Africa has made encouraging progress towards universal health coverage (UHC). The coverage of insecticide-treated bed nets for children, a central element of reducing child mortality, has increased 17% in the last decade1. Key indicators in maternal and child health services, such as antenatal care and skilled birth attendance have also improved2. Yet, wide disparities remain within countries, and gaps remain large for many critical services. Access to HIV/TB and malaria services remains lower than other core indicators of UHC progress and the region is far from reaching the 2030 basic essential health services objective of 80% population coverage3.
Investment in healthcare remains low with only four African countries allocating at least 15% of their annual budget to the health sector as agreed in the Abuja Declaration4. Donor countries have also failed to scale up support5, partly due to a spate of global economic, political, and environmental crisis over the last two decades. The most recent coronavirus pandemic has shattered national economies in Africa and around the world6. This has pushed some donor governments to slash overseas development assistance by over 30%7. Some experts estimate decades lost in human and economic development8, leaving policymakers to re-examine funding models and priorities9 to deliver on their Sustainable Development Goals (SDG) commitments.
Healthcare provision in Africa is predominantly seen as a public good. However, in the absence of reliable state-led health provision, an increasing number of Africans are turning to private health facilities10. In Nigeria, despite the government’s ambition to provide access to affordable healthcare services, a study commissioned by the International Finance Corporation (IFC) reveals that up to 40% of the population in the two lowest quintiles access healthcare from the private sector, with up to 70% of populations in countries paying for these services out-of-pocket11. In 2017, the total healthcare expenditure in Nigeria was $44.1bn with 77.9% provided by the private sector of which 77.2% was out-of-pocket and 0.6% was through social health insurance systems12.
Sub-optimal healthcare provision, both in the public and the private sector, reduces demand for such services with a knock-on effect on the revenue that can be used to improve services. This creates a vicious cycle of poor supply and demand (see diagram) that exacerbates health inequalities. Where health insurance schemes exist to pool risks for the client and stabilise finances for the provider, there has been relatively low uptake. This is partly down to behavioural issues as many potential customers are unfamiliar with the insurance-based model, whilst others simply do not trust the system to give a return on their investment13. With 11 million Africans pushed into poverty every year
due to out-of-pocket health care expenses14, there is an urgent need to find a way to synergise the public and private sector so they can better complement each other in providing quality, affordable care. Advances in technology and data analysis can be used to improve governance as well as the health-seeking behaviour of citizens. It is widely accepted that digital health can play an important role in delivering UHC and addressing global health challenges such as those produced by the COVID-19 pandemic15.
Before discussions around policy changes, it is important to note what UHC is not. According to the World Health Organization (WHO)16, UHC is not free coverage and treatment of all diseases regardless of costs but rather is finding a way to ensure that there is a progressive expansion of healthcare that can be accessed universally, treating both individual and population-based health needs while protecting patients financially. UHC is also not just about health financing but a holistic consideration of all the building blocks of a resilient health system such as service delivery, human resources, facilities, health technologies, information systems, and governance11. This paper sets out interventions that address the vicious circle of low demand and supply and moves the African continent forward on its road to UHC.
Policy Changes and Recommendations
Building trust is central to creating demand in the health sector and moving towards a virtuous cycle. By showing people their health system can provide quality and affordable care, we can convince them to invest in pre-paid insurance schemes and avoid catastrophic healthcare expenses. Questions around the appropriateness of risk pooling in limited-resource settings led PharmAccess to pilot a scheme in Kwara State, Nigeria in 2008. Results showed a clear demand for insurance, even amongst the poorest, if quality and affordable services are available17. PharmAccess worked with public and private partners to design and implement social health insurance schemes using mobile phones to reach more people at lower marginal costs; data generated used to identify gaps and improve services to ensure nobody is left out. This increased transparency builds trust, addressing the central issue in the vicious circle.
Previous models were not doing enough to increase uptake of health insurance, and this caused health insurance utilization to stagnate at single-digit levels18. Due to the successes of PharmAccess’ Community Health Insurance Scheme in Kwara19, the National Health Insurance Scheme (NHIS) decided to encourage State-supported Health Insurance Schemes (SSHIS) as a viable option. This has resulted in 33 out of 36 states in Nigeria legislating for a mandatory state health insurance scheme, and reserves at least 1% of the state’s consolidated revenue to pay health premiums for the indigent. Several states have scaled up enrolment within this framework.
About 5 million people die every year because of poor quality of healthcare, more than double the deaths caused by no access to healthcare, so health quality is a key driver of health insurance uptake20. A major reason why Nigeria is still grappling with low enrolment in health insurance is that the hospitals are perceived to be sub-par, so many do not want to pay for health insurance because they cannot guarantee the quality of the care they will receive21. As public sector budgets fall22, it is becoming more difficult to maintain the quality of health services delivered to residents, even when these residents have contributed to a health insurance scheme.
To improve the quality of healthcare facilities, PharmAccess developed SafeCare; a standards-based stepwise certification approach that rates, improves and recognizes providers’ business and quality performance. Qualified SafeCare assessors assess facilities where compliance against defined quality standards is measured, a Quality Improvement Report (QIP) is then generated with a customised improvement plan to address their quality gaps. The plan sets out transparent and achievable goals using simple tools towards a manageable path to improvement.
An example is Subol hospital in Idimu, Lagos which started operation 22 years ago and has achieved a high degree of acceptance in the healthcare community in Nigeria. Over the years, Subol improved from Level 1 to Level 4 when measured against the SafeCare standards with Level 5 as the highest quality level23. The quality improvement has increased patient encounters and revenue, allowing the hospital to reinvest in better equipment, processes and services delivery.
