‘’Some people in the government talk about alleviating poverty. I don’t like that term. We shouldn’t alleviate, we need to eradicate.’’
Dr. Jetawo-Winter is head of the Kwara Health Insurance Authority in Nigeria. With a strong purpose to promote inclusive healthcare, it isn’t hard for her to get up in the morning. But that drive wasn’t always there: she pinpoints its origin in one event that continues to move her.
Out-of-pocket healthcare costs are pushing millions into poverty. PharmAccess stimulates and optimizes pre-payment and health insurance models so that patients can access care without getting into financial hardship. By empowering patients, we can equally encourage health facilities to deliver quality healthcare services their clients require. Precontracting also stimulates investments. This is how we strengthen the healthcare system.
The importance of demand-side financing
Demand-side financing is critical to strengthening a healthcare system driven by trust. It shifts out-of-pocket payments to prepayments, increasing the financial stability of healthcare providers and reducing catastrophic health expenditure that pushes people into poverty.
Insurance and prepayments are important means of financing care on the demand side. At PharmAccess, we are working with public and private partners to find the right, inclusive approaches and scale them up. All the countries in which we work are scaling their social insurance schemes – some much faster than others – while unlocking local resources. We support governments, raise awareness of best practices, and advocate for financing that gives the greatest number of people access to care.
Nigeria: broader enrollment encourages participation
In May 2022, Nigeria signed a new Health Insurance bill into law, which made health insurance mandatory for all citizens, with a subsidized premium for people in low-income groups. PharmAccess supported the review and alignment of the Act.
In Lagos, more than 760,000 people have enrolled in the state health scheme, up from 300,000 in 2021. Extending the uptake of the scheme to civil servants in Lagos has helped make the scheme more sustainable through reliable premium payments. This has improved the risk pool and the availability of funds to cover medical expenses for all income groups.
In Kwara, enrolment in the state health scheme quadrupled from about 8,000 to more than 41,000, after a few challenging years where few enrolments took place. A major contributing factor to this has been Kwara’s Basic Health Provision Fund and the additional financing from the State Government, onboarding about 80-90% of those enrolled, and providing much needed sustainable premium subsidies for low-income rural communities.
In the past years we have partnered with Kwara and CarePay to introduce the CarePay platform as a digital claims enabler for the insurance program. However, there are inherent challenges involved in implementing the CarePay technology in Kwara, including poor internet connectivity, poor usage of the technology by healthcare providers for data capture and insights, and low IT proficiency, especially in rural areas.
Also utilization of care by enrollees remains a challenge. This is partly because Kwara is rural, so people often need to travel long distances to visit a facility, which can be costly; outreach posts can help with this. But the main problem undermining the utilization of care remains the trust in services delivered.
We continue to support quality through SafeCare, and advocate for more investments in the limited healthcare infrastructure – part of Nigeria’s Basic Health care Provision Fund has been directed to the renovation of primary health facilities, drug supplies and training. In 2022, the first five facilities have been renovated. Kwara’s health scheme also guarantees a minimum level of revenue to healthcare providers, part of which is re-invested in their business operations.
Zanzibar and mainland Tanzania: making crucial health financing decisions
In collaboration with the WHO, Unicef, and USAID and its Public Sector Systems Strengthening Plus (PS3) project, PharmAccess successfully supported the Zanzibar government to develop the first-ever Zanzibar Health Financing Strategy. The strategy will lead to health financing reforms in Zanzibar, towards the introduction of contributory financing, moving away from 'free' healthcare services.
The reforms include the introduction of social health insurance and a health equity fund to finance low-income groups. With support from PharmAccess, the Zanzibar government completed the development of a mandatory health insurance law, which they plan to start implementing in July 2023.
To increase transparency in the provision of healthcare services, 85% of the Zanzibar population in all 11 districts have received a unique medical identification number (Matibabu ID), which are being implemented on a digital system called OpenIMS.
