Perspective Chapter: Public Health Insurance in Developing Countries

Abstract

Public health insurance protects citizens from unexpected high medical costs. It ensures healthcare equity and quality in many countries. Unlike the developing countries, health insurance covers all citizens in the developed countries. Due to low health insurance coverage in developing countries, the health expenditure at both household and national level is souring. Access to quality healthcare remains a big challenge, and many households struggle with high out-of-pocket health expenditures. Many people have even lost their lives because of failure to access healthcare services due to high costs that they cannot meet out of pocket. Countries with functional public health insurance schemes have attained optimal healthcare coverage for their citizens. In an effort to advocate for the development of health insurance systems by countries, this book chapter will cover the following; developing a public health insurance, the impact of a functional health insurance scheme on healthcare access, country-specific public health insurance schemes in Africa, challenges encountered and how to ensure health insurance schemes are sustainable.

1. Introduction

Public Health Insurance (PHI) is a model of health insurance where healthcare plans for citizens are funded by governments at national or local levels. The introduction and expansion of PHI has been a central focus to achieve Universal Health Coverage (UHC) and to ensure healthcare equity and quality in many countries. The PHI scheme ensures that everyone has access to the required and quality health services without financial hardship. It prevents catastrophic health expenditure among the insured people. In majority of the developed countries, health insurance coverage is at 100 percent of the population for instance in Canada, Germany, Japan, and Singapore and about 83 percent in the United States of America [1, 2]. In the United Kingdom, citizens are entitled to free public healthcare provided by the National Health Service (NHS). The NHS receives funding from taxes, and national insurance [3].

Developing countries are increasingly expanding PHI to achieve UHC. However, PHI policies differ from one country to another and each country implements PHI schemes at different levels; for instance, at national or community levels. In some developing countries, PHI is voluntary, and in others it is mandatory. In Philippines, Indonesia, the Lao People’s Democratic Republic, and Vietnam, mandatory payment of public health insurance premiums exists. However, the majority of individuals without formal employment are not able to pay and there is no formal system through which this category of people can pay premiums [4].

Coverage of PHI in most African countries is still suboptimal. For instance, Uganda, South Sudan, Nigeria, and Mali have the lowest coverage with 2%, 2%, 3%, and 7% of people covered respectively. Coverage is 25% in The United Republic of Tanzania, 28% in Kenya, 28% in Ethiopia, 50% in Burundi, 68% in Ghana and 92% in Rwanda. Algeria and Tunisia as well have rates above 80% [5]. In Africa, voluntary PHI schemes are more prevalent than mandatory, and majority are mainly private. Some countries operate community-based PHI schemes and others operate centrally monitored or country-wide PHI [5]. In countries such as Ethiopia and Rwanda, efforts have focused on implementing Community-Based Health Insurance Schemes (CBHIS) on a large scale and national or central PHIs are not well-developed. There are a few countries with functional central PHIs. In countries where both central and community-based PHIs co-exist, integration of the two has not been well achieved. However, Rwanda and Ghana provide good examples where the integration has been successful. In Rwanda, the integration process is reported to have significantly increased outpatient service utilization rates [6].

As a result of very low PHI coverage in some countries, there is catastrophic health expenditure. For instance, in Uganda, out-of-pocket expenditure is currently beyond the set threshold of 10–25% [7]. The country operates 28 CBHI schemes not linked to the national PHI and located in only 22% of the districts throughout the country. The largest number is in Southwestern Uganda [7]. As it has been mentioned above, the coverage of healthcare insurance is suboptimal, this means that access to quality healthcare is also limited, especially among the rural poor people. This leaves the majority with high out-of-pocket health expenditures in trying to access healthcare [8]. Those that may not afford to pay, may end up losing their lives before seeking or even receiving appropriate healthcare. Health insurance ensures that access to appropriate, quality, and affordable healthcare is guaranteed among all people including the less privileged. The fact that most developing countries are struggling to develop PHI schemes in order to achieve UHC needs to be addressed and this book chapter supports the process. The chapter describes the processes of developing public health insurance, including its functionality, and sustainability.

