"Since the inception of this administration, the government made a commitment to improve the quality of life and steer the state towards universal health coverage to ensure Lagosians will have access to quality health services... without financial hardship."
Dr. Emmanuela Zamba, Permanent Secretary, Lagos State Health Management Agency
Supporting the sustainability of social health insurance
We believe healthcare expenses shouldn’t push people into poverty, and that patients should be financially protected from out-of-pocket payments. To drive transformation, we often start with private initiatives and support and grow public social health insurance.
Our work has contributed to the development and passing of social health insurance laws, including allocating budgets to vulnerable populations. However, this progress is not fast enough to meet the global goal of universal healthcare coverage (UHC) by 2030, and with an economic downfall, we are chasing a moving target.
The good news is that major elections took place across Africa in 2023, and UHC is at the top of the political agenda. For the first time, UHC and social health insurance are a priority in many countries. This means they are being protected, regardless of changing political winds and economic challenges.
Tanzania and Zanzibar: bringing the private sector into public health
Members of the public sector enrolled in Zanzibar’s first-ever mandatory social health insurance scheme in 2023, after the law was enacted in both Zanzibar and Tanzania mainland. Having supported the Zanzibar government in developing the Zanzibar Health Financing Strategy (ZHFS), PharmAccess helped design the mandatory social health insurance scheme and the supporting ICT infrastructure for its management.
The key to the success of mandatory schemes like this is the availability of government subsidies. Filling a previous gap for this implementation, the Health Equity Fund is a special fund that ringfences money to subsidize enrolment for those who cannot afford contributions.
In 2024, we will prioritize assisting the Zanzibar government in putting a business case together and supporting them in raising funds to bridge the gap. The ZHFS plans to incorporate the private sector and later the informal sector in the scheme. PharmAccess will work with ZHFS on innovative ways to reach the informal sector.
Next to this, we supported the strengthening of the Zanzibar Private Hospitals Association (ZAPHOA), which can lead to furthering public-private partnership discussions for Zanzibar.
On the mainland, we are advocating for the inclusion of private health insurance companies in the provision of standard benefit packages as per the new Universal Health Insurance Act; private companies have already been recognized in the law as potential providers of national health insurance. Although promising health bills have been passed in 2023, progress on implementing social health insurance has been slow.
Nigeria: digital insights for increased insurance coverage
Under a mandatory health insurance law, residents of Lagos must sign up for a private health plan or social scheme. PharmAccess supported the Lagos State Health Management Agency (LASHMA) by digitalizing its regulatory process for healthcare providers.
In 2023, the Lagos State Health Scheme averaged a quarterly growth rate of 6% in member registration, many of whom were state and local government civil servants and the indigent population. This resulted in close to one million people registered at the end of the year, with informal sector enrolment beginning to grow. This has made the state the first sub-national government to make significant progress in ascertaining the percentage of the population with health coverage.
However, it remains challenging to increase the number of healthcare providers enlisted in the scheme. To address this, LASHMA is looking into its product offering, pricing, and reimbursement tariffs.
In Kwara, another health insurance scheme we support, one faces challenges, including limited revenue for enlisted healthcare providers due to surging operating costs and low enrollee distribution. Scaling remains an issue. To address this, we have been supporting a protracted engagement process with labor unions towards onboarding civil servants and their family members. This hurdle is due to civil servants’ wages being grossly depreciated.
At the national level, PharmAccess participated in two technical committees in 2023, which led to the Basic Health Provision Fund doubling its Federal Government budget allocation to 2%. We also took part in national-level discussions on data standardization and interoperability.
Ghana: transforming with connectivity and data
National Health Insurance Authority (NHIA) coverage extends to over 55% of Ghanaians and covers 95% of commonly reported health conditions. Relying on insights generated from the work of NHIA’s Data Analytics Team with technical assistance from PharmAccess, NHIA has included family planning and pediatric cancers as part of its insurance benefit packages.
The NHIA has almost completely digitalized its claims management system apart from about 5% of remotely located facilities that cannot submit claims digitally due to poor internet penetration at their places of location. The high quality and (near) real-time data on membership and service utilization provided the public insurer with accurate data required to negotiate with the Ministry of Finance to release funds for claims payment to healthcare providers.
To maximize use of demand-side funds, we started exploring a value-based care (VBC) model in Ghana, with the goal of establishing a healthcare system that focuses on optimizing health outcomes and the efficient and effective utilization of financial resources. In partnership with NHIA and the Christian Health Association of Ghana (CHAG), PharmAccess developed and tested the first version of a patient-centered VBC model with 20 providers and over 2,000 patients in six regions, making Ghana the first African country to test this approach.
In this model, the intention is to match funds invested against clinical outcomes and patient experiences and highlight the importance of preventive care. It also harnesses the power of connectivity and data, with a dashboard that collates data to support informed decision-making.
We now face the challenge of aligning healthcare provider behavior with VBC standards. We are collaborating with the NHIA and Leapfrog2Value to design a reimbursement model that takes patient-reported healthcare experience and health outcomes into account. We plan to test this patient-centered model within CHAG facilities.
Kenya: connecting coverage and quality
Thousands of vulnerable households are gaining access to healthcare in Kenya, with insurance schemes at the national and county levels. Since 2018, PharmAccess has provided technical assistance for the Kisumu social health insurance scheme (Marwa) and advocated for inclusion in the national and county budgets to support the sustainability of demand-side financing.
In 2023, Kisumu country included demand-side financing in its budget for the first time, a promising step forward. Kisumu County provides a health cover premium for 5,409 vulnerable households and has budgeted KSH30 million to fund subsidies, through the National Health Insurance Fund (NHIF), for 6,000 informal sector households for 12 months, building on the technical assistance and system strengthening provided by PharmAccess. In addition, the national government is providing 18,000 vulnerable households with NHIF cover insurance. At the county level, Marwa has so far provided 174,000 people in 42,500 vulnerable households access to health insurance since initiation.
However, the resources to support all the identified vulnerable households at the country and county levels are still limited. New health laws awaiting approval will replace the current NHIF cover with a Social Health Authority (SHA) aiming to address the gap.
Although the design of the SHA is promising, and partly inspired and based on the learnings of Marwa, at the same time, the challenge for 2024 is the transition from NHIF to SHA with the whole country registered afresh for health insurance and current unclarity on benefit packages.
People covered by the Marwa scheme can go to any of the 49 Marwa facilities within the County. Thanks to CarePay’s M-TIBA platform, patients can be identified across all the facilities, overcoming the common challenge of fragmentation and non-interoperable systems. M-TIBA captures data at the level of registration and health utilization at the health facilities. The data is then aggregated and presented on a dashboard, giving policymakers actionable insights for decision-making. Based on the results, the national government has adopted the Master Facility concept that increases flexibility in the way patients can use facilities nationally.
In 2023, we piloted an inclusive proposition for an informal sector health insurance product targeted towards motorcycle riders, taking a private-public partnership approach together with private insurance company AAR. The results of the field research for this pilot are currently being aligned with the upcoming Social Health Authority in Kenya.