ACCORDING to the World Health Organisation (2013), Universal Health Coverage (UHC) means people receive the health services they need without suffering financial hardships. Achieving UHC has become a key health policy goal in many countries throughout the world, clearly reflected in the World Health Assembly Resolution 58.33 (2005) and being a key component of the SDG goal 3.8.
By Enock Musungwini
UHC seeks to ensure that all people obtain the health services they need without risking financial hardship from unaffordable out-of-pocket payments (WHO Bulletin, 2013). UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma Ata declaration in 1978 and recently the 2018 Astana declaration on PHC(WHO & UNICEF, 2018).
National Health Insurance is a system of health insurance that insures a national population against the catastrophic costs of health care so that the nation can have access to health care. NHI can be administered by the public sector, the private sector, or a combination of both to ensure accountability and fiduciary oversight.
NHI is one way of ensuring UHC and working towards equitable financing of health care and can include mandatory contribution scheme, funding from taxes like “sin” tax, employer contributions and government part funding.
Funding mechanisms vary with the program and country because context specific factors play a part like the performance of the economy, ability of government to fund, availability of other funding mechanisms, tax base and employment levels. National schemes have the advantage that the pool or pools tend to be very large which is positive for risk pooling.
It is estimated that only 10% of the estimated 15 million Zimbabwe population is on medical aid leaving about 90% without any medical aid cover and exposed to “Out of Pocket expenditure” payments for health (Mugwagwa, 2017; Global Press Journal, 2018).
On funding model, the Zimbabwe National Health Insurance scheme can adopt a hybrid funding mechanism comprised of contributory and Non-contributory means and these will be partly from taxation, government funding and personal contributions especially in an economy that is more informal. In a research by Okungu, Chuma and McIntyre(Okungu, Chuma and McIntyre, 2017) in Kenya on sustainability of Social Health Insurance, it was found that a combination of both contributory and non-contributory models are required to complement each other with contributory model being effective and sustainable in early years and non-contributory model funded wholly by being sustainable in long term.
The call for Zimbabwe National Health insurance as part of the broader Zimbabwe Health Financing Strategy started a long time ago but the momentum died along the way. There have been many theories about the stagnation of the NHI including conflicted interests by doctors who benefit from a lucrative private sector at the expense of government health institutions viability. Another perspective is said to be resistance and challenge from the medical aid industry because of perceived threats to the industry.
These have so-called theories have shared within various professional networks, social and public groups and is a debate for another day. We however applaud the launch of the Zimbabwe Health Financing Strategy 2017 but there are questions on the composition of the Technical Working Group which seem to replicate same cadres at Ministry of Health Head Office only and lacking multi-disciplinary skills and professional diverse.
Furthermore, it does not articulate the NHI as a clear health financing strategy that more home grown without over dependence on donors. The proposed engagement of a Consultant focusing on NHI by the current Ministry of Health administration is commendable to promote wider consultation so that many actors with interest and stake in NHI will have a chance to have submissions(Newsday, 2019).
In terms of Health Policy making principles NHI included, based on the Health Policy Triangle framework(Buse, Mays and Walt, 2012; WHO, 2018a), it is imperative to look at the interaction of process, context, content and the actors in this case consumers, Government, Civil society and pressure groups looking at their interests and how they influence others.
It is imperative to consider who among the actors has the power and influence, who has no power, in whose interest is the policy direction, are other constituencies represented and are there conflicts of interests among policy actors especially those with power.
China successfully achieved universal health insurance coverage in 2011, representing the largest expansion of insurance coverage in human history. China’s achievement is impressive for both the scale of coverage expansion, which is the largest expansion in human history, and the speed of expansion such that by 2011, 95% of Chinese population was insured, compared with less than 50% in 2005(Li, Chen and Powers, 2012).
China success was also a result of political commitment with Chinese leaders holding a high-profile workshop in 2006, at which President Hu Jintao committed to health care reform by stressing that “The goal of reform is for everyone to enjoy basic health care services” (Xinhua, 2006). With political will and support, Zimbabwe NHI will also take shape considering the action by the current health administration.
In a study in Ghana by Aryeetey et al(Aryeetey et al., 2016) on Ghana National Health Insurance scheme, they found that households insured with health insurance had reduced catastrophic expenditure caused by Out of Pocket Expenditure by 86% compared to the uninsured who had a reduction by 64%(Aryeetey et al., 2016).
Another study by Obermann, Jowett and Kwon (Obermann, Jowett and Kwon, 2018) on impact of NHI in the Philippines found that introduction of NHI increased population coverage, increased access to quality health services for rural community. The Philippines NHI was funded from “Sin tax” which raised US$1.2 billion in first year from alcohol and tobacco companies and channelled to health services.
Closer home, South Africa has had the NHI programme on hold for some years but they have taken a bold step to implementation now. The South African Minister of Health Aaron Motsoaledi had this to say about SA NHI “It is about social justice and equality. It is simply about the way countries share their money for health, who gets what when. It is not about sharing budgets of health, no.
“It is about redistribution of the wealth of the country for the health of each and every citizen, regardless of the socio-economic status or their status in life.”
In a study by Booysen and Hongoro (Booysen and Hongoro, 2018) on South Africans public and private sector perceptions about SA NHI, they found that more than 80% considered NHI as a top priority for South Africa with emphasis on having quality improvement of services in the public health services.
Under the National Health Insurance, the principle is that the rich will subsidise the poor. The young will subsidise the old. The healthy will subsidise the sick. The urban will subsidise the rural. It is my strong conviction that Zimbabwe needs a National Health Insurance to increase funding for public health institutions and have everyone contribute to the system.
Health insurance or medical aid has been considered as an employment benefit by many as a result even those with ability to contribute but involved in informal sector will not do so. NHI can co-exist with private medical aid societies giving options for those who want to have private health insurance as additional to the NHI cover.
It is surprising that many people involved in informal sector don’t have medical aid despite earning more than civil servants and other formerly employed people who are contributing tax and medical aid cover. Alcohol and tobacco effects are burdening public health institutions and there should be a way of having contributions from these and many other institutions towards a multi-funding mechanism for Zimbabwe National Health Insurance. Alcohol and tobacco companies taxation and or contributions to health sector are some of the key strategies for tackling NCDs and contained in the World Health Organisation “Best Buys”(Nsingo, 2002; WHO, 2018b). The time is now!
Enock Musungwini is a 2018-19 Chevening Scholar studying MSc Public Health at London School of Hygiene and Tropical Medicine in London, UK. He is a Health Policy and Advocate for Universal Health Coverage and worked as a Research and Information Officer at Association of Health Funders of Zimbabwe (AHFoZ) 2011-14. He holds an MBA, BSc Hons Psychology, DPN and Cert Health Leadership and Management. He is also a Committee Member of the Regional Africa Evidence Network Reference Group at University of Johannesburg, Zimbabwe Embassy UK Health Cluster Committee member and Coordinator with African Diaspora Global Health Café. He can be reached on twitter @Enomark1979 firstname.lastname@example.org
The views expressed in this article are mine