By: Cynthia Kanywuiro, Senior Associate at Deloitte & Touche (East Africa)
The term “healthcare in Africa” draws common buzzwords and phrases to mind; affordability, access, consideration for the bottom – line, technology and potential.
The trump card of them all is Universal Health Coverage (UHC); a socio-economic strategy often proclaimed by a number of African governments, and not without noble intention.
The effort to secure affordable, possibly even free, quality health services, to all residents of a country, remains a lofty but plausible goal on the agenda of many international jurisdictions, let alone Africa. However, what better time to further promote this idea than in the face of a global pandemic, where a shift of thought goes towards ensuring affected individuals are able to receive the medical attention they require.
A SUCCESSFUL HEALTH CARE SYSTEM
The World Health Organization (WHO) elaborates a number of factors that lead up to a successful health care system. These are adequate financing, with pooling of risk; a well – trained and adequately remunerated workforce; information on which to base policy and management decisions; logistics that ensure accessibility of medicines, technologies and vaccines, wherever they are needed; well – maintained facilities; and leadership and governance that provide clear direction and harness the energies of all relevant stakeholders, including communities.
As rightfully enumerated at the top of the list, an efficient healthcare system requires among other vitals, a proper financing structure that employs the contributions of all to cater for some, at any given time (the pooling mechanism). This further supports the notion of ‘national insurance’, often levied as a form of taxation.
SAMPLE GLOBAL HEALTHCARE SYSTEM MODELS
A 2020 survey was conducted on the top things that made Britons proud to be British. Ahead of an assortment of meals, such as fish and chips and The Queen, the National Hospital Service (NHS) took the top spot, (Newton, 2020).
The NHS is a devolved healthcare system in the United Kingdom (UK) that provides registered residents with health services, usually free of charge at the point of use, and that is primarily funded by the government from general taxation. Private health care or insurance is considered an “add – on” to the NHS, and is used by about 8% of the population. In 2016, a survey was conducted to gain public opinion on ways that the NHS could be further funded. About 70% of respondents admitted that they were willing to pay an extra penny in the pound in income tax, if the said contribution was guaranteed towards going to the NHS, (Mason, 2016).
Brazil has adopted the Sistema Único de Saúde (SUS) or The Unified Health System, which was formed to provide free Universal Health Care to all Brazilians. The SUS is termed as the largest government – run public health care system in the world. The system’s financing comes from three decentralized levels of government; the Federal Government, the State Government and the Municipal Government. Each arm makes a mandatory minimum contribution of their tax revenues and social contributions to the SUS, (World Bank, 2014). Similar to the situation in the UK, a majority of Brazil’s estimated population (approximately 75%, (Massuda, 2020)) rely solely on the SUS for their health coverage.
The sample models discussed above are a confirmation of the drivers for a successful healthcare system. Now let’s have a look at Africa’s health sector.
AFRICA AT A GLANCE
The financing prospect of Africa’s health sector is often met with high critique, given the continent’s developing nature. Even as certain countries in Africa have shared and successfully implemented the UK and Brazil’s approach to universal healthcare such as Tunisia, Algeria and Rwanda, the general issues befalling African states such as insufficient government funds, improper planning and poor allocation of financial resources, persist.
For a continent that bears the greatest brunt of disease burden, in conjunction with a number of residents living below the poverty line, financial access and responsibility would understandably top the chart amongst Africa’s healthcare concerns.
Most African countries are dependent on both the public and private sector for financing healthcare services. Where the public sector involves government intervention, mainly via taxation and social contributions, the private sector involves the participation of private insurance firms, donor Non–Government Organizations (NGOs) and persons paying Out–of–Pocket; the final being discouraged as a regressive form of financing health care, in the long run.
- South Africa and Kenya
South Africa, a country ranked as the best in terms of health care in Africa as of 2020 (Ebatamehi, 2020), recorded the highest insurance penetration rate in Sub – Saharan Africa, at about 16.99% in the year 2017, (Rudden, 2019). This high penetration is said to be supported by a sound regulatory environment, diversified multi–channel distribution, and a high level of local competition, (Lyudvig, 2020). However, the private insurance sector covers only about 20% of the country’s population, begging the question as to how persons outside of this bracket are catered for.
South Africa responded by developing a Universal Health Coverage system titled the National Health Insurance (NHI), which would grant all citizens the right to free and affordable healthcare services at the point of use, irrespective of the citizen’s socio–economic background. The system’s funding would be through a combination of various mandatory pre–payment sources, primarily based on general taxes.
Kenya, a leading health care system provider in East Africa, recorded an insurance penetration rate of 2.83% in the year 2017, (Rudden, 2019). A favourable business climate and a growing middle class are among the factors that have improved the prospects of private health insurers seeking to commence or expand their operations within the country.
However, similar to the situation in South Africa, approximately 20% of individual Kenyans reported having some form of insurance coverage, as of the year 2018, (Dutta, Maina, Ginivan, & Koseki, 2018). 89% of these individuals insured were covered under the country’s National Health Insurance Fund (NHIF).
The NHIF is a social contribution initiative by the state, which provides medical insurance to all Kenyan citizens that have attained a monthly income threshold of one thousand (1000) Kenya Shillings. The threshold lies at five hundred (500) Kenya Shillings for the self–employed. This is to enable the registered individual make a monthly contribution to the fund, which then operates on the pooling mechanism from total contributions made. The NHIF grants financial aid to persons at the point of use of healthcare services.
As seen in both cases, South Africa and Kenya’s private health insurance mainly acts as a helpful parallel to the government’s efforts, and may even be seen to alleviate the tax burden imminent from a health sector that is majorly dependent on Government revenue. However, with private insurance services available to only a small percentage of both populations, the sustained intervention of the state is essential.
- Rwanda and Nigeria
In Rwanda, the government has devolved the financing and management of healthcare to local communities through a system of health insurance providers called Mutuelle de Santé. This ensures that healthcare (especially in the form of primary care) is made available at the grassroots. Additionally, a portion of higher premiums paid by the wealthy are used to subsidize healthcare to the poor.
In Nigeria, a case was made to possibly mandate enrolment to the country’s National Health Insurance Scheme (NHIS), in order to widen the contribution base to include individuals from both the formal and informal sector, (Michael, Aliyu, & Grema, 2019) . The premise of the proposal was that Universal Health Coverage could not be successfully achieved without voluntary health insurance. Only a mix of social health insurance contributions and taxation efforts by the government would enable a wide coverage of healthcare access in the country, even to the poor.
The cases of Rwanda and Nigeria further emphasize the need for the government to play a major role in financing the healthcare sector of a state and, more so, go the extra mile in innovating and implementing practical policies in fund collection and allocations.
Rwanda’s devolution system to one of the most basic cells of society (the community) and Nigeria’s call to extend the contribution base beyond the “usual suspects” of the formal working class, highlight plausible policies that African governments can adopt.
The call for Africa to fully engage taxation and fiscal policies strategies to improve health care is commendable. However, in order to encourage whole nations to participate, the safeguarding pillars of trust and accountability must prevail.
At the end of the day, what’s in it for the contributors? Are there transparent systems in place to show how these funds are collected and used to ensure quality and accessible healthcare? Is there a general transformation of the healthcare system, even if in small but measurable steps?
Individual taxation and social contribution measures remain enforceable in so long as visible effects are seen. Where persons are able to trace the benefits, then they may very well be willing to provide that extra “penny in the pound” to support the Universal Health Care initiative in Africa.