Background
Healthcare is a primary need and a development indicator revealing regional differences in quality of and access to healthcare services. Like other developing regions, countries in Africa bear higher health burdens in terms of access and quality of healthcare services relative to developed regions, low and middle-income countries bear 90% of the global burden of diseases and only 12% of global health spending. There is a general discrepancy in healthcare delivery between rural and urban; rural communities in Africa experience relative deprivation compared with urban communities in terms of factors that determine coverage and impact of health insurance schemes. Rural Africa is disproportionately affected by factors including low socioeconomic status of households and undeveloped health infrastructure that limit coverage and impact of health insurance schemes in rural areas.
Access to health insurance is affected by rural household’s socioeconomic status. Evidence from literature shows a positive correlation between insurance enrollment and socioeconomic status of rural households across the continent in Ghana, Nigeria and Burkina Faso in West Africa. Enrollment rises with low, middle and high socioeconomic status at 21%, 43% and 60% respectively. In Eastern Africa, the number of sustained low socioeconomic beneficiaries of health insurance is nearly half the number of beneficiaries with high socioeconomic status in rural and urban comparison studies in Kenya, Uganda and Tanzania. Similarly, among Southern African countries, health insurance beneficiaries who accessed insured healthcare against communicable diseases in Botswana, Malawi and Mozambique were mostly middle- income earners with low-income earners least benefitting from insured healthcare against communicable diseases. These findings reveal that low income families are disadvantaged and are therefore not able to access much needed healthcare because they cannot afford health insurance coverage. Since the continent has an equal percentage of the population in both urban and rural areas it is important that efforts are made to develop a health insurance scheme for rural communities which is affordable and also able to provide the basic health needs of the rural population. This factor coupled with low health infrastructural development in rural Africa weakens the quality of supply and management of health insurance in rural settings. This paper examines some efforts being made to provide health insurance schemes that suit rural African communities.
Literature review
Both public and private sector health insurance schemes have undergone contextualization to enhance rural healthcare delivery. The paper examines both micro and macro health insurance schemes under private and public management that have adopted to conditions in rural Africa.
Community-Based Health Insurance (CBHI)
CBHI is a form of micro health insurance scheme that seeks to promote the management of health insurance to be responsive to the conditions of a specific group of people who share similar demographic and health characteristics. CBHI schemes are based on non-profit objectives, which cover voluntary members who are linked to a healthcare provider often a hospital that is within accessible distance from the insured beneficiaries. CBHI is based on principles of risk pooling, mutual aid and solidarity. CBHI schemes in rural Africa are initiated and run by health facilities, Non-Government Organizations (NGOs), local communities or cooperatives. In the Democratic Republic of Congo and Guinea, CBHI schemes started as local rural responses to sudden halt of healthcare funds by governments. In Ghana and Kenya CBHI schemes originated from the search of mission hospitals for new sources of finance in a time of reduced government subsidies and declining external support after user levying fees proved to be inadequate in rural areas. Rural CBHI schemes in rural Africa have taken into account the unique health needs of communities that they serve. A typical case of rural CBHI schemes contextualizing health insurance in rural Africa is that of the mutuelles de santés” (mutual health insurance schemes) in Rwanda and rural Senegal. These CBHIs have around 500 members on average and are deeply rooted in the rural local setting. Characteristics of the mutuelles de santés which have contributed to its success according to OECD (?) include the following:
- Flexibility in the mode of paying insurance premiums. Households who could not afford to pay the health insurance premium at a go, were allowed to pay in installments to a tontine before joining a pre-payment scheme. In addition, church-based groups collected fees for the indigent, disabled, orphans and widows. Some charitable organizations such as churches also made premium contributions for both members and non-members which has gave otherwise excluded people the chance to participate in the mutual health schemes. Some mutual also adopted a form of financing involving a tombola or lottery, where individuals were selected at random and their payments paid for them.
- Experience in implementing Social Protection Interventions and Community Ownership of Programs. Mutual insurance schemes are likely to perform better, when they are linked to an organization which already has experience in the field of financial services and social protection interventions. Community participation matters, when it comes to the control of moral hazard behavior and costs. The degree of community participation in the design and running of the health insurance scheme can vary widely and is usually greater if funds are owned and managed by the members themselves than if schemes are run by health If members can identify themselves with “their” schemes because they control the funds and have decision-making power, they will tend to foster its growth.
- Existence of a viable health care provider. A major key to the success or failure of health insurance schemes is the existence of viable health care providers, e.g., hospitals that offers services to the insured. The quality of care provided greatly affects funds mobilization for the health insurance scheme. In some settings in Africa, it will even not be possible to set up a viable health insurance scheme and mobilize premiums if quality of healthcare has not already been established. This is because if people feel that they will not get “value for money” at the healthcare providers, they will not be willing to pay premiums.