2. Developing a public health insurance scheme

Achieving UHC is now an essential health policy focus for many countries across the world. This focus became popular following the World Health Assembly Resolution 58.33 (2005) and the Sustainable Development Goal 3.8 (achieving universal health coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality and affordable essential medicines and vaccines for all) [4]. In low- and middle-income countries (LMIC), the concept of UHC, that talks about everyone receiving quality healthcare without suffering financial hardship has been widely accepted and public health insurance schemes have been proposed to be one of the key mechanisms to achieving financial protection and UHC for all including the poor [9]. Operating a PHI scheme requires several managerial and administrative tasks. These are critical in ensuring financial sustainability of the scheme. They include those responsible for oversight and monitoring of the health insurance system. In addition, adequate administrative and management structures are required to effectively address issues relating to quality, utilization, service delivery costs, efficiency, and service provider payments. PHI scheme like any other health insurance scheme is often faced with challenges regarding the pooling of resources that may require administrative and managerial attention to ensure pools are sufficient all the time. For instance, the occurrence of infectious diseases that affect large numbers of people, as well as the increasing burden of chronic illnesses may threaten the insurance income levels or pools. This is because they levy a burden on the income or existing financial resources of the insurance scheme. Therefore, managing financial flows to ensure accommodative financial pools at all times is key to guaranteeing sustainability of the insurance scheme.All these issues need to be considered to create a self-sustaining PHI scheme [10]. Starting a PHI program therefore involves several complex steps that require careful planning, coordination, and resources. The exact process can vary from country to country based on the country’s legal, political, and economic context but may include, although not limited to the following;

2.1 Step 1: conducting needs assessment

A needs assessment is conducted to determine gaps in healthcare delivery. It compares the current situation and the desired and it suggests solutions to arrive at the desired status. Sufficient data is required to ascertain the gap and propose the actual solutions. In the health insurance context, it entails obtaining data concerning the broader health needs of a population, the determinants of health, the legal, political, environmental and socio-economic situations in the country [11, 12]. This will help to justify the current health insurance unmet need. A needs assessment may take different forms. The most common forms include surveys, interviews, focus group discussions, key informant interviews and review of existing data bases. A needs assessment might utilize one or more data collection formats [13]. The ultimate goal for conducting a needs assessment is to determine needs, examine their nature and causes, and set priorities for consideration in the health insurance service package. When Uganda thought of establishing a health insurance scheme in 1995, her assessment and justification for the scheme highlighted contentious issues [14]; that there was a lack of financial access to health services resulting in poor health, and a high disease burden among the poor. It was also found that progress in the overall human development indicators in Uganda was relatively low. The country had a low life expectancy, high infant and under-five mortality as well as high maternal death rate. It also faced a double epidemic of communicable and non-communicable diseases. In addition, the government annual health expenditure was still below the target of at least 15% that was set during the Abuja Declaration in 2001. The proportion of households that incurred catastrophic health expenditure has been high despite the abolition of user fees. Medicines frequently being unavailable in public facilities resulting in patients paying higher prices to acquire medicines at private pharmacies. By then and as of now, the protection of Ugandans is still low, with Community Health Insurance Schemes (CHIS)being accessible to only 5–10% of the population. Private commercial health insurance schemes cover only an additional 1% of the population [14]. With this, the country started the process of forming national health insurance scheme that would cover the health needs of all people including the poor. However, since the emergency of this idea in 1995 until now, the country is still in the process.

2.2 Step 2: define the goals and objectives of the public health insurance program

Goals and objectives inform program design and define what will be achieved. A goal statement summarizes the direction that the health insurance program will take. An example of a goal of health insurance promotion program can be: “To ensure that economically disadvantaged mothers have access to safe and affordable Emergency Obstetric Care at all times”. the main focus according to the goal above is access to obstetric care by pregnant mothers. The second example of a goal is that of the Uganda national health insurance program that is currently under development. It is stated as follows; “To protect residents in Uganda from unexpected and high medical costs by allowing them an opportunity to pay affordable premiums and get treatment when and where they need it without financial hardships” [15]. Program objectives show how program goals will be achieved. While formulating objectives, it is important to ensure that they meet each of the following features; they should be specific, measurable, achievable, realistic, and time-bound. In most instances, program evaluations in the future will make reference to stated objectives and goals. This is made easy when objectives and goals are concisely stated, making this step critical and of crucial focus during program development and in the lifetime of a program.

