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Social health protection - country experiences

Updated by Xenia Scheil-Adlung on 12.06.2015

Healthcare in Egypt is mostly tax-funded and provided by public facilities. A small proportion of the population (approx. 8%) receives benefits from a social health insurance scheme, which provides access to primary care, outpatient hospital services, pharmaceuticals and hospital care. The members of the social health insurance scheme are private sector employees and civil servants. Contributions are shared between employers and beneficiaries. The publicly funded healthcare is provided through hospitals and other facilities operated by the government, with financing being managed by individual funds (“Family Health Funds”) in each Governorate. Overall, the Egyptian social health protection system is characterized by fragmentation and some degree of inequity (particularly regarding access, affordability and quality of care, which is lower at the public facilities, especially in rural areas).

Against this background, the Government supports reform plans to establish a national universal health insurance. While legal provisions for the health insurance are being prepared, upgrading of facilities is already taking place to ensure better quality especially in rural areas.

It is suggested that each citizen will contribute but the contribution rates are differing significantly between different population groups. Furthermore, the draft legislation proposes to raise additional revenues through user fees for outpatient services. The poor would be exempt from contribution and user fees and it is expected that 25% of the population will qualify for at least partial subsidization.

Population (2008) 82 million
Per capita GDP (PPP, Int. US$, 2007) US$ 5,500
Life expectancy at birth (m/f, 2006) 66 / 70 years
Infant mortality rate (per 1,000 live births, 2007) 30
Under-5 mortality (per 1,000 live births) 36
Maternal mortality (per 100,000, 2005) 130
Health expenditure per capita (2006) US$ 316
Staff-related Access Deficit 19%
Skilled-birth-attendance Access Deficit 31%
Source: ILO, Social Health Protection - An ILO Strategy towards Universal Access to Health Care, Geneva 2008 and: UNICEF Country Profiles; IMF World Economic Outlook Database 2009; WHO World Health Statistics 2008

This poses significant challenges for the state budget and it will be of utmost importance to calculate the implications of the social health insurance scheme for the fiscal space. Some funds that are currently being used for the public providers and the government’s contribution to the social health insurance for civil servants might be used for subsidizing the new scheme.        

Kenya has achieved impressive economic growth in recent years, leading to a fall in poverty by 10% to 46% of the population since 2000. Nevertheless, deep social, ethnic and regional inequalities remain. While Kenya is on track for full or partial achievement of some MDGs, the goals on child mortality and maternal health will most likely not be achieved, according to current projections. A significant constraint for accessing good quality healthcare, besides a lack of funds by the households, is the shortage of qualified healthcare personnel, especially in rural areas.

Just over half of total health expenditure is out-of-pocket, while 16% is raised through the statutory National Hospital Insurance Fund (NHIF). The NHIF was established in 1966, making Kenya the first country in Africa to introduce compulsory health insurance. The NHIF covers workers in the formal sector and self-employed and since recently, pensioners and “organized groups” can enroll voluntarily. In total, the scheme has 1.5 million members, which – together with their dependents, constitute 25% of the population (2007). The scheme covers in-patient medical needs and most admissions for a fixed number of days.

A draft bill for a National Social Health Insurance Fund (NSHIF) was submitted to parliament in 2004. However, the NSHIF bill has not been passed until to date because of budgetary concerns on behalf of the government. The NSHIF was planned as a compulsory insurance scheme with solidarity-based and income-rated contributions. Coverage was to extend to the entire population, thus achieving access to affordable healthcare for all. Furthermore, the establishment of a strong payer for health services was expected to lead to significant cost-savings and efficiency gains.

Population (2008) 39.8 million
Per capita GDP (PPP, Int. US$, 2007) US$ 1,711
Life expectancy at birth (m/f, 2006) 53 years
Infant mortality rate (per 1,000 live births, 2007) 80
Under-5 mortality (per 1,000 live births) 121
Maternal mortality (per 100,000, 2005) 410
Health expenditure per capita (2006) US$ 205
Staff-related Access Deficit 60%
Skilled-birth-attendance Access Deficit 58%
Source: ILO, Social Health Protection - An ILO Strategy towards Universal Access to Health Care, Geneva 2008 and: UNICEF Country Profiles; IMF World Economic Outlook Database 2009; WHO World Health Statistics 2008

ILO estimates that currently 60 % of the population have no effective access to health services when needed.

Coverage is mainly provided by the mutual health insurance that plays a significant role in Senegal, especially for covering the rural and informal economy segments of the population. Some 12-17% of the population are covered by statutory social security schemes, mostly private sector workers and civil servants and their dependents. The very poor parts of the population are not included, since they cannot afford even the relatively low premiums of the private, mutual health insurance. It is estimated that 10-20% of the population rely on social assistance programmes for benefits.

