A presentation on the potential to develop a roadmap to achieve universal health insurance in Africa. It discusses the status of universal health insurance in African countries especially Sub-Saharan Africa and the five key pillars to achieve UHI: the package, the coverage, the financing, the providers and the accountability

1. Universal Health
Insurance: A Pathway to
Achieve UHC in Africa
Dr. Alaa Hamed
Senior Advisor, Public Health
January 2023

2. The Definition

3. UHC is the
ultimate
expression of
fairness
UHC is about
ensuring that
everyone obtain
essential health
services of high
quality without
suffering financial
hardship

4. A fair health system will:
Expand coverage for cost-effective services
Give priority to those benefiting the worse off
Provide high financial risk protection

5. Towards having a UHI Definition
All individuals to have access to quality healthcare at an affordable cost.
• Equitable financing, sharing of costs considering contributory capacity of
everyone.
• Open to all segments of the population, informal workers and the poor.
• Entitlement to benefits is contributory, payment made by or on behalf of the
covered individual is required.
• A prepayment system, based on tax contributions or compulsory insurance
contributions payable by employees, public or private employers and the self-
employed.

6. Increasingly UHC is being financed by a mix of NHI and
SHI schemes.
Mandatory Health Insurance (MHI) –
enrollment required for all members of
a population.
Voluntary Health Insurance (VHI) -
enrollment voluntary, based on
willingness, usually targets high income
population groups or informal sector
workers, Private Health Insurance and
Community Health Insurance
Social Health Insurance (SHI) –
financing primarily raised from wage-
based contributions targeted towards
formal sector workers.
National Health Insurance (NHI) –
financing primarily raised through
government taxes targeted towards all
members of a population.

7. The Challenge

8. The UHI Challenge
Conducive macroeconomic conditions –
economic growth and rapid formalization
of labor market – are not always present.
Institutional capacity and good governance
are more tenuous, especially where social
unrest and political instability are frequent.
The market structure is more limited with
less competition, requiring stronger
government oversight.
Given these factors, not
entirely clear whether SHI can
be successful in reaching
UHC.
Yet, in environments where
raising resources for health
through government taxes is
limited, the pull to mobilize
additional resources from
workers is difficult to pass up.

9. The UHI Challenge in Africa
Mandatory health insurance was recently introduced in sub-Saharan Africa in
the last 15 years
(1) Expansion to the poor and those in the informal sector has been difficult
▪ Large informal sector, professional statuses and individual tax base difficult to
identify, adverse selection .
▪ Level of poverty, targeting, enrollment and renewal has been challenging
(2) The operational and financial sustainability of these schemes has also been
an issue. Some are operating at a deficit due to its overly generous benefits
package.

10. Health Systems Challenges
Identifying Key Challenges Facing Healthcare Systems In Africa And Potential Solutions. Obinna O
Oleribe, Jenny Momoh, Benjamin SC Uzochukwu, Francisco Mbofana, Akin Adebiyi, Thomas
Barbera,6 Roger Williams, and Simon D Taylor-Robinson. Int J Gen Med. 2019; 12: 395–403.

11. Health Financing Challenges in
Sub-Saharan Africa
Reliance on direct out-of-pocket
payments , 36% of current health
expenditure compared to 22% in rest of
the world.
Contributions to health insurance
schemes represent a small share of
current health expenditure.
Large share of funding unstable
attributable to external funding sources
(14% compared to < 1% in the rest of the
world).
Challenges in Financing Universal Health Coverage in Sub-Saharan Africa. Diane McIntyre, Amarech G.
Obse, Edwine W. Barasa, and John E. AtagubaSubject: Health, Education, and Welfare Online
Publication Date: May 2018

12. The Status of Health
Insurance in Africa

13. Health Insurance Coverage

14. Four Main Models of Health Insurance in Africa
▪ Community-
based health
insurance (CBHI)
▪ Social security-
type health
insurance
▪ Public health
insurance
▪ Private health
insurance
BMJ Global Health - Universal health insurance in Africa: a narrative review of the literature on institutional models. Mamadou Selly Ly, Oumar Bassoum, Adama Faye.
Institut Santé et Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal

15. Only four countries had coverage
levels with any type of health
insurance of above 20%
Overall, health insurance coverage
was low (7.9%) and Pro-rich
BMJ Global Health - Examining the level and inequality in health insurance coverage
in 36 sub-Saharan African countries Edwine Barasa ,1,2 Jacob Kazungu,1 Peter
Nguhiu,1 Nirmala Ravishankar3
Health Insurance Coverage
▪Rwanda—78.7%
▪Ghana—58.2%
▪Gabon—40.8%
▪Burundi 22.0%.