Data from OpenIMS is already proving valuable, helping the Zanzibar authorities gather information on how they administer care and how it is utilized. Insights from the data collected also informed a policy brief: the data showed that visitors of Zanzibar made up about 1% of the visiting patients in clinics but consumed 15% of healthcare resources. The policy brief advocates for the establishment of a visitors’ insurance scheme in Zanzibar, which is now under serious consideration.
In mainland Tanzania, political debates around the Universal Healthcare Bill continue. The bill proposes a mandatory enrolment for all people working in the formal and informal sector but is missing an important component on how the government will finance the premium for the lowest income groups. Meanwhile, PharmAccess is advocating for revising the financing model of maternal healthcare, adopting value-based care principles.
Kenya: advocating for continued investment
In Kisumu county, Kenya, the Kisumu health insurance scheme (Marwa) is considered an example of a universal health coverage (UHC) model that other counties look up to as a possible scalable model and are inspired by. In 2022, 144,000 people from 42,500 low-income households enrolled in Marwa – about half of the 90,000 low-income households identified.
A main challenge however remains a structural and sustainable fund or vehicle to subsidize the low-income households at the national and regional level. Unpredictable government subsidies impacts long term sustainability of Marwa, and financing is increasingly uncertain due to the ongoing economic crisis. We continue to advocate for sustainable financing approach. We also search for other funding opportunities and a public-private partnership approach, through insights from research results and interventions and facilitate discussions to maintain awareness and interest.
Digitalization has been a significant driver of insurance enrollment and healthcare utilization in Kisumu, and it is helping expand coverage also in other counties. Taking the opportunity provided by Kenya’s mobile technology revolution, PharmAccess worked in partnership with Amref Flying Doctors on i-PUSH – a UHC initiative to bring lasting system change and improve access to better care, with a focus on women and their children in Nairobi and Kakamega, using CarePay’s M-TIBA platform for enrollment and claims data registration.
Through i-PUSH, we connected 77,000 women of reproductive age and their families (230,000 people) to healthcare financing, quality, and knowledge, and enabled facilities to improve the quality of care through SafeCare. Through advocacy, i-PUSH generated interest from state and non-state actors to contribute to the support of low-income households in their communities. The project was made possible thanks to a generous Droomfonds grant from the Nationale Postcode Loterij, which ended in 2022, leaving a lasting impact of better access to care in the counties we worked in.
Find out more about i-PUSH -an UHC initiative with these videos.
Ghana: standing strong, enrollment through the economic crisis
The economic crisis in Ghana was challenging for demand-side financing in 2022. Tariffs are not corrected with inflation quickly, and combined with delayed payments, this has led facilities to prefer out-of-pocket payments, which are not favorable to patients.
Despite this, the National Health Insurance Authority (NHIA) maintained the number of enrollees in the National Health Insurance Scheme. To sustain the scheme, PharmAccess has been working with NHIA to analyze membership data which resulted in adjustments to the insurance benefit package.
The health insurer has deployed the claims app (Claim-IT) in all primary and secondary care facilities to improve the claims reimbursement process, which was co-developed with PharmAccess. The app has 3,000 active users, which translates to efficiency gains for facilities and enhanced data analytics for policy making.
A digital team at NHIA has been able to leverage the power of digitalization to improve the insurance scheme and quality of care delivery – showing the value of capacity building for technical, digital and data skills.
Building toward UHC: our work in 2023 and beyond
We believe there is a path to UHC and greater access to better care, but it is not a quick or easy journey to make. The partnerships we forge and the collaborations we build to advocate for and support demand-side financing are long-term.
We are looking at new ways to connect people to insurance and care; it takes time and effort for all involved to make this work. We are urging governments to prioritize healthcare, and this is often challenging – in 2022 we saw delays in financing and implementation due to economic crises and elections.
Despite the accelerated gains in terms of effective UHC coverage across sub-Saharan Africa, many countries in the region are still lagging. To address the financial challenges governments are facing, we are supporting a greater focus on efficient spending to enable them to do more with available funds. But we need radically different digital approaches that can unlock the value of data in favor of better-quality care, more equity, and much higher efficiency.