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Can regional health insurance accelerate universal coverage for all Africans?


In mid-2023, it is expected that all citizens of Tanzania will have health insurance cover. The lowest contributor is expected to pay Tsh84,000 (USD 35) per year. Big deal? To some countries with well-established national health insurance schemes, it is just normal. To others without such schemes, it is a grand socio-economic achievement, which begs the question: Should Africa’s regional (economic) blocks become catalysts to spread universal health insurance across member countries and enable all Africans to access basic, decent health care? The answer is yes and here is why.

Let us first note that this is not a technical presentation to insurance professionals. Rather, it is a simplified, common-sense explanation of why health insurance should be availed to all citizens of Africa if meaningful development is to be hastened.

It should be noted from the outset that many African countries have government hospitals that provide free service, but these are often under-resourced – in terms of equipment, medicines and personnel – and hardly able to serve the people. Poor maintenance in many cases renders such facilities centres for spreading disease as well, but they are maintained even if inefficiently for political reasons. These do not form part of our discussion.

The lifesaving character of health insurance

Universal health coverage is essential because you cannot know when you will fall sick. When you do, your (family’s) only concern should be getting to the health facility. But in the absence of ready cash or health insurance, the first/main concern when you fall sick is mobilization of cash to pay the health service provider. There are many issues related to that reality.

For one thing, the hunt for the requisite money wastes valuable time and the ensuing delay can even cost life. In some instances, people are required to surrender land title certificates before they are admitted for urgent treatment. In most of these cases, they also have to present substantial sureties to commit that they will pay as if they are criminal suspects seeking court bail.

For another, in the absence of valuable assets and savings, an uninsured patient has to borrow to pay to access health care. This means that after recovery, they start working to pay for a treatment they already had – that is if they still have a job. Paying for health care becomes a debt trap. As a consequence, persons without health insurance –and they are the majority in our countries – are likely to remain stagnant and cannot register significant personal development.

Moreover, even if one has savings at the time they fall sick but have no insurance, it means they have to raid the savings, taking them away from their intended purpose – usually investment for the future in assets like housing and education for children.

Worst still, it may not be the saver’s sickness, but the sickness of a relative, and it is considered ‘un-African’ to ‘sit on your savings’ when a relative needs money to pay for treatment. So even if you have your own health insurance cover, your savings are not safe if your relatives are not insured. This shows that we all remain vulnerable as long as those around us are not health insured.

The case for regional public health insurance schemes

The idea that we can only be safe if our neigbors are equally protected is true at the individual, country and regional levels. The Covid-19 pandemic has reminded us that much.  EAC has some countries whose drive to universal coverage is on a steady course like Kenya and Rwanda. They are soon to be joined by Tanzania, which already has some quasi-public schemes – like those for public servants and for savers under the National Social Security Fund (NSSF) – that cover just a small fraction of the population.

Uganda has several private sector insurance companies providing cover for staff of public and private sector corporates. But there is no public insurer, as even the giant NSSF hasn’t gone in the health direction. As a result, only 375,000 are covered by private insurance health providers in a population of 45 million. Moreover, almost all the policyholders are sponsored by employers, with only 8,000 people in the entire country paying for their own health cover.

For conflict ridden countries like South Sudan, it may not mean much to have universal health coverage when there are hardly adequate health service providers in easy reach, making regional cover (for those who can afford) relevant, until such a time the country can develop basic infrastructure.

But since individual states all have a different approach to financing healthcare, a bold approach that would benefit EAC citizens can originate at the regional level, through recognizing access to decent healthcare as a right and proceeding to enact enabling instruments to make possible the creation of a regional public health insurance scheme. If a well-packaged East African Insurance focusing on health and underwritten by the EAC on behalf of member governments would attract say, fifty million subscribers who can pay Tsh84,000 or USD 35 per year across the region for a start, it would go a long way to start protecting Africans from the danger of leaving their health care to chance. It would also inspire the necessary confidence for the realization of other still–sluggish dreams like common regional currencies.

A public health insurance project that brings millions of consumers into the healthcare market can be revolutionary. The turn-up of hundreds of people (presenting complicated ailments arising from untreated simple problems) at occasional free health camps run in East Africa shows that there is a need for such a revolution. Mass regional cover would attract real investment in the sector for the manufacture of drugs and equipment, establishment of health facilities and hiring of many medical personnel. It would also foster the spread of best health management practices that are still only in isolated corners of the region, like the emerging use of Artificial Intelligence to manage the medical supply chains in Rwanda, which also links the local health facilities to manufacturers abroad. Supply chain management is a cause of huge losses through stock-outs on the one hand and the expiry of stocks on the other in Africa.

In the seven-member East African Community, all countries have private sector insurance companies that can provide all cover policies depending on what a client can afford. You can even insure your cat and your shoes. However, leaving healthcare coverage in the hands of private insurers is ineffective as it only targets the privileged section of the population and leaves the rest to fend for themselves.

Moreover, in many of our countries, the situation breeds abuse in private healthcare funding as health service providers tend to over-claim from the insurers and/or overprescribe.

Further, overmedication in elite families benefitting from employer-sponsored insurance schemes is an emerging problem that needs to be addressed by regulators of health services.

Most importantly, the insurers themselves can hardly break even because the principle behind insurance – of many people facing a common risk (of falling sick) each contributing a little so that few who actually get the problem can be adequately indemnified (treated) – is being defeated. The insurer becomes a mere conduit for payment as virtually all the contributions for insurance are paid to the service providers.

To be sure, similar abuses exist in public healthcare funding as a few privileged public servants access the health budget for their referrals abroad, eroding the funding for the public health facilities where the majority are supposed to get free treatment. Depending on the level of transparency and accountability in a country, some of the public funds for medical treatment overseas can end up funding shopping for the patient’s family

Clearly, initiating regional health insurance schemes across Africa to get the people out of the current approach to health seeking is complicated and difficult. However, provided a comprehensive solution addressing abuses in public healthcare schemes is adopted, it is the right thing to do.



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