Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia

This paper, in the Lancet series on universal health coverage, explores how low-income and middle-income countries are moving towards universal health coverage (UHC).As highlighted in the paper, UHC is a way to reduce financial hardship caused by health spending and increase access to key health services. The structure of national health insurance reforms in nine countries are examined, including Ghana and Nigeria. Methods

• A “functions-of-health systems” framework is used to describe countries’ approaches to raising revenues, pooling risk, and purchasing services
• Progress implementing UHC is based on three dimensions of coverage:  who is covered, what services are covered, and what proportion of costs is covered
• The Joint Learning Network for Universal Health Coverage was used to gain information on country reforms

Key findings from Ghana

• Since starting the National Health Insurance Scheme reform, government spending as a percentage of total health expenditure increased from 51% in 2003, to 59% in 2009
• User fees for all covered services have been eliminated, resulting in a 4% decrease in the proportion of out of pocket spending by individuals
• However, important inequities remain.  52% of the wealthiest quintile are enrolled in health insurance, compared to only 18% of the poorest
• Although, the entire population is targeted by health insurance, only 54% are enrolled
• This paper examines the percentage of births attended by skilled staff as a proxy for coverage of health services. In Ghana 57% of births were attended by skilled health staff

Key findings from Nigeria

• Since starting the National Health Insurance Scheme reform, government spending as a percentage of total health expenditure has increased by between 1 and 3%
• Revenues from debt relief programmes are used for health coverage programmes for pregnant women and children
• Currently, only civil servants are covered by health insurance.  However, there are plans to expand coverage to the informal sector
• Only 3% of the total population is enrolled in the national health insurance scheme
• 59% of all spending on health services is paid for out-of-pocket by individuals
• Taxing mobile telephone bills has been proposed to increased funds available for health care
• This paper examines the percentage of births attended by skilled staff as a proxy for coverage of health services.  In Nigeria, only 39% of births were attended by skilled health staff.

Conclusions and recommendations

• This paper identifies that there is great variety in the structure of health insurance reforms across low- and middle-income countries
• Despite progress, this paper highlights that much work remains for countries to achieve universal coverage, including Ghana and Nigeria
• As outlined, improved definitions of how to measure progress towards universal coverage are needed.  This could enable policy makers and providers to assess how well they are progressing to UHC

To read the full article, click here.This article is one of three in the Lancet series on Universal Health Coverage, to read a summary of the series click here.Lagomarsino, G., Garabrant, A., Adyas, A., Muga, R., & Otoo, N. (2012). Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. The Lancet, 380(9845), 933–43.