16. Coverage of the Poor
Coverage is not effective for
most of the poor
Many of them are covered by
community mutual health
insurance companies which
put up barriers to access due
to delays in payment of
subsidies by the government.
BMJ Global Health - Universal health insurance in Africa: a narrative review of the literature on institutional models. Mamadou Selly Ly, Oumar Bassoum, Adama Faye. Institut
Santé et Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal
▪ Tunisia, Gabon and Rwanda ,best
performers.
▪ In Senegal 19% of population
enrolled in the indigent scheme of
the UHI program.
▪ In Morocco, 19% of population is
covered by the destitute scheme.
▪ For other countries, less than 10%
of the population is registered as
poor in the UHI program.

17. Care Use
▪ In Ethiopia, outpatient services.
▪ In Ghana, hospitalization, antenatal
care, skilled birth attendance and
drugs; increases access to both public
and private facilities for insured;
improves access to care for children
and the poor, reduces self-treatment.
▪ In Kenya, except for hospitalization;
promotes access of maternal
healthcare in private hospitals.
▪ In Tunisia, increase probability of
accessing private care
BMJ Global Health - Universal health insurance in Africa: a narrative review of the literature on institutional models. Mamadou Selly Ly, Oumar Bassoum, Adama Faye.
Institut Santé et Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal
Insurance schemes increase
likelihood of using health
services.
Noted in Ethiopia, Ghana,
Kenya, Morocco, Nigeria,
Rwanda, Sudan, Tanzania and
Tunisia

18. Financial Protection
Noted in Morocco, Nigeria,
Rwanda, Ethiopia, Kenya, Tunisia,
Tanzania
BMJ Global Health - Universal health insurance in Africa: a narrative review of the literature on institutional models. Mamadou Selly Ly, Oumar Bassoum, Adama Faye.
Institut Santé et Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal
▪In Morocco, impact on catastrophic health
expenditure.
▪ In Nigeria, impact on financial protection
except for the poor.
▪ In Rwanda, the poorest quintiles were more
exposed to catastrophic health expenditure.
▪ In Ethiopia, CBHI have lower out-of-pocket
payments, are less exposed to catastrophic
health expenditures.
▪ In Kenya, insurance reduces out-of- pocket
health expenditures
▪ In Tunisia, protection against catastrophic
expenses related to chronic diseases
▪ In Rwanda, protection against catastrophic
expenses
Insurance Schemes have a
positive effect of the health
insurance program, even for
the poorest.

19. Health Expenditures
Contribution of health insurance schemes to
current health expenditure
▪ Highest: Gabon, Tunisia and Morocco,
(35.9%, 33.8% and 30.1%).
▪ Lowest: Ethiopia, Burundi and Nigeria, (1%,
1.9% and 2.9%).
Share of out-of-pocket payments in health
spending
▪ Best performer, Rwanda, (11.67%), same
level as the world.
▪ Highest: Nigeria and Sudan, (70.52%,
67.38%).
BMJ Global Health - Universal health insurance in Africa: a narrative review of the literature
on institutional models. Mamadou Selly Ly, Oumar Bassoum, Adama Faye. Institut Santé et
Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal

20. The Package

21. The Questions
▪ What goods and services should be covered under the
benefits package
▪ What information is needed to inform the selection?
▪ What criteria, methods, and data are needed to inform
the prioritization process

