Thursday, March 8, 2012

Health Systems Financing - what future for insurance

Oxfam recently issued a report criticising Ghana's National Health Insurance Scheme. The report's authors denounced it as inefficient, corrupt and inequitable. They question Ghana's statistics of around 60% membership and estimate that this could be as low as 18% of the population. They propose that the scheme be replaced by a tax funded health system free at the point of delivery.

Reports from colleagues in Ghana suggest a mixed picture. Clearly the scheme is far more successful in towns and cities where health facilities are located. The rural poor are not so easily covered. There have been problems with the administration of the scheme for those church hospitals that service claims. Some have had to wait 6 - 9 months for the scheme to recompense them for services rendered to the insured. This has caused acute cash flow difficulties. But otherwise, our Ghanaian colleagues seem fairly optimistic about the future potential of incorporating everyone into a scheme that combines personal contributions with tax revenues to ensure that health services are more widely available.

There is no doubt a healthy dose of idealism behind the Oxfam report. Many in the global health community feel instinctively drawn to a simple tax funded health system where everyone can get access to health care without the interference of financial systems. Health professionals are not generally drawn to medicine in order to get mixed up with market driven economic planning. Like priests, they simply want to be able to get on with their job of caring for people in need. But health is an expensive business. And even in the UK's National Health System, medics have to respond to concerns about cost and efficiency. Yet another wave of reforms faces them in order that expenditure on health might be controlled by new means.

As it happens, the issue of health systems financing was the theme of the World Health Report published by the WHO just before Christmas. It made reference to the Ghana health system as an example of the benefits of combining tax revenue, donor support and individual contribution into a membership scheme that has thus increased the resources available for health care. Most importantly, the report says, the Ghana scheme has offered financial protection to those who formerly paid user fees for their health care.

Rwanda has made the most progress with a national health insurance scheme in Sub-Saharan Africa. Other countries such as Kenya are at an earlier stage of rolling this out. It remains to be seen how many states in the poorest parts of the world can manage such large schemes successfully. Having lived in the UK and Switzerland I am aware of the strengths and weaknesses of insurance based health systems in comparison with tax based health systems. I do not subscribe to an ideal one way or another. The state surely has an innate responsibility to ensure that its citizens have access to health care. How it facilitates the infrastructure to both fund and deliver this care is a matter for trial and error. Statist or free-market ideologies do not offer idealised solutions.

AHN is supporting a market-based microinsurance project in Tanzania and India. But equally it supports colleagues in Ghana in their partnership with the state system. There is only one absolute: user fees for health services must be abolished one way or another. Everyone agrees with that. Unfortunately too many Anglican health services are delivered still under a regime of user fees. We must work hard together in these various contexts to protect people from financial risk in accessing health care, and at the same time improving what health care they can receive.


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