Vaccination campaign in Liberia / UNMEER via Flickr ; CC BY-ND 2.0

The inclusiveness of health insurance programmes in Africa was the focus of a conference on ‘Strategies towards Universal Health Coverage’ held at Erasmus University Rotterdam, the Netherlands, on 11 June. The two burning questions in this field, as identified by Eddy van Doorslaer of Erasmus University Rotterdam, are: With many African countries experiencing growth, what does this mean for health coverage? And, have initiatives for health coverage improved equity in access to health care?


Agnes Soucat, Lead Economist at the World Bank, opened the conference by contending that ‘Africa’s rapid population growth can be an opportunity or a disaster’, and that ‘universal health coverage can contribute to the demographic dividend and, therefore, to economic and social transformation’. Increased health coverage can reduce child and infant mortality rates, thereby decreasing the number of people depending on the working-age population and creating opportunities for increased economic productivity. However, as Soucat argued, the economic growth that many African countries are experiencing is not inclusive. This is also reflected in the use of services, which is ‘largely and persistently unequal’.

An example of a programme aimed at inclusive, universal health coverage is the Community Based Health Insurance (CBHI) in Ethiopia, which started as a pilot in 2011. This programme is part of a larger trend in which the Ethiopian government is spending an increasing amount of money on health insurance, as pointed out by Arjun Bedi of the International Institute of Social Studies (ISS). The programme is run by the government and communities can choose whether or not to join, which means that they automatically become involved in managing the programme in their community.Bedi and his colleagues are carrying out research on this programme, which, according to him, has had a ‘fairly high’ enrolment rate of 41% in 2012 and 52% more recently. Under the programme, beneficiaries have access to all services that are available at a fee equal to about 0.5% of an average monthly household income.

As credible evaluations are not so common, this research is meant to evaluate the enrolment and impact of the programme. Is the scheme socially inclusive, or does it only benefit the better-off? At the conference he showed that socioeconomic status – as measured by the education of the household head and the consumption quintile – does not influence the likelihood of enrolment. Therefore, Bedi concludes, there is no evidence of social exclusion within this programme. Nevertheless, Bedi noted that it remains to be seen whether or not the communities are really involved in the management of the programme.


To achieve universality, all people need to have access to health care. Whereas formal sector employees are often automatically enrolled, informal sector workers are not, as they would have to subscribe voluntarily, provided their financial means allowed. Caroline Jehu-Appiah of the African Development Bank pointed out that relying only on voluntary enrolment for everybody is not the solution. She said: ‘Voluntary enrolment alone will not lead to universal health coverage. We saw that even with mandatory enrolment, it was difficult to have people renew their subscription each year.’

A lack of financial means is often a constraint. Van Doorslaer noted that ‘It is not the need for health care, but the ability to pay that seems to be the most important determinant for health coverage, as the PhD thesis of Igna Bonfrer shows’.

According to Soucat, the solution might be to achieve universal health coverage through taxation. However, this is not without problems. One of the participants asked if this implies free care as, in practice, free care often means that the quality of care is not good and can lead to a lack of drugs and money being captured by certain clinics.

Quality and politics

The quality of health care was also a concern of Agnes Soucat. She explained: ‘Health coverage is not primarily a matter of ensuring sufficient financing, nor a quest for technical solutions. We already have both. It is mostly a service delivery issue. Most African countries have high coverage, but low quality of health care’. She emphasized that achieving universal coverage of quality health care ‘is about politics, institutions and incentives to spend money on this’.

Financial issues

Nevertheless, a rapid expansion of beneficiaries may also cause problems, as Caroline Jehu-Appiah explained. Ghana’s National Health Insurance Scheme (NHIS), which was established in 2003, witnessed a ‘tremendous’ increase in membership from 2005 to 2014. Claims payments have also increased. According to Jehu-Appiah, the scheme currently has to spend more money on these claims than it receives, which has led to ‘serious financial sustainability issues’ for the programme. She said that she expects these problems to continue in the coming year.

Research and policy

Research on the connections between economic growth, inclusiveness and health coverage is encouraged. Within INCLUDE, seven research consortia study social protection programmes in Ghana, Ethiopia, Uganda, Kenya. INCLUDE links research to policy in national level activities, such as the Research-Policy Practitioners Forum on Social Protection that was held in Kenya.

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