Panel debated with the audiance on the Fund's program

Onno Schellekens
The audience was triggered by a presentation of Onno Schellekens, Managing Director of PharmAccess. Prior to the debate he explained the need for innovation in delivering health care in Africa. He showed how insufficient health care spending through the public sector in Africa is and how the Health Insurance Fund is trying to address this problem through an innovative approach. 
Very little public healthcare spending is available for the ones who need it the most, the poor in Africa. As a result they have to pay for health care out-of pocket, leading to tremendous impoverishment. Schellekens: ‘In my eyes this is a really embarrassing situation.’ 

Subsidized health insurance offers protection against unexpected out-of-pocket expenditure. After paying a small enrolment premium, people are free to go to the clinic with just their insurance card. Treatment thus becomes affordable, leading to a steady demand. In turn, the collection of fees through the community health scheme leads to a stable flow of financial resources for the clinics. This money can be used by these clinics to improve the delivery of health care and ensure that patients receive quality treatment. In short, the program stimulates the demand and supply side of the health system simultaneously, creating a situation where both sides reinforce each other.


Insurance and quality health care
The presentation led to interesting questions on the practical side of this approach. How do you sell the concept of insurance? How do you attract good doctors to these small rural clinics? And is it possible to implement the program throughout Africa? Kees Storm answered first. ‘To be able to sell the concept of insurance effectively, we have chosen to work with clearly defined target groups. These are low-income worker groups, able to spend some of their income for health insurance, like market women in Lagos and farmers in Kwara State.’ An advantage of working with clearly defined groups, Storm explained, is that they feel responsibility for each other, which enhances the concept of risk pooling. Sjoerd van Keulen: ‘And the leaders of the group can take an active role in explaining the benefits of insurance. In Nigeria we have learned that the political and spiritual leaders play a crucial role breeding trust in the concept.’

However, just explaining the concept to the community is not enough. The quality of health care needs to improve as well and it needs to meet the demands of the people. ‘Especially the latter, setting up an insurance package that covers the most common illnesses is a challenge’, says Prof Joep Lange. ‘Clinical data are almost non-existent in Africa. By collecting these data the program gets a better view of these illnesses. For example, we now know that hypertension is quite common and that it needs to be included in the package.’ The program thus constantly adjusts to deliver the best health care, health care people are willing to pay for.

     
    The panel with from left to right: Prof. Joep Lange, Sjoerd van Keulen and Kees Storm.
    Emma Coles is moderating.

Stopping the brain drain
Part of the quality care is having qualified doctors and nurses in the clinics. Kees Storm: ‘A reason for the so called brain drain is that doctors often don’t get paid, or the incomes from out-of-pocket payments are not steady. In the program we can offer them a regular income out of the collective insurance fees.’ But the program does more to make the position more interesting for the doctors and nurses. Kees Storm: ‘We upgrade the clinics, providing them with new equipment and medicines. At the same time we train the medical personal how to use these instruments and inform them on the best treatment methods.’
Catalyst in four countries

But could it be the solution for the whole of Africa? First of all Sjoerd van Keulen stressed that the program is still in its pilot phase. ‘We are learning every day, for example, how best to run the administration in a country where there is hardly any registration of people and how to optimize our market strategy.’ And Kees Storm reminded the audience that the aim of the Health Insurance Fund is to start a program in a maximum of four countries only, to demonstrate that it can be done. ‘However, that does not mean that it should stop there. In Nigeria the program has already worked as a catalyst. The Governor of Kwara State, the honourable Dr. Bukloa Saraki, is now co-financing the program in his state and wants to use the program to achieve the goal of quality health care for the whole state. And furthermore, as Chairman of the Nigerian Board of Governors he is looking for a nation wide insurance program, for which the Health Insurance Fund concept functions as a blueprint.’