2.3 Step 3: creating regulations and guidelines

Designing policies, laws, regulations, rules, protocols, and procedures that guide or influence the insurance scheme is key. Policies can be either legislative or organizational. Policymakers need to have access to a variety of documents as well as research papers to guide how beneficiaries will be selected and how premiums will be collected. They also specify the minimum benefit package and how beneficiaries will relate with their service providers [16]. However, traditional methods based on political lobbying and health providers’ conflicts of interest need to be considered in the process of policy-making [17].

Since Uganda’s idea of establishing a national health insurance scheme in 1995, related laws and acts have been put in place. For instance, the Insurance Act of 2017. Since then, the Ugandan Ministry of Health (MOH) commissioned the first feasibility study on health insurance. The continued poor financing of the health system between 2001 and 2005 led the government to commission a second feasibility study on health insurance and visitations to Thailand, India, and Tanzania to study models of national insurance on how the beneficiaries are selected, how premiums are paid and how healthcare services are provided to the beneficiaries. Observations from these studies and visitations contributed to a lot of improvements in structuring the proposed national health insurance scheme and on March 31, 2021, the parliament of Uganda passed an NHIS bill that outlines the general structure for the scheme in Uganda. However, the NHIS bill awaits to be signed by the president of Uganda to turn it into a law.

2.4 Step 4: stakeholder engagement

At this stage, involving a wide range of stakeholders such as government agencies, healthcare providers, insurance experts, patient advocacy groups, and the general public is key. Consulting these will help to gather input, address concerns, and build support for the program. A substantial amount of work needs to be done to refine policies, guidelines, and regulations in line with feedback from the consultative meetings with the different stakeholders. More so, consulting increases the chances of buy-in. Doetinchem and colleagues argued that it is generally not possible to introduce an insurance program without the broad support of the population and political systems [10]. It is recommended that the population is consulted and adequately sensitized, this may take at least a period of 3 years during which other steps such as policy formulation, and capacity building are as well being finalized [10]. The Ugandan stakeholder engagement process stalled and this justifies why stakeholders should be engaged earlier in the process [14]. Between 2006 and 2011, Uganda’s NHIS met resistance from some stakeholders such as the National Social Security Fund (NSSF). The NSSF initially perceived that health insurance was to be a project of the MOH rather than a broad-based government initiative and so did not see need to actively be involved. The private health insurance owners felt threatened to lose market once the NHIS starts. This showed a need for bringing together the public and private sectors for harmonization. Although the NTF succeeded in bringing together public and private sectors in a common forum, the proposed health insurance plan still lacked the backing of some major stakeholders. These were the private sector employers and employees. NTF continued negotiations with stakeholders from 2010 to 2011 and successfully changed the name from social insurance scheme which implied that the scheme would cover a segment of the population to NHIS which meant that the scheme will cover the entire population. Furthermore, it was recommended to add a CHI component to cover individuals working in the informal sector. The cabinet approved these revised principles in September 2011 and a draft NHIS bill was formed.

2.5 Step 5: financing, budgeting, and infrastructure development

In developing a PHI scheme, financing and budgeting are critical components. Countries vary significantly in how they generate or pool revenue or funds. The various methods may include; government contributions, employer and employee contributions, taxes, and external funding such as international aid. Some countries may use a combination of any of these methods. For instance, a combination of tax financing through government budgets with social health insurance or voluntary health insurance, and other direct payments [18, 19]. For instance, Ghana’s NHIS pools revenue from insurance premiums, payroll tax, and earmarked value-added tax [5].

Revenue redistribution after the pooling of funds depends on the health plan of a country. Revenue may be redistributed equally among regions of the country. In some countries, explicit risk adjustment formulas are used to allocate funds among geographic areas. In countries or geographical areas with multiple or competing health plans, risk adjustment is sometimes used to redistribute money away from plans for healthy individuals towards plans for very sick or highly costed persons. These funds should be collected and managed in a way that ensures the sustainability of the health insurance scheme. In addition, infrastructure, administrative structures, technological systems, operational systems, enrolment processes, claims processing systems, provider networks, and information technology systems necessary to run the health insurance scheme should be developed.

