This paper argues that there are useful lessons for South Africa (and other countries in putting into place the legal and institutional frameworks system and systems for implementation of universal health coverage (UHC). Thailand has received widespread international recognition as one of several middle-income countries that have made enormous progress in building a UHC system and in achieving ‘good health at low cost. Thailand has a strong national fund called the Universal Coverage (UC) Fund, which covers 75% of its population, the rest being covered by social health insurance and the Civil Servant Medical Benefit Scheme. Thailand has a well-developed purchaser-provider split, with the independent UC Fund established by legislation, with a multi-stakeholder governing body including private and civil society representatives. Its internal structure, operating systems, procedures and information technology are firmly established, accessible and affordable in the middle-income country context. It uses capitation purchasing, with a focus on primary care systems. The National Health Security Office (NHSO), which manages the UC Fund, concentrates on pooling and strategic purchasing; it has no revenue collection function, as the scheme is financed through an annual budget. The NHSO manages the disease prevention and health promotion budget for all Thai citizens, thus assisting the other schemes and providing a strong focus on prevention and promotion. The article discusses these and other positive features and the challenges as learning for South Africa and other countries financing UHC.
Resource allocation and health financing
Kenya has had a history of health financing policy changes since its independence in 1963. Recently, significant preparatory work was done on a new Social Health Insurance Law that, if accepted, would lead to universal health coverage in Kenya after a transition period. Questions of economic feasibility and political acceptability continue to be discussed, with stakeholders voicing concerns on design features of the new proposal submitted to the Kenyan parliament in 2004. For economic, social, political and organisational reasons a transition period will be necessary, which is likely to last more than a decade. However, important objectives such as access to health care and avoiding impoverishment due to direct health care payments should be recognised from the start so that steady progress towards effective universal coverage can be planned and achieved.
"In this article we outline research since 1995 on the impact of various financing strategies on access to health services or health outcomes in low income countries. The limited evidence available suggests, in general, that user fees deterred utilisation. Prepayment or insurance schemes offered potential for improving access, but are very limited in scope. Conditional cash payments showed promise for improving uptake of interventions, but could also create a perverse incentive. The largely African origin of the reports of user fees, and the evidence from Latin America on conditional cash transfers, demonstrate the importance of the context in which studies are done."
"The Millennium Development Goals depend critically on scaling up public health investments in developing countries. As a matter of urgency, developing-country governments must present detailed investment plans that are sufficiently ambitious to meet the goals, and the plans must be inserted into existing donor processes. Donor countries must keep the promises they have often reiterated of increased assistance, which they can easily afford, to help improve health in the developing countries and ensure stability for the whole world."
This study explored the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania, using eight focus group discussions with 78 insured and uninsured elderly men and women 60 years of age or older who had utilised healthcare services in the past 12 months prior to the study. Elderly participants appreciated that health insurance had facilitated the access to healthcare and protected them from certain costs, but also complained that health insurance had failed to provide equitable access due to limited-service benefits and restricted use of services within schemes. Although elderly perspectives varied, insured individuals generally expressed dissatisfaction with their healthcare. The authors argue that the national health insurance policy should be revisited to improve its implementation, expand the scope of service coverage and improve service quality issues, including long administrative procedures related to health insurance.
For the past two decades the informal sector has grown very rapidly in Tanzania. In the early 1990s it was estimated to be contributing about 60% of the country's GDP. Some authorities even believe that this figure is an underestimate. This sector provides a "safety net" to many women and youth in the country. Its role in providing for livelihood is becoming more important as the formal sector shrinks due to retrenchment. This feasibility study aimed at assessing how and under what conditions the outputs produced and the activities deployed by the ILO project on social security for the informal sector will contribute to the establishment of a social security system in the two areas. The main emphasis for this study was the establishment of health insurance schemes in the identified areas, i.e., Mbeya and Arusha.
The purpose of this study was to assess individual attitudes towards health insurance policy and the factors that influence respondents’ decision to renew their health insurance policy when it expires. It was conducted in the Volta region of Ghana. A total of 300 respondents were randomly sampled and interviewed for the study. The researchers also assessed factors that influence respondents’ decision to take up a health insurance policy and renew it. The study results indicate that 61.1% of respondents are currently being enrolled in the national health insurance system (NHIS): 23.9% had not renewed their insurance after enrollment and 15% had never enrolled. Reasons cited for non-renewal of insurance included poor service quality (58%), lack of money (49%) and experience of other sources of care (23%). The gender, marital status, religion and perception of health status of respondents significantly influenced their decision to enroll and remain in NHIS. The authors conclude that NHIS is experiencing good levels of uptake, with clients testifying to its benefits in keeping them strong and healthy. Efforts therefore must be put in by all stakeholders including the community to educate the individuals on the benefits of health insurance to ensure all have optimal access.
Some donors and governments propose that health insurance mechanisms can close health financing gaps and benefit poor people. Although beneficial for the people able to join, this method of financing health care has so far been unable to sufficiently fill financing gaps in health systems and improve access to quality health care for the poor. Donors and governments need to consider the evidence and scale up public resources for the health sector. Without adequate public funding and government stewardship, health insurance mechanisms pose a threat rather than an opportunity to the objectives of equity and universal access to health care. This study presents the evidence for and against different models of social health insurance for developing countries. It concluded that models should be assessed for whether they increase universal access including to poorest and most vulnerable.
This report published by Oxfam examines the role of health insurance mechanisms will close health financing gaps and benefit poor people. The mechanisms discussed in this paper are private health insurance, private for-profit micro health insurance, community-based health insurance and social health insurance. It describes those mechanisms and their success or failure to deliver health rights particularly for people living in poverty.
If health insurance is to cover broader population strata in sub-Saharan Africa and to assure satisfactory health services, schemes will require continuous and long-term subsidies to bridge the gap between household capacity to contribute financially and the real costs of health care. The development of approaches addressing this dilemma should be considered as a research priority. They might include initiatives of north–south risk pooling. This necessity is underpinned by the capacity of health insurance to formalise social protection and create a market between health service providers and their “customers”, simultaneously alleviating poverty and empowering communities. Yet, available evidence points out that to play these roles, health insurance needs subsidies.