Start private, grow public
Health is often regarded as the responsibility of the state. However, the private sector often complements public efforts and in Africa over half of the population is served by private clinics and hospitals, especially at the primary care level24. Whilst these facilities provide innovative products and services, additional capacity and financing for healthcare, public sector involvement is critical to bring those initiatives to scale. Therefore a well-functioning public-private partnership (PPP) in health provides a realistic pathway to attaining UHC in Africa.
Advocacy for more private sector inclusion in the management of publicly owned primary health centres (PHC) remains a challenge. PharmAccess is currently piloting a PPP model in Delta State Nigeria where the private sector supports the government in transforming its PHCs. Results so far show an increase in efficiency, accountability, and improved health outcomes such as maternal and child health indicators25 making this framework a model for policy change. This PharmAccess initiative geared towards revitalising non-functional PHCs will result in many non-functional PHCs being revitalised, equipped and “SafeCare-certified” to serve millions of residents especially in the rural areas.
Mobile and digital technology enables efficient pooling of health financing and scaling of insurance at a low cost, and providing data to improve healthcare delivery and outcomes. Africa is the fastest-growing mobile money market where 10% of transactions are via phone payments (compared to 2% in Europe and the US)26, so embracing this trend can accelerate our journey to UHC.
PharmAccess has developed a mobile application for tuberculosis screening (MATS) with the support of the Global Fund that matches suspected TB patients with healthcare providers. The app increases the efficiency and referral process of active in-facility and community-based screening for TB. Over 360,000 people were screened in 280 days, and research shows that identification of new TB cases was three-fold higher using MATS (10.8%) versus using a paper-based system (3.5%). The app also integrates TB screening and poverty assessments making it possible to offer sustainable plans that include tuberculosis care and treatment.
Digital technology increases financial inclusion in health by enabling UHC through pre-payment models. It is estimated that over 30% of the Nigerian population (60 million) will have greater access to healthcare services through digital technology if some challenges are addressed; 1) Governments should provide a more enabling environment for innovation as innovators have outpaced most health regulators causing friction in the adoption of digital innovations; 2) Collaborative partnerships between telecommunications companies and health institutions should be emphasized and improved as telecommunications provide the foundation on which all digital health solutions are built; 3) Digital literacy must be prioritised for providers and consumers to gain the inherent benefits from digital health solutions.
Africa has long had an inordinate share of the global disease burden27, with very little input of health financing and health infrastructure28. While a lot of progress has been made in reducing the loss of life from many types of diseases – maternal and childhood diseases, communicable disease etc.29, the impact of these diseases still accounts for the most health loss in the region30. The recent increase in the penetration of mobile and digital technology31 has opened up opportunities for health access and financial protection that were not previously available. This has been clearly demonstrated in the global response to COVID-19, which will not be the last pandemic to prey on weak health systems. Well-designed health insurance systems are going to be necessary to lift persons out of poverty while providing increased access to healthcare services. An insistence on health quality will save many more lives, but its key driver cannot be regulatory fiat alone. New models that incorporate quality care may be more seamlessly adopted. Donors can also be part of this change by redesigning their incentive structure and results framework to encourage more sustainable financing systems for vertical programs. The focus should now be on developing innovative and sustainable solutions to these age-old problems that use newly available technologies to improve the health and well-being of Africans. Finally, we need to prepare for future pandemics. Pandemic preparedness is pertinent to maintaining current health system capacities while advocating and working to improve them.
The policy recommendations can only be accelerated when two critical elements are prioritised. Firstly, the political will and commitment of government leaders and policymakers. Evidence from countries that have made significant progress towards UHC demonstrates that political will and commitment are critical to the adoption of new policies and implementation strategies. And secondly, related to the first point, if the role of advocacy is better acknowledged to ensure buy-in of all stakeholders. This advocacy would include, but not be limited to:
1) Replacing OOPs with more equitable modes of financing such as mandatory health insurance schemes.
2) Articulating clear policies on PHC financing, with private sector collaboration and financing. Investments in quality primary health care will be the foundation for achieving UHC in Africa.
3) Aligning donors and developmental partners support with Africa’s development strategies in line with the Paris Declaration on aid effectiveness instead of promoting vertical programs which may not be sustainable.
4) Leveraging digital technologies to accelerate UHC. Without digital or mobile technology, the attainment of UHC will become a mirage.
Njide Ndili is the Country Director for PharmAccess Foundation, an international NGO that facilitates access to quality health care by stimulating investments in the healthcare industry through partnerships with private sector and government institutions. Her activities support demand side financing through insurance, supply side quality improvement using SafeCare Methodology, access to finance for healthcare SMEs through the Medical Credit Fund, develops and promotes innovative digital solutions to improve access and health outcomes.
Njide serves as a Commissioner for the Lancet and Financial Times Commission on Digital Health and AI, set up to explore how digital and frontier technology can be used to accelerate UHC especially for the young population and low-income countries, and is a member of UN Global Compact Healthcare Expert Group focused on Sustainable Infrastructure to accelerate the SDGs by leveraging Technology. Njide has an MSc in Health Economics, Policy and Management from London School of Economics, an AMP from INSEAD Business School, MBA from the University of Houston, Post Graduate Diploma in Finance and B. Sc. in Computer Science from the University of Nigeria.