2.6 Step 6: enrolment of eligible individuals and families

This step is perhaps the most complicated yet the most needed for the kick-starting of the scheme as well as its sustainability. It involves enrolling legally qualified individuals, families, and companies into the scheme. Different criteria can be used. For instance, payment of premium by an individual or family a pre-requisite for enrolling in the program. However, some segments of the population may be exempted from the payment of the premium [20]. Some East African countries like Tanzania and Kenya have implemented compulsory schemes such as the National Health Insurance Fund (NHIF) of 1999 in Tanzania that offered compulsory coverage for all formal sector workers [21]. The Community Health Fund (CHF) and Tiba kwa Kadi (TIKA) schemes for individuals with no formal employment in Tanzania [22]. The National Hospital Insurance Fund (NHIF) 1960s covered employees with formal jobs in Kenya [23]. Kenya also implemented the CBHIS for citizens with non-formal employment and the Social Health Insurance Benefit (SHIB) scheme for citizens in the private sector.

Enrolling eligible individuals and families into a health insurance scheme involves creating a systematic process for individuals to sign up for enrollment. This process can include; outreach and awareness campaigns to inform the target population about the application processes, expected benefits, and requirements for registration such as identification documents, address, and other relevant information. Verification to confirm the eligibility of applicants based on pre-determined criteria such as income thresholds, age, citizenship, and other factors may be required as well. It may also be required that support to individuals who may need help with the enrolment process, especially those with language barriers, limited internet access, or other challenges is organized.

2.7 Step 7: ongoing communication

Ongoing communication helps to maintain open communication with the public, stakeholders, and policymakers to keep them informed of the progress of the program, changes, and benefits. Communicating with stakeholders has always been integral to the business of health insurance because it keeps members engaged, involved, and informed, and helps them get the most out of their benefits.

2.8 Step 8: monitoring and evaluation

Monitoring of the health insurance scheme entails regular review of the performance of the scheme. It is usually part of the wider national health sector performance review and involves continuously collecting data to document trends in diseases, healthcare uptake, and coverage. As well, it documents the healthcare inputs, outputs, and outcomes of healthcare provision. It correlates disease burdens in the different regions of the country with inequalities in healthcare access. Therefore, disease surveillance and risk factor assessment are part of program monitoring. It also involves implementing mechanisms to continuously monitor the program’s performance such as metrics related to enrolment, healthcare utilization, financial sustainability, and patient satisfaction. The process may also regularly evaluate the program’s impact on health outcomes, healthcare access, and financial protection of beneficiaries. Studies have proved that health insurance schemes can curb costs by implementing an elaborate monitoring system to control provider claims through monitoring provider behavior, controlling balance billing, and curbing the practice of overprescribing drugs and overproviding services [10, 24].

3. The impact of a functional health insurance scheme on health care provision

Beneficiaries of a health insurance scheme are more likely to use health services than the uninsured. This is because they are less likely to suffer catastrophic out-of-pocket medical bills. The insured are likely to afford services such as inpatient care, and maternity services. These patients can access services at both public and private hospitals. Health insurance also ensures access to healthcare services by key populations such as children, pregnant women, elderly, and the poor [25]. This is because, it pools funds from the old people to the children, from the healthy to the sick, and from the rich to the poor. In so doing, it ensures equity in healthcare access. In the context of health service utilization among key populations, a study conducted in Ghana, Indonesia, and Rwanda found that health insurance improved maternal healthcare utilization [26]. The findings particularly revealed a positive impact of health insurance on facility-based delivery and on the use of antenatal care. In another study conducted in Ghana, using propensity score matching estimation, Mensah and colleagues found that women insured through the NHIS were more likely to attend antenatal care, have a hospital delivery, attend postnatal care and turn up for immunization of their children [27]. Similar to the findings of another insurance program in Bangladesh that found a higher probability of antenatal care utilization, institutional delivery, and postnatal care [28]. Several other studies have also demonstrated a positive association between health insurance coverage and use of maternal health care [29, 30, 31].

