The Reporter (Addis Ababa)

Ethiopia: Health Insurance - a Far-Sighted Scheme?

Tamrat Berhanu, a 67-year-old civil servant has always thought about getting sustainable healthcare ever since he was diagnosed with diabetes. Guarding a private company in daytime, he earns 700 birr to lead a modest life with his wife and three children.

He has been receiving some medical treatment with the help of his brother-in-law for the past few years but he does not know how long this will go on. Recently, he heard something which made him happy. "Now I think I can stay a little longer to feed my children," he says. However, he is not well aware of what the new scheme means and how will it help people like him. "I am not well aware of it but what I heard is good for me as well as others," he says.

Ethiopia, as a developing country, lacks many social services that are considered to be necessities for its citizens. Healthcare has been one of those necessary needs for its people for many years. War and disease have always been significant causes for poverty in a country like Ethiopia. And peace and stability have always been mentioned as a crucial element that attracts development. Nowadays, Ethiopia is being mentioned as one of the fastest growing nations across the globe by different governmental and international organizations.

A healthy society is one factor that impacts the development of a nation. When citizens are well protected from any illness that hampers human productivity, the country is on a reliable track to development. The Ministry of Health has sometimes been taken as a model for others on the continent for carrying out a well-organized and effective health service. The former health minister and the current foreign minister, Tedros Adhanom (Ph.D.), was hailed for transforming Ethiopia's health sector. For instance, it was noted that Ethiopia has increased family planning access from 11 to 35 percent in a short period of time on the third international family planning summit held in Addis Ababa a month ago.

The health extension program which was also started under the leadership of the former minister has gone far more to be an example for others. Nevertheless, health has always been a critical issue for the country. Lack of health facilities, skilled manpower, and equipment are some of the problems encountered throughout the country.

Although the country graduates some 600 physicians every year compared to the 100 in the past couple of decades, the doctors-to-patient ratio is still insufficient for the second most populous nation in the continent. Reducing mortality rate in many deadly diseases, including HIV/AIDS and malaria, can be a big success as the country implements a prevention-based health policy. Economic development differentiates countries in the kind of health service that they are delivering to their citizens. However, health services are the basic needs of humanity and any government has to prioritize it, commentators say.

The Ethiopian Health Insurance Agency was established three years ago to deal with the citizens' health problem. It was about to become effective this time around as citizens have already begun registration to get their medical ID that will help them get access to healthcare. Now, it has been postponed for months until senior government officials, regional officials, and the public debate on the issue. "It is for the sake of having a well-elaborated and insightful conception on the way it is going to be done," Roman Tesfay, director of the agency said. "People need to be well aware of it, and it should be done carefully," she reiterated. The Ethiopian Health Insurance has two major classes, namely a social health insurance scheme and community-based health insurance. While the social health insurance includes civil servants, private employees and employers, the community-based health insurance scheme is for non-employed citizens, farmers and the rest of the society.

Citizens must contribute only 3 percent of their income or salary before tax and the government and employers have to pay 3 percent of their employees' salary too, according to the director. Retired citizens can also be admitted by the selected health institutions when they have paid 1 percent of their income. The government will also pay 1 percent to the pensioners. Civil servants have to be registered in their respective regions and offices first and get the medical card before February 7 next year. "The preparation has been fully finalized and we are going to launch it," Mengistu Bekele (MD), deputy director of the agency said. He asserts that the health insurance scheme will benefit citizens when they are well aware of it. "There must be clear understanding amongst the public at large," he says. Furthermore people who can contribute more than the amount placed by the agency could help others who have much lower income than them.

The health stations that provide the service have been selected and identified by the agency and they will be able to render the service by the time the program is fully put in practice, according to Mengistu. Except for organ transplants, dialysis, drug-caused illness, and medication directed to be taken overseas all medical services given in the country will be available in the scheme. So far, the community-based health insurance has already started to take place as a pilot project in 13 different districts in Oromia, Amhara, Tigray and the Southern Nations and Nationalities and Peoples Regional States and results have been promising so that the program has been extended to 161 districts throughout the country, according to Mengistu. This program is believed to have been increasing the willingness of people who save some 120 to 180 birr per household a year. And the federal and the regional governments contribute some 35 percent of the total expense.

Mengistu, who reiterates that this sort of health insurance is needed for the country so as tackle the problems in the health sector and attempts to draw the initial basic inputs upon which the Ethiopian health insurance agency was established. "The two different approaches followed by different countries to realize the health insurance were the Bismarck, and the Beveridge models," he said. According to him, when the Bismarck model imposes a cut on salary, the Beveridge model aims at taxation. And Ethiopia's health insurance scheme is drawn from these two old thoughts. Mentioning the obstacles that may hinder the program, he analyses how important it would be when people debate it. "Since the ultimate goal is benefiting the people their views and concerns should be scrutinized by policymakers and officials," he adds.

For commentators who fear that this health insurance scheme is a bit expanded, it may not alleviate all the health problems of the people. On the other hand, many of the government health stations have a lot of problems such as equipment and medicines. "Honestly speaking it would have been much easier had they managed these problems first," Haileyesus Geta, a health program coordinator from non-governmental organization said. Commentators who appreciate the effort that aims at supporting the poor citizens accessing healthcare, forward their views that the citizens who have more income than employed citizens should contribute much so as to get a better service. Moreover, the structure that sees inpatients suffering in government hospitals should be restructured in such a way that every patient can have the freedom and justice on medication.

For many, however, the sky-rocketing cost of living may not make them turn their back on the 3 percent cut on their salary and, after all, the benefit can be a much better. Nevertheless, the majority of those who are below the poverty line only have a cent to buy bread and nothing is in their pocket to be paid for health insurance, and may need an exemption or other mechanism should be developed to keep them in the system. On the contrary, some citizens employed by non-governmental organization view it differently that they may receive low-quality service in the governmental health institutions. "I am not sure that I can receive similar treatment in governmental hospitals as I receive in a private one," Bethel, a non-governmental organization employee says. On the other hand, as a citizen like Tamrat is now feeling happy because at least he may have a consistent healthcare with less amount of money than what he currently pays from his pocket.

He also hopes that the government and well-to-do citizens will contribute much to help out citizens like him who have very low income that is absolutely incompatible with the current living cost. All in all, citizens who want to stick to the government health insurance scheme would like to imagine that they are no longer exploited by some selfish private clinics whose medical fee is high. Moreover, they feel that they may experience visiting a health post much frequently since they pay in advance to get the service.

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