Healthcare: Top priority

consequence of user fees in developing countries as only the rich can access healthcare. Although the MTP states the desire to allocate 15 percent of the national budget to the health sector, government tax revenue financing is usually constrained by insufficient levels of revenue.
This implies that few resources are thinly spread across the whole population, leading to congestion at public health facilities or simply poor quality care. Through risk pooling, health insurance is the best way towards attaining universal health coverage.
As a policy measure, the MTP mentions that one of the strategies to be employed to increase access and healthcare utilisation will be the promotion of health insurance schemes. Health insurance provides financial protection when need for healthcare utilisation actually arises. Health insurance addresses equity in two ways. Firstly, the healthy subsidise those who fall ill more frequently. In addition to that, an effective health insurance will have low pre-payments within the reach of the poor.
This ensures that even the poor can access healthcare. In Zimbabwe, private health insurance markets which exist are largely in favour of the formal working class leaving the majority informally employed or the unemployed uncovered for medical expense uncertainty. According to data from the 2005/6 Zimbabwe demographic health survey, 91 percent of the Zimbabwean population has no health insurance cover. The figures could even be worse at the present moment given that the monthly premium at the moment for basic services is more than US$5 per head.
The premium will be higher if one wants to cover beneficiaries. It is bearable for those formally employed who are partly or fully covered by their employers.
Social health insurance which has been used in developed countries would be the most desirable in that it covers even those who cannot pay premiums.
However, this form of health insurance requires a relatively large working population in order to subsidise the unemployed. It is thus common in high income countries whilst its failure in developing countries like Zimbabwe would be imminent due to high unemployment levels estimated to be above the 70 percent mark. Community based health insurance (CBHI) which has been successful in East and West African countries and more recently, in India provides financial coverage for those in rural areas and in informal employment. Basically, CBHI schemes are non profit making insurance arrangements developed for and by the unemployed, the informal sector and rural communities. They are based on the concept of mutual aid and collective pooling of health risks. The communities are involved in the management of these schemes. While the major aim of these schemes is outpatient and inpatient care, members can sometimes include funeral and transport cover in the package. Under the scheme, the community makes an arrangement with a local healthcare provider, public or private, to provide care to its members.
In India, there are three basic CBHI designs depending on the insurer. In the first type, the hospital that provides healthcare also runs the insurance. This has a potential of the problem of supplier induced demand prevalent in the health sector. In the second type, a voluntary organisation that co-ordinates the scheme, for example an NGO, is the insurer. It purchases care from independent healthcare providers. Under the third and more popular type, the voluntary organisation plays the role of an agent. It purchases insurance from insurance companies and also purchases care from healthcare providers. The main challenge with CBHI has been sustainability. This is brought about by the challenges in risk pool sizes, premium charges and management. In order for the scheme to attract more membership, the premiums have to be very low. Indian CBHI schemes have premiums from as low as 50 cents to US$2,50 per head per year collected in a specified period of time.
In Uganda, premiums are around $1 albeit, monthly.
However, since all members, whether low risk or high risk, tend to pay the same premiums, schemes that charge premiums per head are more prone to problems of adverse selection. This is whereby people with low expected risks drop out of the insurance scheme since they are charged the same premiums as those with high expected losses. The willingness to pay method is the easiest way to elicit community preferences for premium contributions to the scheme. Acceptable premiums have seen membership increasing to as high as 10 000 individuals in some CBHI schemes. As of management, the members or selected representatives can take charge. The scheme can form partnership with an organisation prepared to volunteer, usually NGOs in the case where management skills are not available in the community.
The organisation might choose to run the program for a period of time in which it trains or facilitates training of individuals from the community. Alternatively, this voluntary organisation can take up long-term responsibility to manage the scheme, however, with community participation in decision making.
In addition to that, research shows that CBHI contributions are usually in the range of 60 percent to 100 percent of actual healthcare demanded by members. This thus requires that these schemes find long term partners who are willing to subsidise the gap. The partners can be government, NGOs and the private sector as corporate social responsibility.
Limits to insurance cover might be necessary to avoid collapse of the health insurance schemes. These can be waiting periods before specified conditions can be covered by the scheme, exclusion of certain diseases and setting spending limits per member. Management has to be wary of stringent conditions which may drive out membership.
To promote CBHI schemes, government will have to accept and take up the role of the sponsor. This involves subsidising the contributions to actual expenditure gap and also training of community members for management skills. The private sector could also consider the role as corporate social responsibility. The local hospitals and clinics have to appreciate the role played by these schemes, specifically, the provision of funding for quality care. The government, private sector and NGOs could also help to increase the capacity of the communities to contribute. This is through financing small income generating projects or even agriculture in rural areas. On the other hand, the society can also be initiative and start these schemes. We have had replica of such schemes in the traditional burial societies. CBHI has been a real success story in sub-Saharan Africa with Rwanda 65 percent and Ghana’s 87 percent populations accessing healthcare under this scheme.