Int Health 2018; 10: 1–3
doi:10.1093/inthealth/ihx046 Advance Access publication 9 January 2018
Social health insurance schemes in Africa leave out the poor
Ama Pokuaa Fennya,*, Robert Yatesb and Rachel Thompsonb
aInstitute of Statistical, Social and Economic Research (ISSER), University of Ghana, PO Box LG 74, Accra, Ghana; bCentre for Global
Health Security, Chatham House, Royal Institute of International Affairs, London, UK
*Corresponding author: E-mail: amafenny@yahoo.co.uk
Received 30 October 2017; editorial decision 2 November 2017; accepted 20 November 2017
Keywords: Governance, Health financing, Political will, Social health insurance
In many sub-Saharan African countries, evidence shows that vulnerable groups. However, many of these targeted services
the poor bear the highest burden of diseases and experience are not within the reach of the poor and, as a result, many are
high levels of catastrophic health expenditures.1 Social health not covered by health insurance schemes.9 Of the selected
insurance (SHI) is considered a key mechanism for achieving countries, Rwanda is the only one with wide coverage of the
universal healthcare by providing financial protection.2 Social poor.8 Rwanda’s Ubudehe programme provides an effective
health insurance programmes are expected to protect people mechanism to identify those most in need of exemptions under
from catastrophic healthcare costs by pooling funds to allow the CBHI. Ubudehe follows a concept rooted in Rwanda’s culture
cross-subsidization between the rich and poor and between the whereby assistance is provided within communities to members
healthy and the sick. Some African countries, grappling with dis- that are in need and have no form of assistance. These are often
satisfaction from the public over exorbitant fees charged by orphans, widows and the elderly. Rwanda has invested in a strati-
health sector providers, have introduced social health insurance fication process that has systematically identified poor groups to
schemes as a way to ensure access to all income groups, especially enable them to access all social programmes in the country, not
the poor.3 However, relatively little is known about the experience just health insurance. The schemes in Ghana and Ethiopia cover
of how countries that have adopted this health financing strategy less than 2% of the poor even though they have exemption
have tackled the issue of ensuring coverage of the poor. schemes. Tanzania and Kenya have no specific exemption
A comparative study of five African countries sought to help fill schemes for the poor, but some waivers are given to patients in
this gap by looking at how social health insurance schemes have Tanzania who are assessed to be too poor to pay their bills.
been able to cover the poor or not, as the case may be. Selected To assess the performance of these schemes, the study exam-
countries have either national or community-based insurance ines the proportion of women who delivered with the assistance
schemes with the intent of providing health insurance for all citizens of a skilled health professional in relation to their wealth status,
(more than 10 million inhabitants). The selected countries are relying on the Demographic and Health Survey (DHS). For women
Ghana, Tanzania, Kenya, Rwanda and Ethiopia. Ghana, Tanzania and of reproductive age, Rwanda’s poor groups have almost the
Kenya have similar social health programmes, although their target same level of access to a doctor/midwife as compared with richer
groups differ.4–8 Ghana’s National Health Insurance Scheme (NHIS), groups (Figure 1). On the other hand, Ghana, which has premium
covers every citizen by law, with exemption entitlement to some seg- exemptions for pregnant women under the NHIS, has huge gaps
ments of the population. Tanzania and Kenya have separate insur- in access. In Ghana, less than 50% of women in the poorest
ance schemes for the formal and informal sectors. Rwanda and quintile deliver with the assistance of a skilled professional, com-
Ethiopia operate a Community-Based Health Insurance (CBHI) pro- pared with 97% in the richest quintile.