22. What goods and services
should be covered underthe
benefits package?
Explicit costing of the benefit package
Implicit packages or negative lists of the
services not included are more common
than having explicit lists of services
included.
A list of services that hasn’t been
costed, linked to available resources
and budget allocations leads to implicit
rationing of services.
Facilities will frequently lack the
personnel, drugs, equipment, and
resources needed to deliver effective
services.
Table 2: Benefit package in selected countries
Ghana ▪ Comprehensive inpatient and outpatient services for all;
negative list of services not covered
Kenya ▪ Initially limited to inpatient
▪ In 2010, NHIF introduced a civil servant scheme that
included inpatient and outpatient services, treatment
abroad, and funeral expenses
▪ In 2015 the NHIF expanded and harmonize benefits for
noncivil servant formal and informal sector workers to
include comprehensive inpatient and outpatient
entitlements
Nigeria ▪ NHIS: Comprehensive inpatient and outpatient services
including dental, lenses, cancer treatment, and renal
dialysis
▪ HUWE: 56 essential interventions covering 60% of the
disease burden mostly related to maternal and child
health, adult malaria, and family planning
Rwanda ▪ All services in the public sector provided they follow the
referral system
Tanzania ▪ NHIF: both inpatient and outpatient services but has
spending limits
▪ CHF: only covers primary level facility services
Sudan ▪ Comprehensive package including outpatient and
inpatient; negative list of services not covered
Source: (McIntyre, et al., 2018) (Umeh, 2018) (World Bank, 2019)

23. What goods and services should be covered under the
benefits package?
Globally, there is a
strong convergence to
first include maternal
and child health and
communicable disease
interventions and then
gradually expand
services as resources
increase.

24. Can priority setting be fair and ethically acceptable?
Priority setting is inevitable on the path towards UHC
Health needs exceed resource availability, not setting
priorities may lead to unfairness
Countries experience gap between their population health
needs and what is economically feasible to provide
Fairness requires unmet health needs to be addressed, but
in a fair order.

25. What information is needed to inform the selection?
In the absence of country-specific costing
studies, the Disease Control Priorities (DCP3)
initiative costed all services in its essential
and high priority packages.
▪ The total cost per person for sustaining a
HPP and an EUHC at 80% coverage
estimated to be
▪ $US42 and $72 respectively in low income
(LIC) countries
▪ $58 and $110 respectively in lower-middle
income (LMIC) countries

26. What information is needed to inform the selection?
Information on supply side constraints
Clear diagnostic and treatment protocols – including referral
pathways – developed for each intervention included in the
benefit package to assess whether facilities are capable of
delivering interventions at acceptable standards.
Health facility surveys - to inform decisions on which services can
be delivered at what level of care (e.g. primary, secondary,
tertiary); help target additional resources to front line facilities to
meet increased demand for services.

27. What criteria and methods are needed to inform the
prioritization process?

28. Transparency and accountability around the priority-setting process to avoid the implicit
rationing of services.
Many non-mutually exclusive criteria are used to set priorities:
• effectiveness (is the intervention evidence-based? does it work?)
• cost and potential budget impact (would the intervention be catastrophic if paid out-
of-pocket? Can the scheme afford it?)
• cost-effectiveness – the centerpiece of most economic evaluations (is the
intervention efficient? bringing together effectiveness and cost criteria)
• supply side constraints (is the system able to provide the service?)
What criteria and methods are needed to inform the
prioritization process?

29. Priority-setting and selection of the benefit package is a political exercise.
▪ Many stakeholders outside the Ministry of Health are involved
▪ Decisions are constrained by the institutional framework within which the annual budget
law is prepared, approved, and executed.
▪ Important to have transparent decisions around what is included/excluded in the benefit
package, based on what criteria, and by what authority is transparent and consistently
applied.
o Publication and dissemination of health technology assessment findings
o conflict of interest disclosures
o Having an independent health technology assessment unit
What criteria and methods are needed to inform the
prioritization process?

30. What criteria and methods are needed to inform the
prioritization process?

32. The 3rd Edition of the Disease
Control Priorities initiative
(DCP3) selected 218
interventions that form a
model concept of Essential
Universal Health Coverage
(EUHC), further prioritized to a
108 high priority package (HPP)
As many low-income countries
will unlikely be able to fund all.
They were chosen because they
• provide good value for
money;
• are feasible to implement
in low- and middle-income
countries;
• address a significant
disease burden.

34. The Coverage

35. The Questions
▪ Who should be covered?
▪ How should beneficiaries be targeted?
▪ How should beneficiaries be enrolled, and renewed?

