Africa has the highest burden of disease in the world. However, in 2007 more than half of the 53 African countries spent less than $ 50 per person on health. Of the total health expenditure, 30% came from governments, 20% from donors, and 50% from private sources – of which 71% was paid by patients themselves, the so called out-of-pocket payments. Since health payments regularly take up a disproportional share of the household resources, out-of-pocket payments are an important barrier for seeking health in Sub-Saharan Africa. So, out-of-pocket payments create inequity in access to health care. A social health insurance can be a solution to improve access to health care. Kenya is the only country in Sub-Saharan Africa which successfully implemented a social health insurance at national level. Other countries, including Uganda and South Africa, aim to implement a national health insurance as well, but they seem to be unsuccessful. Apparently, there are country-specific conditions which influence to what extent a country is suitable for such healthcare reforms. So what does Kenya have that other countries do not? What determines the success of implementing a national health insurance?

The importance of health insurance

In Africa, about half of health care expenses are out-of-pocket payments. Health care costs are a major barrier in health seeking behaviour and lead to an unequal access to health care, disadvantaging the poor. Introducing a health insurance programme is one way to ensure the poor of access to health care facilities and protect them against catastrophic health payments. In the past 25 years, several countries in Sub-Saharan Africa introduced a form of Social Health Insurance (SHI). In the majority of the countries these were small projects, only covering a city or region. The major setback with SHI schemes in Africa is the limited number of enrolled people: 95% of the insurance schemes count less than 1 000 members. The small scale of an insurance scheme implies poor financial viability due to limited risk pooling, and danger of bankruptcy. Therefore, implementing a national health insurance – managed by professionals – may be the solution for African countries on their way to universal health coverage.The insurance scheme covers all primary health services, outpatient and inpatient services and medication. First evaluations show that the number of visits per cardholder to out-patient-departments has increased since its introduction. Uganda and South Africa show great interests in a large-scale insurance system, but both fail to carry out such a programme. Apparently, a national health insurance cannot be implemented just everywhere.


Country-specific features

There are several key differences between Kenya, Uganda and South Africa that may explain why Kenya successfully implemented a national health insurance scheme and Uganda and South Africa fail to do so.
First of all, Kenya was the first Sub Saharan country that became independent from colonial rulers and eventually installed a government that led to a stable political climate in the following years. Uganda’s post-colonial development, however, is shaped by Idi Amin’s military dictatorship (1971-1979) which destroyed much of the country’s health care infrastructure. When eventually democracy was initiated, health care reforms failed, causing a corrupt public health care system. In South Africa, the years of apartheid entrenched inequity into the provision and financing of health services, producing a lack of access to essential health services for the majority of the population. The post-independence stage is of major importance in creating a suitable environment in which governments are able to carry out strong social health reforms. Kenya evidently made more constructive progress in developing a suitable health care system than Uganda and South Africa.

Also, there are differences in how current health systems are organized and financed. In Kenya, the government is the main financer of health. But in Uganda, one quarter of all financial means comes from international donor organizations, and one third of health expenses is paid by out-of-pocket payments.

Moreover, an important share of health services in Uganda is managed by religious organizations. In South Africa, the government finances 40% of health care expenditure and 40% is financed through private health insurances. Countries in which health care is mainly funded and organized by private or external organizations are less likely to convert into a government controlled social health insurance.

Furthermore, the extent of the health insurance sector is an important predictor of a successful implementation. In Kenya there were only small-scale insurance programmes active, and in Uganda only 2% of health expenses are paid through insurance programmes. In contrast, in South Africa there are more than 120 private health insurance programmes. Efforts to replace these insurance programmes by a national health insurance caused major resistance by private insurance companies. Private companies fear to lose their share of the insurance market once a national system is installed.

Quality of care is another important factor. Although Uganda’s health expenditure is comparable to that of Kenya, Uganda’s health services are of lower quality and the distance to health clinics is bigger. Low quality and unequal distribution of health services play an important, discouraging role in the patients’ willingness to pay for any type of health insurance. Also, societal characteristics influence the success rate of a national health insurance. Since rich inhabitants will pay higher premiums than the poor and usually suffer from fewer diseases, the wealthy share of the population partly subsidizes the health care for the poor population. In order to maintain a social health insurance, a minimal level of solidarity is essential. In South Africa, income per capita is exceptionally unequal and solidarity across socioeconomic classes is limited. A lack of solidarity causes resistance against implementing a national health insurance.

In Kenya, the reforms of a national health insurance started with an election promise by one of the bigger political parties to abolish out-of-pocket payments. After being elected, this party put great efforts in developing the insurance scheme, implementing it before the end of the term. It shows that major national reforms call for strong political willingness.

Lessons learnt

Policy makers and politicians in Sub-Saharan Africa should move towards a comprehensive national health policy, and invest in the quality and number of health services, before developing national health insurance. Furthermore, government health expenditure should increase and the financing of health must become independent from external donors. Also, countries must overcome problems of unequal income distribution and lack of solidarity across classes, prior to implementing social reforms. And to intercept resistance, all stakeholders must be involved in the process of policy making, especially established insurance companies because they have indispensable local experience.

More research on the background of succeeding and failing of national health insurances must be done, starting with critically evaluating the Kenyan National Health Insurance Scheme. Rumour has it that the Kenyan health system has difficulties in raising sufficient funds to pay for all enrolled patients, and some say that the insurance scheme will shortly go bankrupt due to its own success. Nevertheless, important lessons learnt in Kenya can guide policymakers in Africa on their way to universal health coverage.