Senegal and its partner countries in the West African Economic and Monetary Union, with support from the ILO’s STEP project and ILO Social Security Department, have worked over several years on strengthening all key actors involved in establishing, managing and supervising mutual health organizations. This process culminated in the adoption of a legal framework for mutual social organizations by the WAEMU Council of Ministers in June 2009, which gives the mutual organizations a legal status and defines the supervisory function of the relevant ministries. Currently, the framework is being introduced in the WAEMU countries, involving communication, registration and technical assistance for the mutual organizations. The ILO contributes to this process by supporting the development of a national framework for contracting of providers through mutual organizations, providing tangible technical support to the setting up, IT management and networking of mutuals.

As a result, health indicators and health financing have improved greatly. Significant progress has been made in life expectancy and in government spending on health, increasing the government budget’s share in total health expenditure by over 20% since 2000. Nevertheless, significant challenges exist, notably with regards to access to healthcare.

Population (2008) 13.7 million
Per capita GDP (PPP, Int. US$, 2007) US$ 1,730
Life expectancy at birth (m/f, 2006) 56 years
Infant mortality rate (per 1,000 live births, 2007) 66
Under-5 mortality (per 1,000 live births) 115
Maternal mortality (per 100,000, 2005) 400
Health expenditure per capita (2006) US$ 72
Staff-related Access Deficit 88%
Skilled-birth-attendance Access Deficit 42%
Source: ILO, Social Health Protection - An ILO Strategy towards Universal Access to Health Care, Geneva 2008 and: UNICEF Country Profiles; IMF World Economic Outlook Database 2009; WHO World Health Statistics 2008

The staff-related access deficit measured by ILO indicates that 88 % of the population have no access to health services when in need. The National Social Protection Strategy is supposed to address the gap and aims at increasing health insurance coverage from 20% to 50% by 2015.

Mutual health insurance allows for covering specific parts of the population efficiently and through using existing social structures. Additional efforts of the government aim at focusing on groups that are difficult to reach, such as informal economy workers. This includes various projects and activities aiming at providing effective access to health services.

The social health protection scheme in Sierra Leone is currently based tax funded services that are hardly affordable, often not available and of poor quality. Further, financial protection for user fees and out-of-pocket payments is absent.

As a result, the health indicators of Sierra Leone are amongst the worst in the world. The low life expectancy and the high infant and maternal mortality rates point to severe problems in access to adequate and timely healthcare. The access deficit indicators point to the fact that the large majority of the population does not have access to adequate healthcare as a result of insufficient availability and/or training of healthcare personnel and that the majority of pregnancies and deliveries occur without adequate maternal care.

Against this background, the Government of Sierra Leone together with the workers’ and employers’ representatives are committed to progress by introducing the Sierra Leone Social Health Insurance scheme (SLESHI). SLESHI is designed as a universal, unitary national scheme that covers the entire population, including the vulnerable and poor.  Related reform discussions are currently underway.

It is suggested that the benefits of the scheme includes primary healthcare services and limited secondary care at district-level hospitals. Further, it is envisioned that the SLESHI benefits will complement existing donor programmes e.g. on maternal protection and that the benefit package will include coverage of catastrophic healthcare expenditure. The establishment of SLESHI should go along with a strong push for upgrading healthcare facilities and improving the quality of care at all levels.

Financing might be based on funds from various sources, such as taxes and contributions, thus ensuring that sufficient funds are generated and financial sustainability can be achieved.

Population (2008) 5.1 million
Per capita GDP (PPP, Int. US$, 2007) US$ 310
Life expectancy at birth (m/f, 2006) 37 / 40 years
Infant mortality rate (per 1,000 live births, 2007) 165
Under-5 mortality (per 1,000 live births) 286
Maternal mortality (per 100,000, 2005) 1300 - 2000
Health expenditure per capita (2006) US$ 7.5
Staff-related Access Deficit 88%
Skilled-birth-attendance Access Deficit 58%
Source: ILO, Social Health Protection - An ILO Strategy towards Universal Access to Health Care, Geneva 2008 and: UNICEF Country Profiles; IMF World Economic Outlook Database 2009; WHO World Health Statistics 2008

It is proposed that contributions for the most vulnerable and poor be waived and covered by taxes whereas economic active workers gaining income should contribute according to their capacity-to-pay. Other sources of funding include the introduction of an employers’ contribution and it is suggested to redirect a proportion (2-3%) of both the general goods and service tax as well as VAT revenue.

ILO significantly supported the development of SLESHI and related preparatory work.

Rwanda has made remarkable progress since the civil war in 1994. Infrastructure quality, access to education, economic growth and poverty rates improved greatly in recent years. However, large inequities still exist between rural and urban parts of the country, over one third of the population still live in extreme poverty and just over half below the national poverty line. The high population growth rate (2-3% in the last years) and the large number of orphaned children (resulting from the HIV/AIDS epidemic) are challenging economic and social development.

