lack of policies & legislation to suppo poor governance & overall system management Health Reform in Africa Taking a step back to move forward successfully Healthcare in the spotlight Healthcare reform has received significant attention in recent years due to increased awareness of social injustices worldwide and the recognition of the strong relationship between population health and economic growth. Health reform has also been ignited in many countries by the United Nations Millennium Development Goals to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women for which all 191 UN member states have agreed to try to achieve by the year 2015. The ultimate goal for many health reform initiatives is the concept of universal coverage, which is defined by the World Health Organisation as access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access. In tandem with this goal is the need to reduce the probability of catastrophic health expenditure by achieving equity in financing. For most countries, the achievement of these goals requires large scale reforms in various sectors and the initiatives taken will depend largely on the conditions prevailing with each country. Health reform should be recognised as a lengthy process that requires thorough consideration of all the factors that contribute to the development of an enabling environment. It is therefore essential that Governments take E.Lambo & L.G. Sambo (2003) Health Sector reform in Sub-Saharan Africa: A synthesis of country experiences
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high out-of-pocket expenditure,
unemployment
lack of funding, resources & infrastructure
lack of policies & legislation to support development
poor governance & overall system management
Innovation
Economic growth
Health Reform in AfricaTaking a step back to move forward successfully
Healthcare in the spotlight
Healthcare reform has received significant attention in recent years due to increased awareness of social injustices worldwide and the recognition of the strong relationship between population health and economic growth. Health reform has also been ignited in many countries by the United Nations Millennium Development Goals to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women for which all 191 UN member states have agreed to try to achieve by the year 2015.
The ultimate goal for many health reform initiatives is the concept of universal coverage, which is defined by the World Health Organisation as access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access. In tandem with this goal is the need to reduce the probability of catastrophic health expenditure by achieving equity in financing.
For most countries, the achievement of these goals requires large scale reforms in various sectors and the initiatives taken will depend largely on the conditions prevailing with each country. Health reform should be recognised as a lengthy process that requires thorough consideration of all the factors that contribute to the development of an enabling environment. It is therefore essential that Governments take a step back and assess their current circumstances and thereafter, implement reasonable steps towards the achievement of their objectives. This should be done bearing in mind that the process will require refinement and adaptation as conditions change.
Where is Africa on the road to healthcare reform?
The pressures of reform for African countries are intensified by the high burden of disease, which is exacerbated by poor living conditions and lack of access to quality care. Health statistics for African countries as a whole are poor in comparison to the rest of the world and efforts for reform are problematic given the typical issues faced by low & middle income countries.
E.Lambo & L.G. Sambo (2003) Health Sector reform in Sub-Saharan Africa: A synthesis of country experiences
Challenge: Maximising population coverage
Possible Approach: Separate the population into groups according to the relative ease at which they are willing and
able to pay for health cover.
Implementation of NHI/SHI of some formGhanaNigeriaTanzania
Design of Social/National Health InsuranceKenyaSouth AfricaNamibia
Decentralisation & strengthening of district health systemsTanzaniaZambia
Sector-wide approaches (SWAps) as a framework for undertaking helath reformUganda •ZamibiaTanzania •EthiopiaGhana
However, although these countries may be starting off on the back foot, they benefit from rapid economic growth and the ability to learn from the experiences of other countries. Furthermore, the blank slate that many of the African countries had to face has provided the opportunity for innovation to flourish.
Most African countries have taken cognizance of their deficiencies and are making notable progress towards reform. In fact, some countries are being recognized as ‘leaders’ in certain areas of reform, including Zambia, Ghana, Tanzania, South Africa & Namibia1. The ultimate goals of universal coverage and fair financing are still quite far-off, but the step are being taken in the right direction to create the enabling environment, provide basic services and expand access to the poor.
Key Reform Challenges & Considerations
To create an environment of equity in access and fair financing, principles of social solidarity need to apply. Prepayment according to affordability and pooling of funds ensures that the risk of unexpected health expenditure is borne by the entire risk pool as opposed to the individual themselves. The larger the risk pool, the greater the predictability of health expenditure as the effect of large claims is spread over a larger membership base. It is therefore critical to formulate a strategy to ensure that the entire population obtains health cover and reduce the levels of out-of-pocket expenditure that lead to impoverishment.
