Social health insurance schemes in Africa leave out the poor

Abstract

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).