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Is Community Health Insurance the shortest path towards Universal Health Coverage in Africa?

By Abubakar Kurfi
on December 15, 2014

Last Friday, December 12,  World Universal Health Coverage day was celebrated for the first time. This is meant to be a day to celebrate progress made by the world towards the achievement of UHC. It is also intended as a day for advocacy and to hold leaders accountable towards the provision of equitable health care for all – as a case in point, see for example the statement released by the African civil society network for UHC. UHC is today a necessity in Africa because health is a fundamental human right as enshrined in all known international charters and conventions.   In addition, different nations at varying levels of socioeconomic development have shown that it is possible to achieve UHC with the right political and economic commitment.

In spite of the global momentum, Universal Health Coverage remains – at least in some circles – a contentious term that is difficult to define. What comes to one’s mind when UHC is mentioned? Who are the potential recipients? What is the range of services to be covered? And what quality of health care is needed? What are the socioeconomic variables needed for the provision of UHC in nations? Is achieving UHC a political or a technical issue or both? And how realistic is the 2015 mantra of achieving UHC for all? Above all, how does one measure the attainment of UHC by nations? David Stuckler et al, in their analysis of the political economy of UHC (background paper for the first global symposium on health systems research in Montreux), also posed the following questions:

  1. Why do some countries have UHC, while others do not?
  2. What are if any, the social and economic preconditions for UHC?
  3. How does the experience of these nations offer lessons for low and middle income countries?

Since then, the literature on UHC (including the political economy & measuring of UHC) has obviously moved on, but UHC still remains a somewhat controversial concept (see for example Amit Sengupta   at the closing plenary of the latest HSR symposium in Cape Town), even if UHC is now widely considered   one of the key components of the Sustainable Development Goals (SDGs)to be finalised in September, 2015.

Despite these challenges and ongoing controversy, the definition of UHC as provided by Thai UHC proponent Nitayarumphong, which was later modified and accepted by the WHO Commission on social determinants of health still remains the most comprehensive definition to date in my opinion. It views UHC as a situation whereby the whole population of a country has access to good quality services according to needs and preferences, regardless of income level, social status, or residency and whereby the people are empowered to use these services. The Idea of describing UHC as a situation turns it into an issue that is attainable, at least in principle, and progress towards it measurable.

However, many low income countries experience difficulties in achieving UHC, either as a result of lack of or inadequate political commitment, a poorly developed tax funded health system, lack of a robust tax base or low institutional capacity to effectively collect taxes, among other reasons. And since most countries acknowledge these impediments to universal financial protection, there is a need for  more comprehensive, people inclusive and community driven financing methods to circumvent the political, and structural difficulties inherent in achieving UHC among low income nations, hence the need for Community Health Insurance Schemes – at least as part of the toolbox. I’m well aware that this stance is not exactly in vogue for the moment.

Community based health insurance (CBHI) is a common denominator for voluntary health insurance schemes organized at the community level – they are labelled as micro insurance schemes, mutual health insurance schemes, etc. The common characteristics of CBHI as enumerated in a 2010 WHO Health report background paper by Soors et al are community-based social dynamics and risk pooling, whereby schemes are organized by and for individuals who share common characteristics (geographical, occupational, ethnic, religious, gender etc.); CBHI schemes also rely on the principle of solidarity, where risk sharing is as inclusive as possible within a given community and membership premiums are independent of individual health risks.  Participatory decision-making and management as well as a non-profit orientation and voluntary affiliation are also some the key attributes.

On all socio-economic and health indicators Africa lags behind the rest of the world, in spite of undeniable MDG progress made in some respects. And in spite of all the talk of a Grand Convergence   by 2035, this gap is still widening, with its overall negative consequences on the lives of the most vulnerable groups on this continent. Direct payments still contribute the largest share of African spending on health while most developed nations have long since facilitated comprehensive social health insurance or a tax financed health system for their citizens. Corruption and mismanagement of scarce resources have also contributed to the diminishing budgetary allocation to health and other critical social services in many countries (with Sierra Leone at least partly as a case in point?), even if the Abuja Declaration has been confirmed recently.  This has led to massive poverty which in turn has crippled or slowed down the emergence of a private sector led economy including a (well-regulated) private health care system.

The Lancet Commission ‘Global Health 2035, a World Converging within a generation’ mentioned progressive universalism as a pathway to UHC, targeting the poor from the outset, as an efficient way to achieve health and financial protection. Therefore, as Shafik et al have argued in a 2011 WHO Bulletin Editorial, CBHI should not be too easily discarded. In my opinion, Community Based Health Insurance  should remain an option in African countries with large majorities in the population trapped in poverty and excluded from formal social security systems. And therefore it should be made into a movement to either improve access to healthcare for a greater proportion of the population, or to ensure a stable source of income for healthcare provision, or both.

The challenges of financial sustainability, weak technical capacity, poor coordination of the numerous donor driven community based health insurance schemes, ineffective monitoring and evaluation, dwindling community ownership and participation as well as poor political will and commitment, among other reasons, have become an impediment to the massive roll out of community health insurance schemes in Africa.

For this to change, I feel that although voluntary participation is considered a critical ingredient of community health insurance, there is a need for African nations to make community health insurance schemes mandatory and see them as a component of their various national poverty reduction strategies. Government subsidized premiums for the poorest   will go a long way in increasing coverage, while supply side interventions like performance based financing can be integrated in the schemes to ensure quality and effectiveness of the whole process.

Rwanda and to some extent Ghana have shown that it is possible to roll out community based health insurance schemes on a massive scale and still achieve major results. However, doubts still exist among numerous scholars whether or not Community based health insurance schemes are indeed effective towards the achievement of UHC in low-income nations.

As for myself, even if it’s not a very popular thing to say these days, I do believe that with the right political commitment, a clearly developed plan of action backed by the necessary financial and technical skills, Community based health insurance will not only succeed in Africa but can serve as a catalyst for Africa to achieve UHC. It is imperative for us to realize that on the world’s journey towards UHC, Africa must move with the others, perhaps not at the same speed but definitely in the right direction. Community based health insurance schemes can serve as one of the vehicles for Africa to provide comprehensive, equitable, accessible health care to the generality of its populace as it moves towards achieving Universal Health Coverage for All.

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