E.Lambo & L.G. Sambo (2003) Health Sector reform in Sub-Saharan Africa: A synthesis of country experiences
Some of the key strategies adopted by various Africa countries
World Health Statistics 2012, WHOHealth Statistic
Life expectancy at birth (years) Physicians
Nursing &midwifery personnel
Pharmaceutical personnel
Total Health Expenditure (THE)
(% of GDP)
Private Health Expenditure (%
of THE)2009 2009 2009
African Region 54 2.2 9 0.7 6.5 50.7Region of the Americas 76 20 72.5 - 14.4 50.7South-East Asia Region 65 5.6 10.9 4.1 3.8 62.9European Region 75 33.2 65 5.4 9.3 24.8Eastern Mediterranean Region 66 10.9 15.6 5.4 4.7 49.1Western Pacific Region 75 14.8 18.4 3.8 6.6 35.6Global 68 14.2 28.1 4 9.4 40.8
Density (per 10000 population), 2005 - 2010
Challenge: Maximising population coverage
Possible Approach: Separate the population into groups according to the relative ease at which they are willing and
able to pay for health cover.
Challenge: Achievement of cost-effective, quality care
Possible Approach: Make use of alternative reimbursement methods with providers such as capitation, fixed fee and
per diem arrangementsThese arrangements assist by transferring some of the risks associated with benefit provision to the provider thereby promoting service efficiency
Incentive structures can also be formulated that align the interests of both parties and provide rewards that are commensurate to the degree of risk transferred and the performance of the provider. Performance can be assessed against defined objectives agreed at outset
Challenge: Lack of resources and infrastructure
Possible Approaches: Focus on increasing the quality and quantity of health professionals leaving training institutions
to be able to service the demands of the population Conduct an assessment on the number and condition of existing infrastructure (such as
hospitals, clinics, laboratories & community centres) Determine funding required to improve these facilities, ensure geographical access to
healthcare for all and above outcomes
Challenge: Formulating an appropriate benefit package
Possible Approaches: Determine the needs of the population and current burning priorities Consider whether the focus will be on curative or preventative care Consider the main categories of benefits e.g. hospital, primary care, medication etc. Note that the package will need be affordable, yet comprehensive enough to provide an
appropriate level of healthcare protection for the population An iterative costing exercise will need to be performed taking consideration of the demographics
and expected claim experience of the population Consider benefit design tools that would control utilization e.g. annual benefit limits, limits per
benefit category, co-payments, deductibles, gatekeeping systems etc.
Pooled funds are then used to purchase goods and services from health care providers. These services could be delivered through the public or private sectors and such relationships need to be managed to ensure that cost-effective, quality care is provided to consumers.
Many countries are experiencing a shortage of health care professionals. This could be due to insufficient academic and training facilities or the loss of resources to other countries primarily due to poor working conditions, insufficient pay or general international demand.
The nature of health care is complex. Due to the limited supply of resources available to meet the unlimited demand for health care, services need to be rationed. Furthermore, the emotional significance of health makes resource allocation even more difficult as we are dealing with life and death decisions.
E.Lambo & L.G. Sambo (2003) Health Sector reform in Sub-Saharan Africa: A synthesis of country experiences
Public / Private Sector
Infrastructure
Single Fund
Multiple Funds
Provider Contracts
Reimbursement Methods
General / Earmarked Taxes
Mandatory Contributions
Direct Payroll
Self-employed
Informal Sector
Comprehensive
Basic Minimum
Delivery
Pooling
PurchasingFinancing
Revenue Collection
Benefit Package
Health Reform
Resources
Monitoring & Evaluation
Regulation
Administration
Systems
Conclusion
The economic and political instability in many African countries as well as civil war has put health care reform on the back foot. Lack of national policy, legislation and good governance are critical inhibitors to the formation of a stable enabling environment for health care reform. Furthermore, information and monitoring systems need to be put in place to ensure the successful implementation and sustainability of reform initiatives. However, African countries also benefit from high economic growth, a platform for innovation and the ability to learn from each other’s experiences.
Health reform is a long complex process with wide-ranging implications for the entire population. The process will need to be broken down into key steps and milestones to ensure smooth & successful progress over time. In addition, the role of each stakeholder and the consequent impact of reform will need to be assessed prior to implementation of reform initiatives. Stakeholder engagement is critical to prevent resistance to reform.
Ultimately, health reform will provide extensive benefits for the upliftment of a country as it relies on reform in many other sectors of the country and is based on principles of efficiency, quality, cost-effectiveness, social solidarity and governance that may be applied in many other areas. The responsibility lies with government to protect and strengthen the health of the nation and therefore, due to the complexity and intricacy of reform, governments need to seek the skills and expertise of those with experience in the health care arena.
E.Lambo & L.G. Sambo (2003) Health Sector reform in Sub-Saharan Africa: A synthesis of country experiences
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