gramme, but Rwanda’s CBHI system (CBHIS) is mandatory (Table 1). In spite of provisions made to cover the poor, SHI pro-
Countries have used different methods to expand coverage grammes have faced challenges in enrolling this group. Defining
for health services for some vulnerable groups. Some countries, who the poor are is a task that policymakers have grappled
such Ghana, Rwanda and Ethiopia, have exemption schemes with. Many terms have been used to identify the poor—ultra-
within the health financing framework that target poor and poor, very poor, indigent and vulnerable, to name a few. Coining
© The Author(s) 2018. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is
properly cited. For commercial re-use, please contact journals.permissions@oup.com
1
EDITORIAL
Downloaded from https://academic.oup.com/inthealth/article-abstract/10/1/1/4794744 by University of Ghana. Balme Library user on 23 July 2019
A. P. Fenny et al.
Table 1. Structure of health financing reforms in five sub-Saharan countries
Country Structure/type of scheme Year of Revenue generation Health insurance coverage, Risk pooling
reform % of the population
Single Multiple
Ghana National Health Insurance 2005 72% taxes 38% (2015) *
Scheme (NHIS) 20% SSNIT contributions
4% investment income
3% premiums
1% other sources
Rwanda CBHI, informal sector 1994 66% household premiums 80% (2015–2016) *
14% government
10% global fund
10% other sources
Kenya NHIF, formal sector 1966 34% government 11% (NHIF) *
29% OOP 1.3% (CBHI)
19% NPISH financing schemes
CBHI, informal sector 1999 9% voluntary health insurance schemes
SHIB, private sector 5% social health insurance schemes
employees 4% others
Tanzania NHIF, formal sector 2001 6% salary contribution split between employee and 17% *
employer
CHF, informal sector (rural) Member contributions ($3–$6) are matched by 4%
government at district level
TIKA, informal sector (urban)
Ethiopia CBHIS 2010/11 70% household premiums 7.5% *
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.
100 96.7 97.2 95.2 Many have questioned whether African countries have been too92.7 eager to adopt Western-style policies that are not necessarily
90 84.2 appropriate to their fiscal context. The selected countries are
80 74.9 characterized by large informal sectors, making it difficult for
70 the rolling out of health insurance scheme models that depend
60 on this group. After almost 12 years of introducing national
50 46.9 health insurance in Ghana, less than 40% of the population are
42.1
40 covered by the scheme.
31.1 The role of governance and political interests cannot be over-
30
looked. The fact that many of the schemes were introduced
20 17 with the backing of strong political interests has resulted in the
10 inconsistencies we have seen among the selected countries.
0 Ghana’s insurance scheme has been a political pawn since its
Ethiopia Ghana Kenya Rwanda Tanzania creation. The two leading political parties—the New Patriotic
Lowest Second Middle Fourth Highest Party (NPP) and the National Democratic Congress (NDC)—have
Figure 1. Proportion of women, ages 15–49 years, who delivered with often disagreed over the manner in which the scheme should
the assistance of a skilled health professional by selected African coun- be run. The scheme was introduced by the NPP in 2005 to fulfil
try, DHS data (%). Source: Ghana (DHS 2014), Kenya (DHS 2014), its promise to improve access to healthcare. The NDC, after win-
Rwanda (DHS 2014), Ethiopia (DHS 2011) and Tanzania (DHS 2015). ning the elections in 2008, failed to implement the one-term
premium promise it made during the 2008 election campaign. A
these terms and explaining what they mean and who qualifies national review that took place just before the most recent elec-
to be categorized as such has become not only burdensome but tion in 2016 pointed out several flaws, such as delays in reim-
costly—and political.10 bursing providers, false claims from some providers, difficulties
The findings from this research suggest that setting down with registration into the scheme and poor quality of care at
policies or programmes does not guarantee reaching the poor. health facilities, that needed to be addressed. However, with the
2
Downloaded from https://academic.oup.com/inthealth/article-abstract/10/1/1/4794744 by University of Ghana. Balme Library user on 23 July 2019
International Health
NPP back in power, these recommendations (owned by the wrote the manuscript. RY and RT did critical review of the manuscript
opposition) have been largely ignored. Meanwhile, the scheme is and revision of the manuscript. All authors read and approved the final
in crisis and many millions of Ghanaians are without access to manuscript.
health services.
