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Expanding Health Insurance in Developing Countries

Rwanda will host a regional conference next week (9-11/13), with a focus on health insurance. Rwanda has been praised for moving toward universal coverage¹ for its population. But many say it’s a complicated issue that does not have a one-size-fits-all solution.

The Conference on Social Health Protection in the East African Community will consider various approaches to providing universal health coverage in Rwanda, Uganda, Kenya, Tanzania and Burundi.

Universal coverage is the subject of a new study that reviewed health systems in 12 African and Asian countries.

The World Health Organization’s Joe Kutzin says universal coverage is more of a “direction than a destination.”

“What it means you want to move towards universal coverage, which means you want to improve access. You want to improve financial protection and you want to improve quality. And in that sense, those are goals for every country in the world. So it’s relevant to every African country, every European country, the U.S. and so on, to make progress towards those goals,” he said.

Kutzin is coordinator² of health financing policy and analyzed³ the study published in the Bulletin of the World Health Organization.

Dr. Ernst Spaan, one of the authors, said, “There is a lot of debate going on on how to finance health services in developing countries. In Asia and Africa there is a lot of debate on should they focus on social health insurance or community-based health insurance? And we actually looked into that and we found out there are a lot of studies, but it’s a bit patchy. So we decided⁴ to do a systematic⁵ review of the literature.”

Spaan is a senior researcher and lecturer in public health at the Radboud University Nijmegen Medical Center in the Netherlands.

The study looked at what he calls impact indicators⁶. These include the way financial resources are collected to fund insurance plans, the amount of coverage provided to recipients⁷, whether that coverage is provided to all segments of society and whether there’s been an improvement in the quality of life.

It says social and community health insurance plans “hold untapped potential” for achieving universal coverage. But Spaan says for that to happen, funding issues need to be addressed. For example, he says social plans are generally mandatory⁸ and may be funded through payroll⁹ deductions¹⁰.

“That of course poses a problem in many developing countries because of the fact that the informal sector¹¹ is quite large. Sometimes even 60 percent of the population or higher is not in formal employment. Also because of the large agricultural sector income is dependent on harvest times, so it’s also very erratic,” said Spaan.

WHO’s Kutzin said some insurance systems may also require a user fee that’s paid at the time of medical services.

“When people have to pay a lot at the time they use services it poses a real, severe economic risk to their households. Very often you find cases where, for example, people have to sell off their assets, whether that is in cash or in animals. Whatever may be the main source of wealth, people are selling off their assets in order to raise the money to pay for care,” he said.

Spaan and his colleagues also looked at community insurance plans.

“These are organized, generally, on a smaller scale. And in many countries you find these schemes are linked to, for instance, one hospital or even to a school. So they insure school children, for instance, or they insure the people around a certain health facility. But what is more important is that it’s a certain scheme where the local population is more involved in the set-up of the scheme. And least that’s the ideal,” said Spaan.

He added that the study’s findings “back the World Health Organization’s view that pre-paid financing mechanisms¹², such as health insurance, are a key route to universal coverage.”

But Kutzin said there are many ways to provide health coverage besides those presented in the study.

“One of the best known cases we have is from Thailand, which in 2002 instituted a program called the Universal Health Coverage Scheme. It’s neither community-based nor is it contributory. It is a system where the government using general tax revenues puts all of that money into a single pool. And anyone is entitled to sign-up for the program. They don’t have to contribute anything. That pool pays for services on behalf of the entire population,” he said.

He said Rwanda uses a multiple funding approach for its mandatory health coverage, including general tax revenues and donor¹³ funding. And it uses its community-based systems in a coordinated¹⁴ way.

Universal health coverage has been a controversial topic here in the United States, but not in many other countries. Kutzin said that’s because there has not been a clear discussion about what universal coverage is trying to achieve. He says the main question is whether two people, one rich and one poor, with the same medical condition, have access to the same treatment?