4. Country-specific public health insurance schemes in Africa

4.1 Public health insurance scheme in Rwanda

Following Rwanda’s independence in 1962, the country implemented the “free of charge” health care provision strategy. However, this became ineffective in meeting the healthcare demands of the people and it was later abandoned. This created a total vacuum, leaving the entire population exposed to diverse risks. The government responded by creating mandatory health insurance for public servants called Rwandaise d’Assurance Maladie (RAMA) and that of the military personnel called the Military Medical Insurance (MMI). These covered only a very small portion of the population and it called for a community-wide Community-Based Health Insurance System [32]. The CBHIS covers 85% of the population, and 92% of the population with other insurance schemes including RAMA, MMI, and private insurance. Health care packages provided under the health insurance scheme in Rwanda have been formulated based on the different services provided by the different health facility levels in the country.

The CBHIS schemes in Rwanda are country-wide community partnerships that provide health insurance coverage to populations employed in the rural and informal sectors. Revenue is generated through three main mechanisms; beneficiaries’ premiums, general government revenue, and other external contributions. Pooling of revenue is organized at three levels; (1) the community pool from the local beneficiaries, (2) the district pool that brings together contributions from the community pool and subsidies from the Local Government, (3) the national pool that is funded by national revenues, contribution from the district pools, as well as cross-subsidy from RAMA, MMI, private insurances and external funders. The majority of low-income households in Rwanda are provided with health insurance coverage based on their own contributions and supported by a third party (either the state, districts, donors or non-governmental organizations). To ensure risk pools are adequately funded, all private health insurance and social health insurance schemes contribute to the national and district pooling mechanisms. The health package is comprehensive and beneficiaries are entitled to all preventive and curative services provided by health centers, district hospitals, and national referral hospitals. Benefits include outpatient, inpatient, maternity care, essential drugs, medical imagery, and laboratory tests. The CBHIS is governed and managed by the Rwanda Health Insurance Council (RHIC). The RHIC is constituted by members from the Ministry of Finance, Ministry of Local Government, Ministry of Health, CBHI representatives, Civil Society Organization representatives, MMI, RAMA, private health insurance companies, health providers, and citizens’ representatives. The roles of the RHIC are; (1) informing revision of health insurance and cross-subsidization policies, (2) maintaining a database of health insurance organizations in the country, (3) conducting studies to generate evidence and inform the functioning of health insurance schemes, (4) conduct analyses to support the periodic revision of contribution and premium policies, (5) generating the necessary evidence for adopting fair provider payment modality policies, (6) obtaining a better understanding of the factors associated with non-enrolment, (7) propose safeguard measures, (8) conduct cost, benefit, utilization and client satisfaction assessments. Each section of CBHIS from community to national levels has operational management staff. The local members are well represented in management bodies at each section and all levels from community to national levels.

4.2 Public health insurance scheme in Tunisia

Following independence in 1956, the government established a universal system of healthcare provision. In 1956 and the late 1980s, service delivery was improved and social health insurance was established for the employed. However, the pace of improvement was not kept and by 1990’s, it had declined in terms of healthcare quality and uptake. It was at this point that the government thought of new investments in health and boosting the coverage of health insurance alongside other health financing modalities. The government therefore used a wide range of healthcare financing mechanisms in addition such as government revenue, and private financing. However, social health insurance contributed the biggest share. From 1980 to 2010, the total government expenditure on healthcare rose from 3.2% to 7.0%, with financing coming from general governmental expenditure (23.8%), social health insurance (27.7%), private insurance (7%), and private expenditure (41.2%). However, this was not the best situation and between 1995 and 2011, private health spending by households rose rapidly at an annual rate of 19 percent. Due to this, the government established the free medical assistance program under the Caisse Nationale de l’Assurance Maladie to support the poor [33]. It was financed by transfers from the central government to the MOH to cover the estimated social health insurance contributions of beneficiaries. The Ministry of Social Affairs was responsible for determination of potential beneficiaries. Eligibility included; self-declared (unverified) household revenue falling below the poverty line, number of household members, consideration of household members with a disability or chronic health condition, household living conditions and physical assets. The inability for the head of household to work due to an impairment was another consideration. The Ministry of Health was majorly responsible for the delivery of services and was not involved in the selection of beneficiaries.

