Kenya has had a mandatory insurance mechanism for several decades for hospital care for government employees, which is now slowly morphing into a contributory scheme for all levels of care and the whole population. Ghana opted for big bang, albeit based on its history with decentralized district Community-Based Health Insurance. In several cases, a combination of these sequencing approaches has been used. I have observed three approaches for sequencing the setup of national health insurance: (i) big bang, which is to say covering the whole population and the whole country in one go, (ii) starting with a population segment, usually the formal sector, in some countries simultaneously with the poor (creating the “missing middle” problem), or (iii) starting with a certain level of health provision, e.g. My assessment is that developing a national health insurance scheme is a challenge, not necessarily because managing such a scheme is complicated and administratively burdensome (although that is certainly true) but because of the prevailing approaches to setting it up.
I’ve been reflecting these last few months about the challenge of sub-Saharan African countries engaged in the development of some sort of (contributory) national health insurance as a means to move towards UHC.
Many countries don’t want to lose the direct revenue from the population – pre-payment is therefore the preferred option.
There is a tension between the objective of mobilizing resources for health – which suggests to maintain user fees – and the objective of access to all – which suggests to remove user fees.
Health in many low-income countries is currently financed through a combination of tax revenue, out of pocket expenditures and donors. It’s striking how much the Universal Health Coverage (UHC) agenda has been, from a financing perspective, conflated with contributory health insurance.
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