Rwanda introduced a new health sector strategy after the civil war in 1996, which incorporated the principles of the Bamako initiative. It focused on primary healthcare, decentralization and community participation and the development of better human resources for health. With regards to social health protection, the government has strengthened the role of communities in managing and funding healthcare provision.

Existing Mutual health organizations received technical support and new mutual organizations were established since 1999. Since 2008, every Rwandan is obliged to have health insurance and most have opted to enrol in a mutual scheme, normally on a per-household basis and with an annual contribution of approx. US$ 2 per family member. Healthcare costs have fallen and utilization health services have increased since this requirement was introduced.

This strategy has been underpinned by a strong commitment of the government to invest in the health sector. As a result, it has raised its health expenditure to 12% of the budget, up from 4.25% in 1996. Over half of the budget is transferred to the health districts, thus strengthening local structures in the health sector.

A challenge for further extending coverage lies in ensuring that poor households are being covered.

Population (2008) 10.4 million
Per capita GDP (PPP, Int. US$, 2007) US$ 1,043
Life expectancy at birth (m/f, 2006) 50 years
Infant mortality rate (per 1,000 live births, 2007) 109
Under-5 mortality (per 1,000 live births) 181
Maternal mortality (per 100,000, 2005) 750
Health expenditure per capita (2006) US$ 210
Staff-related Access Deficit 85%
Skilled-birth-attendance Access Deficit 69%
Source: ILO, Social Health Protection - An ILO Strategy towards Universal Access to Health Care, Geneva 2008 and: UNICEF Country Profiles; IMF World Economic Outlook Database 2009; WHO World Health Statistics 2008

Latest data available reveal that legal coverage of social health protection amounts to 36.6 % of total population. However, effective access to health services is very limited: Some 85 % of the population have no access to health services when in need.

Contributions are not based on capacity-to-pay of the household and, therefore, there is only a limited degree of redistribution of the financial burden of healthcare from the poorer to the richer households. Furthermore, due to constraint capacity, the financial sustainability of the mutual organizations seems to be fragile.

Uganda has made progress in reducing poverty in the last years but still faces severe problems in healthcare coverage and health status. Its mortality rates for mothers, infants and children are among the highest in the world, but life expectancy increased and the ratio of the poor decreased since the beginning of the decade. Its skilled-birth-attendance access deficit is higher than that of countries with much lower health expenditure per capita (for example, Sierra Leone). Over three quarters of the population have no access to healthcare as the result of insufficient staff levels at healthcare facilities.

The draft of the National Health Sector Policy 2010-2020 raises the concepts of universal coverage and social health protection (specifically risk-pooling and prepayment). This is in accordance with statements by the government to achieve access for all to a minimum package of services, to ensure equitable distribution of services and to make more effective and efficient use of health resources.

Against this background, the government has recently launched an initiative to reform social health protection in the country with a view to achieving universal coverage. The reform will build on experience with social health insurance. In this context possible roles of the existing social security institution (the National Social Security Fund - NSSF) and a new National Health Insurance Scheme are currently evaluated with a view to covering different groups of the population as well as sharing administrative functions.

A National Health Insurance is proposed, which would ultimately become a mandatory scheme for all residents of Uganda, financed by contributions, offering a minimum health services package and being managed by an independent government agency.

The issues currently being debated refer to the appropriate strategy for achieving universal coverage for all citizens and residents. The current plan foresees a timeframe of 15 years to reach universal coverage, rolling out coverage to civil servants only in the initial stages.

Population (2008) 32.7 million
Per capita GDP (PPP, Int. US$, 2007) US$ 320
Life expectancy at birth (m/f, 2006) 52 years
Infant mortality rate (per 1,000 live births, 2007) 75
Under-5 mortality (per 1,000 live births) 137
Maternal mortality (per 100,000, 2005) 435
Health expenditure per capita (2006) US$ 27
Staff-related Access Deficit 78%
Skilled-birth-attendance Access Deficit 61%
Source: ILO, Social Health Protection - An ILO Strategy towards Universal Access to Health Care, Geneva 2008 and: UNICEF Country Profiles; IMF World Economic Outlook Database 2009; WHO World Health Statistics 2008

In latter stages, the formal sector would be covered and universal coverage, including for the informal economy workers and their families, would be achieved. Furthermore, the NSSF is planning to broaden its range of benefits for its members from the formal sector to healthcare services.

Uganda is an example of a pluralistic and gradual approach to extending social health protection coverage. The need for coordination within the existing and proposed structure of social health protection in Uganda is evident and the potential benefits of managing the various approaches with a view to universality and equitable access are clear: Coverage could be extended through using the most efficient mix of existing and new structures, e.g. covering the existing NSSF membership through an extension of NSSF benefits and also ensuring that the reform benefits broad population groups, including the poor and informal workers, from the beginning.

 

From the report:  Extending social security to all – A guide through challenges and options (section 6.1).

From the report: Input to the background document for the African Regional Conference 2010 on Social Health Protection in Africa.