Households enrolled in the Caisse Nationale de l’Assurance Maladie received 100 Tunisian dinars monthly to uplift them to slightly above the poverty line and a free health card. In addition, they are given 10 Tunisian dinars monthly as child allowance for up to a total of three children. Families that did not meet the criteria for free medical assistance but are near-poor qualified for subsidized health cards. The free health card is issued for a period of 5 years. Financing is by funds from the MoH mainly. Beneficiaries are entitled to outpatient visits and inpatient care at regional and university hospitals. However, household survey data show that low-income groups spend out-of-pocket for health services despite the free medical assistance program.

4.3 Public health insurance in Ghana

National health insurance of Ghana was established in 2003 and by 2014 it covered 40 percent of Ghana’s population [34]. Ghana National Health Insurance Authority (NHIA) has strengthened the insurance scheme over time and is financed primarily by tax revenue, NHI levy, Social Security, and National Insurance Trust (SSNIT) deductions. Ghana is one of the countries that are widely known to finance their health insurance schemes through value-added tax. In this case, the insurance revenue grows with the country’s economic growth. However, revenue pools may not increase at the same pace as insurance coverage. This is because all citizens and non-citizens are eligible for the NHIS coverage and not all are required to pay premiums. For instance, enrollees under the age of 18 or over the age of 70 do not pay premiums. Public and Christian-owned facilities receive funding from the MoH, whereas private providers do not receive it. Because of this, the reimbursable cost of a consultation is higher for a private hospital than it is for a public hospital. Health facilities require NHIA accreditation to provide services to NHIS through the NHIA’s quality-assurance department. The NHIS covers 95 percent of diagnosed conditions, and it has no cost-sharing requirements. It also covers all outpatient, inpatient, and emergency care. Members pay no out-of-pocket costs for services or pharmaceuticals based on the policy. The NHIA subjects requisition for payment to a 5-step process i.e., fulfillment, vetting, data entry, vetting-report generation, and initiation of the payment for the request.

5. Challenges faced by public health insurance schemes

Public Health insurance schemes could be voluntary or involuntary and are prone to challenges. The integration of the population especially those who are in informal employment and those with no regular incomes along with the poor poses challenges as the majority are left out. The lack of knowledge about the insurance scheme and its enrolment processes is in most cases the most critical barrier to this group of people as well as the lack of income to pay their premium [35]. This means that the low-income earners, the unemployed, and other dependents such as the elderly and children may not be protected by the safety net offered by the insurance schemes and could suffer catastrophic payments when ill. Many countries are in a situation where those employed in the private sector and those in public sector but with better pay remain outside the public health insurance scheme. Even when joining the scheme is compulsory for those in the formal sector, private companies may not abide but choose to pay for better health packages for their staff [36]. Employees may also have deficient information from their employers concerning what benefits insurance can offer. Poor-quality health services at public hospitals are also a major contributor to the failure to choose social insurance schemes.

There is a concern about failing to attain the purchaser-provider split. Just like general taxation, public health insurance schemes may not offer any additional benefit in terms of ensuring there is a split between the purchaser and provider [37]. The government could be in control of the scheme and still remain in the position of purchaser and at the same time provider. This compromises the quality of care since the one purchasing is the one providing and so cannot criticize self. The health insurance scheme may not be equitable in cases where the structure has a similar premium to be paid by all, irrespective of income capabilities. This approach benefits the rich more than the poor. The one-size-fits-all health insurance structure is not favorable [38]. Information asymmetry is another issue that affects insurance schemes. The insurer and the insured may have different levels of information. Potential members know their disease risk levels better than the insurers. Members could take advantage of this information asymmetry and those who are at high-risk may be able to purchase insurance at a lower premium than their disease risk. On the other hand, if the premium is fixed based on the average disease risk of the potential members and willingness to pay, then that is known as adverse selection [39]. Adverse selection makes the cost of running such insurance schemes high and unsustainable.

