A framework policy analysis of national health insurance policymaking in sub-Saharan Africa

Abstract

National health insurance (NHI) is a financing mechanism established by a national government with the goal of covering all or almost all of its citizens. A number of low- and middle-income countries have established NHIs as part of a strategy to progress towards universal health coverage. The establishment of an NHI presents a potentially significant shift in national health sector governance, but little is available in the literature regarding how policymaking authority and health governance is shared between NHIs and ministries of health (MOHs). To answer this question, we conducted a descriptive, qualitative comparative analysis of policies, including legislation, guidelines and webpages, from four sub-Saharan African countries that have established or are in the process of establishing an NHI scheme as of 2019 (Ghana, Kenya, Zambia and South Africa). We developed a novel conceptual framework comprising 16 NHI policy domains and conducted a deductive review of relevant policies. We then extracted and indexed policy elements according to this framework to facilitate comparative analysis. We found substantial variation across countries in the types of policies developed and the decision-making authority around those policies. MOHs in all four countries retained at least some decision-making power over the NHIs through regulations and appointment of board members. However, NHIs were often delegated policymaking authority in key areas including financing mechanisms, provider payments, member payments, benefit schemes, accreditation and relationships with private health insurance schemes. The results of this analysis illustrate many aspects of health regulatory power and oversight that will need to be defined as part of establishing NHIs. The approaches from these four countries and the conceptual framework presented in this manuscript may be helpful for other countries in evaluating differing approaches to shared health governance between NHIs and MOHs.

Rational design of an essential diagnostics network to support Universal Health Coverage: a modeling analysis

“…Ghana was chosen because three of the co-authors are Ghanaian working in Ghana, and another three have done work in the country. Further, a number of studies have been published to landscape diagnostic capacity in the country, providing some context [ 22 – 25 ] and the Ghanaian National Health Insurance Scheme [ 26 ] reimburses a set of diagnostic investigations that could be informed by this study.…”

A socio-political history of the South African National Health Insurance

“…Alongside this contentious policy development process, the country was suffering a series of corruption scandals and governance failures that signi cantly undermined public trust. [24] Perhaps the de ning corruption scandal of the new democracy was the 1999 Arms Deal, under Mbeki's presidency [25] , in which the 'Strategic Defence Package' to modernise South Africa's defence capacities saw contracts totalling tens of billions of rands improperly awarded to various arms manufacturers in exchange for bribes paid (reportedly) to Mbeki and Zuma, among others [94,140,162]. At the time, there was controversy over whether spending on defence was appropriate or necessary given the need for spending on social services [162][163][164].…”

“…At present, South Africa's health system is sharply divided between public and private sectors [23]. Both public and private sectors are governed by the Minister of Health whose mandate includes setting national policy priorities and regulating all health sector actors [24,25]. The vast majority of the population (84%) receive means-tested, often free, care in the under-resourced and overburdened public sector [23,24].…”

“…The implementation of an NHI would involving creating a single funding pool which would be used to purchase a standard package of services to ensure equitable access to healthcare for all [16,25]. The single pool would be funded through mandatory prepayment mechanisms including taxes [16,25].…”

“…Together, means-tested public services and voluntary health insurance protect most users from catastrophic healthcare payments [24]. However, access and quality of care received still depends in part on socio-economic status and signi cant inequities persist, which the NHI is intended to eliminate [23,25]. In addition, public perceptions of poor quality care in the public sector, corruption, and general mistrust of government as a service provider exacerbate frustrations at the inequities ingrained in the health system [23,26].…”