- Community and household Socioeconomic and sociocultural characteristics. The demand for health insurance is a crucial factor if the benefits expected from community financing schemes are to be realized. The demand of households for health insurance depends not only on the quality of care offered by the health care provider, on the premium and benefit package, but also on socio- economic and cultural characteristics of households and communities. Widespread absolute poverty among potential members can be a serious obstacle to the implementation of insurance. If people are struggling to get even the basic nutrition, they will be less willing to pay insurance premiums in advance in order to use services at a later point in time. Socio-cultural beliefs could also play an important obstacle to people buying health insurance. There have been cases where people were not willing to pay health insurance premiums because they felt that sickness was not random but was a direct result for spiritual punishment of magic. Others also felt that putting “money away” to fall on during times of sickness was a way of “inviting sickness” and were therefore dissuaded from paying health insurance premiums.
Benefits include low cost expenditure and in-cost of hospitalization. Members paid substantially reduced fees for specific treatment and services that are prevalent in their communities. Members of the CBHI enjoyed better access to health care compared with non-members, in case of a serious illnesses members paid half of the amount non-members have to pay.
Public Sector Integrated Social Protection Models
Some public sector social protection interventions integrate health insurance schemes as part of the conditions required to enable eligibility to receive cash transfers on social protection interventions that target the rural poor. These integrated health insurance schemes increase the coverage of health insurance among rural poor households who are already targets of social protection interventions. In some instances, the social protection measure requires households to access applicable health insurance coverage conditions to meet requirements for cash transfers. A case example is Rwanda’s Ubudehe program that profiles poor people in a stratified manner that allows them to access health insurance and other social protection measures including cash transfers. The project is rooted into a cultural concept of assistance popular in Rwanda whereby, assistance is provided within communities to members that are in need and have no form of assistance. These are often orphans, widows and the elderly. Rwanda has invested in a stratification process that has systematically identified poor groups to enable them to access all social protection programs in the country including health insurance. This health insurance integrated in social protection frameworks specifically identified pregnant women and required them to access health care from licensed service providers. Ubudehe was highly successful in making rural impact, for women of reproductive age. Rwanda’s rural poor experienced almost the same level of access to a doctor/midwife as compared with people with higher socioeconomic status. This was some significant improvement over previous years when insured reproductive health was not integrated into the Ubudehe. Another case of integrated health insurance into social protection interventions is the Livelihood Empowerment Against Poverty LEAP social protection where enrollment insurance on Ghana’s National Health Insurance Scheme (NHIS) is a requirement for cash transfers. This has increased the coverage of NHIS among LEAP beneficiaries significantly in Ghana.
Discussions
Rural Africa continues to struggle to attain universal health care primarily because of the level of poverty and the absence of well-equipped healthcare facilities and providers. In the few instances where some healthcare provision is available, the cost element prevents access. One solution to providing much needed healthcare to rural Africa at cost is through CBHI Schemes. These have proven to be viable especially, in Senegal and Rwanda.
CBHI schemes in rural Africa thrive on mostly social capital and the existence of a viable health care provider within accessible reach from beneficiaries. Their unique advantages are that (a) they insure against health conditions that are prevalent in member communities at a cheaper cost (b)they also offer flexible payment arrangements to members. In some instances, payments are in the form of small financial and non-financial contributions. Many African government and non-government agencies are actively engaged in increasingly diverse forms of CBHI schemes (both micro and macro) that show positive short- term impacts with sustainability concerns in long-term forecasting. The micro schemes which are community initiated and owned seems to foster a communal sense of in-group identity and shared support. At the micro level, inter-community networks seem to be more important than material resources in sustaining CBHI schemes that enhance healthcare provision.
The macro health insurance schemes are often integrated into national social interventions and outreaches. Some national social interventions involving cash transfers often make rural health insurance a precondition for social protection interventions to increase coverage of health insurances beneficiaries in rural areas. The concern with this approach is that the method of selecting beneficiaries is often skewed in that health benefits are given to beneficiaries of social protection interventions who are already receiving some form of social support at the expense of yet to be covered and socioeconomically disadvantaged rural dwellers outside the reach of rural social protection programs. After targeting rural areas, they ae still some rural poor residents who are unable to meet the subsidized enrollment and retention health insurance expenditure. While it is assuring to notice that some CBHI schemes provide free coverage to these extremely poor rural dwellers due to cultural norms of communal support and social capital it is understandable that some social pessimists predict that growing urbanizations and industrialization will cut into the much-needed funding to support networks that extend health insurance to the very disadvantaged in rural areas.
Conclusions
The dominant basis for prioritizing rural public (macro) and private (micro) sector health insurance approaches that contextualize health insurance is the pervading high level of among rural communities. Other factors only reveal an evolving multidimensional understanding to rural deprivation that includes other factors that impact health. There should be more private sector involvement in CBHI efforts to ensure cost effective healthcare delivery in rural areas through vibrant small-scale community mobilization activities of Civil Society Organizations (CSOs), Non-governmental Organizations (NGOs) and Faith based Organizations (FBOs) that increase access to health insurance in rural areas. These groups collaborate with government and development agencies in mobilizing community members for CBHI schemes and securing service relations with hospitals and other service providers including remote clinics in rural underserved communities. The only concern is how far rural coverage is extended since most CBHI schemes have some preconditions which eliminate the pro-poor who are unable to meet enrollment and retention requirements. Best practices which promote CBHI should be adopted and replicated across the continent to supplement government efforts at providing cost effective healthcare to rural communities across rural Africa.
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