36. Moving from
regressive
inequitable
trickle-down
coverage..
… to a progressive bottom-up health care system that prioritize
coverage for left behind lower-income populations
From Regressive to Progressive Coverage
Coverage
expansion
from
he
top
down
Formal
sector
Non-poor
Informal sector
Vulnerable
Poor
Coverage
expansion
from
the
bottom
up
Poorest
Income
Richest
Poverty line
Vulnerability line
Need for
public
subsidization
Highest
Lowest
Trickle-Down and Bottom-Up Expansion of Health Care

37. Who should be covered?
Government and compulsory social
health insurance schemes in sub-
Saharan Africa have generally
favored higher income groups.
lack of resources in many low- and
middle-income countries, weak
targeting mechanisms often lead to
formal sector workers being
covered first. 5.4
75
99
7
27
16.6
29.8
25
93
73
14
6.5
60.1
45.4
2
8
5 1
7.3
Ghana Kenya Nigeria Rwanda Tanzania Sudan
Other
Pregnant women
Children <18
Poor
Informal sector
Formal sector
Despite rhetoric to prioritize coverageof poor households, children, and pregnant women only Ghana and Sudan
do so in practice.
Coverage by membership type (%), latest available
Source: World Bank, 2019 and Sudan NHIF as of November 2019
Prioritize poor and vulnerable households; mothers and children for
coverage

38. How should beneficiaries be targeted?
Several welfare-based targeting methods are used to identify poor and vulnerable
households.
• Community-based targeting using community leaders to decide who benefit,
subjective, common, easy and cheap to administer.
• Categorical targeting use differing categorical criteria that recognize individuals
particularly vulnerable in childhood and old age or during pregnancy and allocate
benefits to these population groups, more accurate, requires supporting
documentation which may limit access especially if fees are required to obtain
• Geographic targeting using poverty maps or focused in rural areas.
• Proxy-means testing (PMT) provides a more objective ranking of household welfare
based on easy to observe characteristics such as housing and assets.
• Means-testing, the gold standard for assessing welfare, uses collected, and often
cross-verified, information on households’ income or wealth; costly and time
consuming to develop as well as infrequently done.

39. How should beneficiaries be targeted?
Imperfect targeting in Ghana, Rwanda, Tanzania, and Sudan that operate
premium or fee exemptions for certain groups leads to the inclusion of
many who should not be eligible and the exclusion of those who are
most in need.
Infrequent updating of registries and the lack of formal grievance redress
mechanisms also contributes to the exclusion of the poor.
Technology and information system capabilities are typically a limiting
factor for more efficient maintenance of population, social and
beneficiary registries.

40. How should beneficiaries be targeted?
An integrated social registry
also acts as a common
gateway for assessing the
eligibility of several social
assistance schemes (i.e.
instead of having each social
assistance program – health
insurance, conditional cash
transfers, food subsidies –
collect information, assess
needs, and determine
eligibility separately).

41. The Financing

42. The Questions
▪ How should national health insurance schemes be
financed to reach UHC?
▪ Where will additional fiscal space for health come
from?
▪ How should resources be pooled?

43. How should national health insurance schemes be
financed to reach UHC?
Expansion via SHI is slow
Only as the capacity to enforce
contributions from the
informal sector increases and
participation becomes de facto
mandatory, do countries attain
high coverage rates

44. How should national health insurance schemes be
financed to reach UHC?
Few countries have been able to achieve universal health coverage
following a contributory social health insurance type approach;
governments often end up following a mix of contributions and tax-based
subsidies.
A common approach has been to cover formal sector workers via social
health insurance schemes while using tax-based financing to cover poor
and vulnerable households.
Yet countries differ on how to expand coverage beyond this group.

45. How should national health insuranceschemes be financedto
reach UHC?
Persistent informality in sub-Saharan Africa
makes it difficult for countries to broaden
their tax base and raise significant revenue
via social health insurance.
Countries that struggle to collect tax
revenue will equally struggle to collect SHI
contributions.
Overall, the largest source of health
expenditures is often out-of-pocket
spending as in Ghana, Nigeria, and Sudan or
government revenues as in Kenya, Rwanda,
and Tanzania.
11.0 4.6
1.0
12.1
1.5
7.1
0%
20%
40%
60%
80%
100%
Ghana Kenya Nigeria Rwanda Sudan Tanzania
Rest of the world financing schemes
Household out-of-pocket payment
Voluntary health insurance schemes
Compulsory SHI schemes
Government schemes
Figure 5. Compulsory SHI schemes contribute the least among pre-paid or pooled sources of health financing
Source: (World Health Organization, 2019)
Source of health financing by scheme (%), 2016

46. How should national health insurance schemes be
financed to reach UHC?
When considering the revenue potential of SHI, countries should consider several factors:
▪ the size of the labor force,
▪ the share of wage and salaried workers,
▪ the average annual labor income,
▪ the acceptable/feasible contribution rate that will be deducted from payroll,
▪ the unit of enrollment (i.e. individual or family),
▪ and the ability of government systems to track and enforce contribution compliance.
More recently, countries that have pursued SHI systems with large informal sectors have had to heavily
subsidize contributions through general revenues to expand coverage (e.g. China (rural scheme),
Vietnam and Ghana.
National health insurance initiatives in SSA are predominantly funded by general government revenue.