Efforts by the Tanzanian government to cross-subsidize and Acknowledgements: The authors are grateful for comments received in
widen the insurance pool has faced much opposition in Parliament conferences where this paper was presented.
in recent years. Like Tanzania, Kenya has several insurance schemes
targeting various groups of people. Sadly, the attempt to pool Funding: None.
these schemes and ensure coverage for the large number of peo-
ple in the informal sector has proven futile. Although Rwanda’s Competing interests: None declared.
national health insurance scheme is heavily donor funded, it has
proven that where there is strong political will and good govern- Ethical approval: Not required
ance 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 References
goals of these processes within the various country case studies 1 World Health Organization. Health systems financing: the path to
and draw some key conclusions, including: universal coverage. World Health Report 2010 Geneva: World Health
Organization; 2010. http://www.who.int/whr/2010/en.
• Poor and vulnerable groups are left out of schemes because 2 Mathauer I, Schmidt J-O, Wenyaa M. Extending social health insur-
of difficulties in the identification process, even where there ance to the informal sector in Kenya. An assessment of factors
are legal requirements for doing so. affecting demand. Int J Health Plann Manage 2008;23(1):51–68.
• Poverty is a dynamic process and therefore categorizing poor 3 Acharya A, Vellakkal S, Taylor F et al. Impact of national health insur-
and vulnerable people into rigid categories may lead some ance for the poor and the informal sector in low- and middle-
into financial impoverishment as a result of health shocks. income countries: a systematic review London: EPPI-Centre, Social
• Fragmented risk pools discourage income cross-subsidization Science Research Unit, Institute of Education, University of London;
among the pools, making them unsustainable in the long term. 2012.
4 National Health Insurance Authority. National Health Insurance
Have we been too optimistic in thinking that our national health Authority Annual Report Accra: NHIA-Ghana; 2013.
insurance schemes can cover the poor? Which system of health 5 Marwa CW. Provision of national health insurance fund services to
financing will work better in the African context? Is it time for its members; pain or gain? Unif J Sport Health Sci 2016;2(1):1–6.
reforms? For many African countries, it is time to look at reforming 6 Deolitte CL. A strategic review of NHIF and market assessment of private
the health sector. Political leaders have a penchant for using their prepaid health schemes Nairobi: Ministry of Medical Services; 2011.
power to cripple the very policies they set up amidst a flurry of 7 Feleke S, Workie M, Hailu Z et al. Ethiopia’s community-based health
activities to garner more votes for the next election. As we advo- insurance: a step on the road to universal health coverage
cate for the poor, we must not forget our politicians, who have the Washington, DC: US Agency for International Development; 2015.
power to drive the success of our social health programme. Will 8 Kunda T. Increasing equity among community based health insur-
health insurance schemes cover the poor? Let us speak to our poli- ance members in Rwanda through a socioeconomic stratification
ticians. Integrating the poor into SHI will require the strengthening process. Paper presented at the Third International Conference of
of institutions and an increase in the political will to effectively the African Health Economics and Policy Association, 2014.
implement exemption policies across all sectors of the economy. 9 Spaan E, Mathijssen J, Tromp N et al. The impact of health insurance
in Africa and Asia: a systematic review. Bull World Health Org 2012;
90(9):685–92.
10 Aryeetey GC, Jehu-Appiah C, Spaan E et al. Costs, equity, efficiency
and feasibility of identifying the poor in Ghana’s National Health
Authors’ contributions: APF, RY, and RT conceived and designed the Insurance Scheme: empirical analysis of various strategies. Trop Med
study. APF, RY, and RT did data acquisition. APF analyzed the data. APF Int Health 2012;17(1):43–51.
3
Downloaded from https://academic.oup.com/inthealth/article-abstract/10/1/1/4794744 by University of Ghana. Balme Library user on 23 July 2019