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Leadership Forum (April 2004)

Author: Gilles Dussault, Senior Health Specialist - is a member of the HNP team at the World Bank Institute where is responsible for the regional activities of the Flagship Program on “Health Sector Reform and Sustainable Financing” in French-speaking Sub-Saharan Africa, Portuguese-speaking Africa and the Latin America and the Caribbean.


It is now widely accepted that health insurance is a potentially effective and equitable mechanism for improving access to health services and protect populations against the impoverishing effects of illness. The strengths, weaknesses and strategies to manage shortcomings of health insurance are now well known. Although only a small part of the population in Africa is covered through different health insurance mechanisms, many now recognize the potential of such an approach to health care financing and are beginning to experiment with different types of insurance coverage.

It is in this context that delegates from 15 French-speaking Sub Saharan Africa countries will meet in Paris from April 26 to 30 to discuss recent efforts to improve access to health services through health insurance (see ). The meeting is the final in a series of workshops and videoconferences on “Expanding the Coverage of Health Risks” that have been organized since 2001 by the Joint Africa Institute (JAI) and the World Bank Institute (WBI). It is hosted by the JAI, WBI and other international partners such as WHO, ILO STEP program (Strategies and Tools against Social Exclusion and Poverty) GTZ and CIDA.

The Paris meeting is unique opportunity for participants too share country experiences with other countries, insurance experts and the international donor community on strategies for expanding insurance coverage and its impact on access to health care for the poor.


Leadership by JAI and WBI in Sharing Country Level Experiences

When the JAI and WBI started the joint learning program on health insurance in 2001, most participant countries had less than 5% coverage through such financing mechanisms (Rwanda at 19% was an outlier). Critics often say that health insurance is not needed at low income levels when governments provide free access to publicly finance health services. Reality tells a different story. At low income levels, few countries have the capacity or resources to finance health care through general revenues. As a result patients – even the poor – end up paying for health services, drugs and other consumables through formal and informal charges. The poor who simply cannot afford to pay such charges end up deprived of access to services they need.

Attempts to address this problem have been numerous. International and bilateral agencies working in the health sector – the Bank, WHO, ILO, GTZ, CIDA, the French foreign cooperation, etc – have recently helped low income countries in the Africa region explore alternative financing mechanisms, ranging from community financing to revolving funds to social health insurance.

In order not to duplicate such efforts – or be prescriptive in promoting a particular solution – the JAI and WBI have offered countries a learning opportunity to familiarize themselves with the various alternatives for dealing with financial risk against the cost of illness. This approach was based on the observation that countries were already following different paths.

For example, Gabon and the Ivory Coast are trying to achieve universal coverage through a combination of voluntary and compulsory insurance. Mali is promoting a mix of community financing and compulsory social health insurance. Mauritania is just starting to experiment with community financing, an insurance for pregnant women. Senegal, Benin, and Togo focus on expanding community financing (“mutuelles de santé”). Non Francophone countries in the Africa regions are following a similar path. Kenya has recently introduced a national health insurance program. Ghana is currently in the process of introducing a decentralized system of district mutuals. South Africa, Zambia and Namibia have a long tradition of employer based voluntary health insurance. In each case, there are great variations in the use and understanding of the term insurance, suggesting a need for a common language and of a deeper knowledge of the technical dimensions of insurance.

From observations made so far, it is clear that although countries face similar problems (cultural resistance to risk pooling, large numbers of the very poor population unable to contribute, small formal sector, and weak technical capacity to manage complex insurance schemes), there is no single solution.

The learning approach chosen by JAI and WBI was to: (a) target participants who are actively involved in developing alternative health financing mechanisms; (b) follow up with the same people over time to build competencies and networks of insurance practitioners; (c) develop a program of activities rather than single free standing events; (d) progress in incremental manner in consultation with the target audience; and (e) involve other interested development partners. The Paris colloquium is illustration of the application of these principles.


What next?

The participating delegations will meet before the colloquium to review reports they have prepared on the status of health insurance coverage in their countries, and to discuss the presentations they will make at the colloquium. They will also have an opportunity to learn about the experience of other African countries, namely Ghana, Kenya, and Tunisia.

A discussion of the next steps will also take place immediately after the colloquium. The establishment of a network of practitioners, acting as a clearinghouse and a source of technical advice to countries, is one desired outcome from the meeting. Such a network could also be used to advocate expansion of coverage and act as an interlocutor for countries and for the international development community.

Bank, which reiterated its commitment to “making services work for the poor “in the World Development Report 2004, and other members of the international donor community, are privileged by the opportunity of being able to participate and learn from this valuable exchange of experience among low income countries in the Africa region.


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