47. Where will additional fiscal space for health come from?
Countries in sub-Saharan Africa will have to look beyond social health
insurance schemes and recognize that reaching universal health
coverage will require a significant increase in public financing for
health.
Public health expenditure in SSA countries that have launched SHI
or national health insurance schemes is less than US$30 per capita;
amounts would have to increase by an average of US30 and US$71
per capita more to reach high priority and essential UHC benefit
packages. These amounts represent just a small increase in GDP.

48. Where will additional fiscal space for health come
from?
There are a number of ways in which additional fiscal space for health can be
met:
First and foremost are conducive macroeconomic conditions and increases in
overall government revenue – even if the share to health does not change, the
size of the overall pie is larger.
In most countries, economic growth will be the most likely source of additional
revenue and annual GDP per capita growth rates, debt to GDP ratios, and
revenue projections help give an indication of economic outlook.

49. Where will additional fiscal space for health come
from?
Second is ensuring that resources get allocated to the health sector through earmarking
and specific commitment devices such as pre-paid insurance schemes.
Many low and middle-income countries have introduced taxes over the last decade,
providing additional government revenues that flow totally or partly to health. For
example, in Ghana, a national health levy of 2.5% of the VAT accounts for 70% of all
NHIS premiums making it a predominantly tax-financed system even though it has a
contributory SHI element.
Many countries also tax products known to be harmful to health (sometimes known as
“sin taxes”) and earmark a share for the health sector for activities such as health
promotion, tobacco control, alcohol reduction programs treatment, or to subsidize
health insurance contributions for some population groups (e.g. the Philippines).

50. Where will additional fiscal space for health come
from?
Third, is a re-prioritization of health in overall budget allocation decisions – even if the
size of the pie does not change, the share to health is larger.
Fourth, is access to health sector grants and donor aid. External resources play a small
part in financing UHC schemes and are not sustainable in the long-run. Only in Tanzania
and Nigeria do they form a significant share of overall current health expenditures.
Fifth, is improvements in efficiency which will ensure “more health for the money”.
Countries with constrained macroeconomic prospects should focus on policies that aim
to improve efficiency and deliver cost-effective quality care as additional resources for
health will be limited in the short-to-medium term.

51. How should resources be pooled?
A single payer i) pools the risk of the entire Nation (or State) into one risk pool; ii) covers
everyone in the risk pool with one uniform benefit package; and iii) follows one uniform
payment methods for reimbursing providers and one set of rules for quality of care
Multiple payer systems have multiple risk pools with each plan offering its own benefit
package and setting its own rules for purchasing care from providers
Some countries with multiple pools have managed to cross-subsidize schemes and adopt
features of single payer systems such as using the same provider payment method and
fee schedule or rely on government regulations to manage the market.

52. How should resources be pooled?
The larger and more diverse the risk pool the greater the financial sustainability.
The pool size depends on the nature of the package. If confined to routine care of common
conditions where expenditure is predictable and can be delivered locally, small risk pools may be
satisfactory. Coverage of less common, more expensive care may require larger pool sizes to
ensure the sustainability of the scheme from random large expenditure shocks.
Multiple or parallel pools have greater potential for fragmentation by socioeconomic status and
risk with implications for equity; increased administrative costs; and less purchasing power. Once
established, different pools are politically difficult to integrate and harmonize.
Indeed, there is a global trend to merge multiple risk pools and consolidate revenue and
expenditure control into a single organization.

53. How should resources be pooled?
Decentralization also affects pooling decisions.
In low and lower-middle income countries, the revenue raising capacity of subnational
governments is generally limited and dependent upon transfer from central government.
When pooling at the Local government or administrative level, revenue raising potential, capacity
to carry out the functions of an insurer (e.g. enrollment, contracting, claims management), and
the portability of schemes should be given additional consideration.
Assignment of the same functions to all Local governments regardless of capacity carries a risk of
substandard service provision.
The lack of human resources, experience, and standardized information systems further impact
the capacity needed to start and manage multiple subnational funds.

