In Africa, most people pay for health care out of their own pockets, and few can afford it. But new efforts are underway that enable the cost burden to be shared.
The Dutch non-profit organization, PharmAccess, has introduced a health insurance scheme that it says builds solidarity while enabling Africans to get the health care they need.
"Those that can pay should pay," said Onno Schellekens, managing director of PharmAccess, in an interview. "It is enormously important that large organizations that run into the billions [of dollars] in total turnover take responsibility for their employees, even if it's a loss-making activity."
He said companies had a moral imperative to help their employees: "You cannot afford to offer insurance and healthcare for your people in the Western world, and suddenly in Africa you don't because the productivity of your employees is too low or something like that."
Health solidarity
PharmAccess, founded in 2001, is active in about 30 African countries. It aims to improve access to quality basic health care, including HIV/Aids treatment. It offers services and supports programs to assess and upgrade clinics, hospitals and laboratories and to build capacity for medical staff. It works closely with both private and public sectors.
Its health insurance schemes rely on risk pooling, donor support, co-payments and use of local private infrastructure to help extend coverage to the poorest of the poor.
"The ultimate form of non-solidarity is the fact that 60 percent of total expenditures on health care in Africa are out of pocket," Schellekens said. "So we should be working on risk pooling and on health insurance because that is the only way forward in terms of solidarity. The moment you start offering solutions then people have to act."
Elizabeth Ashbourne, a senior operations officer at the World Bank, acknowledges that some are skeptical about the capacity of insurance to help Africans access healthcare but does not share their doubts.
"That financial model is really strong," said Ashbourne, who formerly coordinated public-private partnerships for HIV/Aids in Africa. "If you're looking at the cost of treatment in the future it's going to be a heavy load for the developing world, so different ways of seeking out sustainable financial models should really be encouraged. Not everybody believes that insurance is going to really answer the need but I do."
Through the pre-payment program of PharAccess, a pool of money is created to insure participants.
Expanding coverage
Schellekens is especially proud of the achievements of PharmAccess in Namibia. He said in 2004 only the wealthiest 10 percent of Namibians had health insurance, and that did not cover HIV/Aids. PharmAccess offered to sponsor the HIV/Aids part of the insurance package but wanted lower-income people to receive general health insurance as well.
To share the risk, PharmAccess supported the establishment of a risk equalization fund whereby employer-based insured and previously-uninsured groups contributed premiums to a risk pool with a defined set of HIV/Aids treatment benefits. As a result they now share the financial risk of high medical costs related to HIV/Aids treatment.
The Namibian government and the country's unions strongly supported the program and now it is very successful, Schellekens said.
"Employers are big-time enrolling this and are purchasing this product for their employees that have low income," he said. "Prior to this they had nothing and now they have basic health coverage with some hospitalization."
In Nigeria, donor money is used to subsidize insurance premiums for previously uninsured low-income Nigerians. PharmAccess has enrolled about 30,000 farmers and market women in a health insurance plan, which is administered through the Dutch-based Health Insurance Fund.
In addition, Schellekens said, PharmAccess recently signed a large contract with the World Bank and the International Finance Corporation to sponsor health insurance for about 40,000 people living in an area where several information and communications technology (ICT) companies are operating near Lagos.
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In Rwanda, PharmAccess has partnered with Heineken brewers and the Rwandan Ministry of Health to extend health insurance coverage to some 5,000 farmers and their families – about 35,000 people – for basic medical expenses.
Sustainable assistance
Despite its successes, PharmAccess continues to battle skepticism about its efforts in Africa.
"Health insurance is about pre-payment," Schellekens explained. "A lot of people say Africans are skeptical about prepayment because it doesn't work and therefore they are not willing to pre-pay. But I think the mobile telephone industry demonstrates that people are willing to prepay provided the service works."
He agreed with those who say healthcare is a human right and should be free.
"It is true. It is absolutely true. But if you say something like this then you should also bring the money to the table. And if the money is not there then the consequence is that the poor pay the price and it is nothing more than sloganeering."
