
Demand-side financing

Kisumu Governor, Prof Anyang Nyong’o, and Health Cabinet secretary Hon. Mutahi Kagwe danced with community health volunteers during the UHC scale-up event in Kisumu, Kenya on March 2nd, 2022.

Our interventions on demand-side financing are designed to increase the use of healthcare services and empower patients, giving them the purchasing power to access the healthcare services they need. Read more about what our initiatives on demand-side financing entail, as well as the status and the role of PharmAccess in the key countries where we operate.
2021 IMPACT
Nigeria, Ghana, Tanzania and Kenya have embarked on national policy reforms to achieve Universal Health Coverage (UHC). PharmAccess supports counties and national governments with various approaches to reach the goal of UHC.

Innovation on the demand side: A journey that needs commitment
PharmAccess offers support on demand-side financing in the key countries we operate in: Nigeria, Ghana, Tanzania (including the Zanzibar archipelago), and Kenya. We play the role of technical assistance partner, supporting governments in their rollout of effective and sustainable health insurance models, exploring different financing mechanisms, and offering the necessary (digital) technical support. The approach is combined with support around quality, which you can read more about in chapter 6: strengthening the quality of healthcare services.
Digitalization has brought significant opportunities to make health insurance models work for low-resource settings, including the vulnerable and the poor. It is less effort for people to enroll and participate in insurance programs, and they can make digital payments via their cell phones. Furthermore, health insurance authorities are better able to redistribute funds and create health allowances. Importantly, digitalization allows for the identification of indigents – the most vulnerable in society. They can be targeted effectively and receive subsidies to access their health insurance entitlements. At the same time, digitalization creates transparency for the payer; we can provide data on how funds are spent and advise how spending can be made more effective. It also allows for the pooling of fragmented financing streams.
In all of PharmAccess’ operating countries, we have built cooperative relationships with the main health stakeholders. This ownership and (political) commitment are key to sustainability. Demand-side financing interventions can be both private- and public-driven. PharmAccess has a long history of working with private partners, but our scaling up takes place through public, government-supported programs.
Inevitably, the different stages of innovation and demand-side financing models in the countries we support experience ups and downs. They also vary, depending on the route and progress of the country in question. In some countries, we work on the very first design phases of a health insurance model (Zanzibar), while other interventions are in a testing and scaling phase (Kenya, Nigeria), or even in the phase of further refinement of a national scheme (Ghana). Let’s take a closer look at the status of demand-side financing interventions in our operating countries in 2021:
Tanzania: (Re)designing the demand-side financing strategy in Zanzibar
The quality of healthcare in Zanzibar is low, and health facilities have limited funds to improve quality. With this situation in mind, PharmAccess has been asked by the Zanzibari government to support the redesigning of the island’s health financing strategy. The government aims to move away from the notion of “free healthcare” and toward universal health coverage (UHC) through insurance-based approaches. As we are assisting in the development of the health insurance strategy, we are equally helping to explore and design initiatives that can bring in more funds – for example, by introducing new taxes for tourists to contribute to health services. At the same time, our advocacy team is supporting the establishment of a Health Insurance Fund that will ultimately have to provide funding for the new national health insurance. The Minister of Health is aiming to present the proposal for the new fund to the Zanzibari parliament next year.
Our support in Zanzibar is truly an ecosystem approach. SafeCare, our quality improvement methodology, has been adopted by the government – an important step in guaranteeing broad participation in the health insurance program.
On the Tanzanian mainland, the scaling of the national health scheme iCHF, supported by PharmAccess, has slowed down pending legislative decisions by the government. We will continue to stay in close contact with the relevant ministries and advocate for the use of poverty mapping tools to identify households that are most in need of subsidies for health insurance coverage.
Kenya: Implementing a county-wide digital health insurance program as a model for national scaling
In Kenya, the Marwa Kisumu Solidarity Health Cover was launched in 2019. This is a universal healthcare insurance program for all citizens of Kisumu, where 90,000 vulnerable households are supported through premium subsidies. It is an inspirational example of an inclusive healthcare scheme supported by data and technology. Well into its third year, the Marwa Kisumu Solidarity Health Cover program is often referred to as a leading example subscribing to the government’s Big 4 Agenda. In partnership with the County Government of Kisumu (CGK) and NHIF, PharmAccess and CarePay implemented the initial stage of the Marwa scheme by registering and identifying households eligible for a subsidy, assessing, connecting, and training 49 healthcare facilities, and providing the CGK with management and operational support. For the financial year 2022/23, the CGK has committed US$ 900,000, which will grow at 10% per annum for the next three years, as a budget line item to cover the vulnerable. The County Health Act is also being revised to allow for direct county contributions to the Marwa package. As PharmAccess we have supported the revision of the County Health Act by sharing lessons learned from our interventions, and providing technical legal assistance. The first 42,500 vulnerable households of Marwa that are enrolled are covered by donor funding. Our ambition is to help create best practices in building inclusive digital health ecosystems that can inspire other counties in Kenya to follow suit.
Scaling up in Nigeria: Challenges and opportunities
In the last five years, Nigeria has made significant progress toward achieving health insurance coverage. More than thirty states have enacted their social health insurance legislation, and PharmAccess has been supporting several of these. The successful implementation of the Kwara State Health Insurance Scheme and proof of concept was instrumental in shaping the policy formulation for the statewide health insurance model. However, the institutionalization and scaling up of the Kwara program proved to be difficult, even more so due to the economic effect of the COVID-19 pandemic. In Kwara, 45,000 users are enrolled, but the state’s ambition is to give 3.4 million inhabitants access to quality healthcare. We continue to lobby for advancing to larger risk pools, which include both the very poor and self-paying citizens, and more importantly, to work with both public and private sector stakeholders to unlock additional funding mechanisms for universal healthcare coverage. PharmAccess Nigeria is in constant contact with policymakers at the national and state levels. The lessons we have learned from the implementation of rural and urban programs have proven to be valuable in the states we are supporting through various arrangements.
In Lagos State, our work is currently focused on quality assurance, embedding SafeCare in LASHMA (Lagos State Health Management Agency) policy. On a national level, the National Health Insurance Act is in place, making it mandatory for the government to cover the poorest 83 million Nigerians. As we move forward, our advocacy work will focus on the implementation of this National Health Insurance Act across several states.
Ghana: Successful national implementation, and further digitalization of the system for transparency
Ghana’s healthcare coverage is currently over 50% and, in that sense, a leading example for many other African countries. The PharmAccess Ghana team has been able to work closely with the National Health Insurance Authority (NHIA), which is responsible for managing the National Health Insurance Scheme (NHIS). PharmAccess was entrusted with providing data analytics to improve the health insurance model’s efficiency and effectiveness and boost its use and popularity.
The PharmAccess Ghana team also advocated strongly for the integration of the NHIA with the National Identification Authority System (responsible for the introduction of the Ghana Card, used to validate citizens’ identification within the country). This digital integration makes it a lot easier for people to enroll in health insurance, as their personal data is already in the system. Ease of enrolment is a key criterion for the successful rollout of any health insurance program.
PharmAccess has equally been advocating for the integration of HefRA (the healthcare regulator) with NHIA, as they have overlapping mandates. Digital integration of their systems has now ensured that health facilities do not have to register twice. We will continue to support HefRa as they put more emphasis on the digitalization of their processes.