54. The Providers

55. The Questions
▪ How should providers be paid?

56. How should providers be paid?
Provider payment methods embody specific incentives which influence provider’s
behavior in treatment decisions, and thus the quantity, quality and efficiency of
service provision.
In designing payment systems, key considerations include:
▪ whether payment is made prospectively or retrospectively;
▪ the unit of payment;
▪ the level of payment.
Most countries use a combination of payment methods to balance out the strengths
and weaknesses of various methods.

57. How should providers be paid?
Table 6: Strengths and weaknesses of various provider payments methods
Definition Strengths Weaknesses
Increasing
level
of
service
bundling
→
Line-Item Budget: Providers receive a fixed amount of resources for a
certain period to cover specific input expenses (e.g., for salaries, medicines,
equipment, maintenance, etc.) to provide a stipulated set of health services
▪ Easy to implement ▪ Incentive to expand input use
▪ Incentive to under-provide services
▪ Incentive to refer up
Fee-for-Service: Providers are paid for each individual service provided per
episode of utilization; fees are usually fixed in advance for each service or group
of services
▪ No incentive to skimp on necessary care
▪ Can be used to incentivize under-
provided services
▪ Incentive to increase unnecessary care
▪ No incentive to control costs
▪ Administratively costly
Per diem: Providers are paid a fixed amount per day that an admitted patient
stays in the facility
▪ Incentive to reduce unnecessary services
per day
▪ Incentive to extend length of stay as cost
of treatment drops precipitously after
first 3 days
Case-Based: Providers are paid a fixed amount per admission depending on
patient and clinical characteristics, regardless of number of days; diagnostic-
related group (DRG)
▪ Incentive to use resources more
efficiently
▪ Incentive to reduce unnecessary care
▪ Incentive to skimp on services per
admission
▪ Incentive to up-code and discharge
prematurely
▪ Administratively complex
Capitation: Providers are paid a fixed amount for each individual
covered/enrolled for a certain period to provide a stipulated set of health
services
▪ Incentive to reduce unnecessary care
▪ Incentive towards prevention,
promotion, and early detection
▪ Incentive to avoid high-risk/chronic
patients (i.e. cream skim)
▪ Incentive to skimp on care and refer up
Global Budget: Providers receive a fixed amount of funds for a certain period
to cover aggregate expenditures to provide a stipulated set of health services;
provider can allocate budget with flexibility and resources are not tied to specific
line items
▪ Incentive to use resources more
efficiently
▪ Incentive to reduce unnecessary care
▪ Incentive to skimp on care and refer
sicker patients elsewhere
Source: (Yip, et al., 2014)

58. How should providers be paid?
In prospective and bundled payments greater risk is borne by the provider,
incentivizing them to manage resources more efficiently. They may also incentivize
other undesirable behaviors such as skimping on costs and avoiding chronic or sicker
patients.
▪ Prospective payments assign a fixed payment rate to specific treatments before the
care has been delivered.
▪ Retrospective payments are paid after based on actual care received.
The more aggregate the unit of payment is (i.e. the more bundled), the greater the risk
borne by the provider.

59. How should providers be paid?
Countries often start out with line-item and fee-for-service and move towards
more bundled payment methods as their administrative capacity and cost
accounting systems develop.
Capitation and case-based payments are generally considered the most efficient
provider payment methods for primary health care and hospitals respectively if
implemented well.
Facilities are funded on the same basis for the same package of services (in the case
of capitation) and the same activity (in the case of case-based payments),

60. The Accountability

61. The Questions
▪ How will the health insurance fund be managed?
▪ Who decides what?
▪ What operational systems and skills are needed?

62. How will the health insurance fund be managed?
There are many different governance arrangements with respect to the organization of MHI or
NHI schemes. The most significant feature is the level of independence or autonomy that is
retained.
▪ The health fund may be a State agency (e.g. part of the Ministry of Health (MOH)) governed
by civil servants and reporting to the MOH;
▪ an autonomous institution under public law governed by professional managers (non-civil
servants) and a Board of Directors;
▪ a mix of these two arrangements.
It can retain all of the tasks related to managing the health fund or it can outsource some of the
functions to private or non-governmental organizations.
Decentralization adds another layer of complexity bringing in potential subnational actors into
the decision-making process (e.g. local government or decentralized branches of the MOH or
health insurance agency).
Most SHI agencies are independent or quasi-independent, but even when they are embedded
within the MOH they retain a significant amount of operational autonomy.

