Criel 1998a) – in consequence, costeffectiveness declines.

  Furthermore, the contribution of user fees to health care financing turned out to be far smaller than expected, and hospitals were increasingly facing the problem of rising “bad debts”, because a considerable proportion of patients left the hospital after recovery without ever paying the bills (Musau 1999). On the average, national user fee systems have generated only about 5% of recurrent health system expenditures (Gilson 1998). In contrast to user fees, health insurance encompasses risk-sharing and is supposed to reduce unforeseeable or even unaffordable health care costs (in the case of illness) to calculable, regularly paid premiums. But in Africa, public and private health insurance cover almost exclusively the formal sector, and therefore achieve a coverage rate of no more than 10 percent of the population. The majority of African citizens – informal sector workers and the rural population – have never had access to this kind of social protection (World Bank 1994). Partly as a response to this lack of social security, to the negative side-effects of user fees and to persistent problems with health care financing, non-profit, voluntary insurance schemes for urban and rural self-employed and informal sector workers have recently emerged (Jütting 2000a, Atim 1998). This paper shortly describes the hopes set into this community based health insurance (CBHI)2 schemes, shows their geographical distribution in Sub-Saharan Africa together with their size and period of foundation, and summarises experiences and lessons learned from their implementation.

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