Other multitude of challenges include; (1) inadequate commodities, and services for treatment at partner health centers, (2) delays for reimbursement as claim management capacities may be limited, (3) over-prescription and over-charging by service providers puts financial sustainability of the insurance system at a threat, (4) drug prescriptions for the insured patients may be filled in private pharmacies without reimbursement, (5) Financing of primary pools still relies mainly on the contributions of households who are relatively poor in some countries and this is a challenge in cases where cross-subsidization from richer groups is not improved, (6) in situations where contribution policies are based on a flat rate for all income groups, underfunding of the insurance system is likely, (7) weak administrative capacity for resource mobilization in some countries leads to low financial capacity of the health insurance scheme, (8) in countries where the primary funding mechanism are premiums from members with no other additional funding, these countries are at much higher risk of bankruptcy and are unlikely to achieve financial sustainability, (9)the tendence of households rising out-of-pocket payments on health care despite the existence of health insurance coverage is still common in some countries in Africa, this is an indication of inefficiencies in the health insurance systems and is a sign of lack of satisfaction of beneficiaries (10) Poor quality-of-service which is made worse, by an increase in the prevalence of chronic ill health that requires long-term, health care coverage, and (11) in some countries, the systems have been prone to accusations of corruption and a lack of transparency and equity.

6. Sustaining a public health insurance scheme

To sustain a public health insurance scheme, a number of interventions and strategies could be considered. To ensure that both low- and high-income earners benefit from public health insurance, innovative methods such as special low-income schemes especially focused on the poor and other vulnerable groups could be considered [40]. Alternatively, the Government could pay insurance premiums for such individuals. To achieve equity, adjusting could also be in the form of raising the premium or lowering the reimbursement tariff of the high-income earners and vice versa for the low-income earners [38]. Another important issue to consider at the start is assessing the “willingness-to-pay” insurance premiums. This is an important step that would help understand the citizens’ level of acceptance before the implementation of an insurance scheme. This would also help clarify the amount that they are willing to pay to ensure sustainability [41]. Other factors that favor the successful implementation of the health insurance scheme in a country include ensuring good economic development and a strong financial and administrative capacity of the government through well-established systems through which premiums can be collected [42]. Chances of sustainability are higher if the insurance scheme is well managed. In addition to coverage for secondary and tertiary care, the health insurance scheme should have other benefit packages such as health information, education, counseling, and disease prevention related to the prevention of non-communicable diseases [43]. This lowers the cost of insurance due to long-term or chronic disease hence sustainability. Creating a national health insurance scheme could be initiated by integrating various existing community-based healthcare financing schemes into the national scheme. This is likely to increase the pooling of funds and ensure risk distribution across a wide range of people including the poor [44]. To encourage more enrolment of informal sector families, the premium should be affordable and subsidized by the government and this can be achieved if the government adequately supplements the premium with funds from government budgets [45]. Finally, a likely workable solution is to create a hybrid scheme of general taxation with the health insurance scheme, and factor in complementary or supplementary private insurance depending on the extent of coverage [46].

7. Conclusions and recommendations

The impact of health insurance on healthcare utilization is closely associated with its characteristics, such as premiums, benefits, location of healthcare services, and for whom the services are intended. Three types of public health insurance schemes are commonly implemented in low- and middle-income countries namely, national health insurance scheme, social health insurance scheme and community-based health insurance schemes. These differ in enrolment requirements, funding, size of the risk pool, associated fees, and reimbursement mechanisms. However, some countries have made efforts to integrate all of them to contribute to one single public health insurance scheme in one way or another. The public health insurance scheme is essential for the financial security, well-being, and overall health of individuals and society. It promotes access to healthcare, encourages preventive care, and contributes to economic stability by improving the quality of life for many and ensuring universal access to healthcare by the poorest.

Acknowledgments

Authors extend their gratitude to Mountains of the Moon University www.mmu.ac.ug for the favorable environment and access to online resources via the university online library during the writing of this book chapter.

Conflict of interest

Authors declare no conflict of interest.