63. Who decides what?
While there is no verdict on the success and performance of different
arrangements, countries implementing a MHI or NHI scheme are moving
towards splitting the purchasing function – the buying of goods and
services from the function of service delivery – the providing or supplying
of goods and services.
The main goal of such initiatives is to remove any potential conflict of
interest and improve provider performance, to allow purchasers to
introduce financial incentives and monitoring tools to influence the
quantity, quality, and efficient production of services.

64. Who decides what?
Passive purchasing allocates resources based on historical patterns of priority setting
usually through line-item or input-based budgeting; it is primarily geared towards
addressing financial accountability.
Strategic purchasing allocates resources based on active, evidence-informed decisions
on:
▪ what to buy (i.e. benefit package, essential drugs list),
▪ from whom to buy (i.e. public or private providers), and
▪ how to buy (i.e. provider payment methods and contracting terms).
Decisions are made in order to maximize quality, efficiency, and sustainability.

65. Who decides what?
The shift towards more ‘strategic’ purchasing must be matched with appropriate authority,
resources, and managerial discretion to allow the purchaser to be effective.
There is no blueprint on where key purchasing functions should sit, patterns emerge based
on the respective mandates of different stakeholders. Most health insurance agencies are
responsible for choosing provider payment arrangements, setting tariffs, and contracting
with providers – their primary objectives being fund management and solvency.
Provider accreditation and quality assurance are more commonly managed by the MOH
whose primary objectives are often service delivery and ensuring quality standards.
Allocating resources to the health insurance agency, determining premiums, and selecting
the benefit package have a broader set of stakeholders
Despite these divisions of labor, what is clear is that health insurance agencies and Ministries
of Health cannot work in isolation from each other.

66. Who decides what?
Who does what?
Budget allocation for health insurance agency/Premium setting
Determine the benefit package
Develop provider payment systems
Set payment rates
Contract with providers
Monitor quality

67. Who decides what?
Accountability requires specification on what an institution will be held accountable for and
to whom. Health insurers are primarily financial institutions and financial accountability is the
primary focus of Ministries of Finance. Accountability, especially performance accountability, is
commonly the least well-defined function.
▪ Financial accountability requires minimum capital requirements and reserves, adequate
internal controls, external auditing, and timely financial reports to regulatory and oversight
authorities. Health insurers are also responsible for paying providers in a timely manner for the
delivery of quality services.
▪ Performance accountability requires setting up mechanisms to supervise health care
providers, verify the quantity and quality of services provided, and reimburse claims.
▪ Public accountability requires increased transparency/dissemination on utilization of services,
levels of performance, and achievement of targets and setting up complaints and grievance
redress protocols for beneficiaries.

68. What operational systems and skills are needed?
Table 8: Key tasks of a National Health Insurance Agency
Beneficiary management ▪ Authenticates identify at enrollment and point of service
▪ Checks eligibility status
▪ Assigns beneficiaries to primary health care provider
▪ Provides customer service
Provider network management ▪ Provides primary health care providers with an updated list of beneficiaries and
capitation allocation (monthly)
▪ Checks credentials
▪ Negotiates contracting terms
▪ Supports referral management, notification/disease surveillance, and patient follow-up
Claims management ▪ Checks appropriateness of care
▪ Verifies claims
▪ Adjudicates claims
▪ Reimburses providers
Information and data
management
▪ Maintains up-to-date databases on beneficiaries, eligibility status, providers
▪ Analyzes data to inform the design of new cost containment and fund management
policies
▪ Generates and shares reports

69. The Conclusion

70. Yes, If Countries
▪ Design an affordable package of services within a country’s means
prioritizing health needs of its population.
▪ Prioritize the disadvantaged groups, targeting the poor efficiently
using unified means to deliver integrated social services across
ministries/ organizations.
▪ Increase significantly public financing for health.
▪ Use provider payment methods that influence provider’s behavior in
treatment decisions, and thus the quantity, quality and efficiency of
service provision.
▪ Ensure that operational systems and institutional capacity needed are
developed and are in place to carry out responsibilities for good
accountability.

71. Thank you!