You need to keep access to healthcare on everyone's agenda

Could you briefly explain what PharmAccess (PA) is doing in Namibia? 
PA would like to scale up access to treatment for HIV and AIDS in ‘resource limited settings’ through innovative approaches. Many of the state’s health care facilities are being used by people with money who are taking up space that really, really poor people are not able to access. So if we could get people in formal employment into private medical care, we will be able to relieve some of the burden on the state, and also give more people the benefit of private medical care. But in order to do that, you will have to make private medical care more affordable, and this is why we are working with the various medical aid funds.

Why should money raised from Dutch citizens wanting to help poor people be used to assist a private sector industry, particularly one as affluent as the Namibian medical aid industry? 
In Africa, people earning low to middle incomes – the people we are targeting – very often look after a large number of people who are actually poor or unemployed. We believe that the state has a responsibility to look after the poorest of the poor, and that the private sector has a strong role to play in complementing the public sector by filling the gaps that the public sector cannot fill.

But if it works, PA’s support to the Health is Vital risk equalisation fund will enable medical aid funds to offer lower-cost medical aid schemes to well-off people.
Solidarity works both ways. So yes, your more well off may benefit from lower premiums. But less well off people will benefit from having access to something they have not had access to before. The subsidies we provide are simply a catalyst to allow the products we support – not just the risk equalisation fund, but also NHP’s Blue Diamond and Economic medical aid options – to gain sufficient volumes to sustain themselves.

But isn’t there a danger of distorting market forces?
Both the risk equalisation fund and the NHP Blue Diamond products are aiming at a completely different market than any of the other existing medical aid products. So there is no market distortion as such.

Aren’t you making HIV and AIDS a special case, given that it is not the main chronic illness that the medical aid funds are having to deal with right now? 
Yes, a lot of money being spent on the cover of other chronic diseases. But there is no disease in Namibia at the moment that drops the life expectancy of the entire nation in the way that AIDS does. There is no other disease that has an overall prevalence rate like HIV and AIDS. For private sector employers, and public health in general, HIV and AIDS are a far greater threat than other chronic diseases like heart disease, diabetes or hypertension. But until last year, the lower-cost medical aid products did not have sufficient HIV and AIDS benefits.

PA’s initial goal was to establish sustained HIV and AIDS treatment through private-public partnerships. Where is government in all this? 
In order to achieve our objective, we first had to get the private sector working together. The public sector is pretty well organised in terms of their (HIV and AIDS treatment) programme. The private sector was very segmented, and there was a need to get the private sector to co-operate and start focussing on HIV and AIDS too. I think in future, especially if the risk equalisation fund starts to grow, hopefully the private sector can start complimenting government, and that’s where you are going to find your public-private partnerships.

Government and the medical aid industry seem suspicious of each other. Why? 
They don’t talk to each other. There are misunderstandings on both sides because there is no dialogue. Perhaps things like the risk equalisation fund can provide a platform for more dialogue. But because the industry doesn’t really operate as one, it’s very difficult to get that dialogue going.
Why did it need an organisation like PA to be a catalyst for the changes now taking place? 
All of them had given these concepts some thought. All of them had started developing something. I do believe that this would have happened without PA. I think PA has helped speed up the process a little bit by providing some subsidies and some advice that may have otherwise been lacking. There is so much innovation and so many great ideas coming out of Namibia, but sometimes you just need that little bit of reassurance from someone called an ‘expert’ that you’re on the right track.
Elsewhere, risk equalisation funds are usually brought about by the state through legislation. To what extent is Health is Vital a risk equalisation fund in the true sense? Why is it a private rather than a public initiative? 
I think the private sector in Namibia was countering what they expected government to do in a couple of years time, by establishing a platform that could serve as a national medical aid fund once the government is in a position to advocate for that. The Namibian market is so small, and if you want to expand that market it only makes sense to share risks and to share infrastructure. The entire medical aid fund industry in Namibia is smaller than the smallest medical aid fund in South Africa. So from a risk principle point of view, it doesn’t make sense to keep doing things in small risk pools.

But the motive behind Health is Vital is risk reduction, whereas state-initiated risk equalisation funds are founded on strong social principles such as non-exclusion and basic, life-long benefits for all.
The aim of the Health is Vital risk equalisation fund is not just to reduce risk but also to grow the market. Sure, the way it is structured now, the risk equalisation fund is not for everyone. But the infrastructure that supports the fund could quite easily be expanded to provide health care for all on a non-exclusive basis by way of a basic benefits structure. The risk equalisation fund and its HIV and AIDS benefits are just the very first step towards building such a platform. The way it has been designed does not exclude it from expanding to any other medical condition, or to include different target populations.

But the people running the fund are business people.
No, the risk equalisation fund is a friendly society established by a board of trustees that is composed not only of the medical aid funds, but also government, employer representatives, NGOs, the donor, the regulator. So it’s not just one organisation that will determine the benefits for the future. All the stakeholders can influence not only the premiums but the benefits too.

Are HIV-positive people represented on the board? 
Not yet, but they can be through, for example, organisations of people living with HIV.

What will it take for medical aid schemes to provide medical aid cover to semi and unskilled workers?
It will take leadership from the business community. It is one thing to get the private health care industry to develop the products. It is another to get business leaders to start supporting the products, and not just to expect their employees to pay. Which is another reason for our subsidy, so we can say to employers: ‘We are making a contribution, how about you making a contribution too?’
How ready is business to provide this leadership?
How do you eat an elephant? One step at a time. To change attitudes and perceptions takes time, and we are going to need companies to start to experience the new (medical aid) products and then build on that. We’ve had a lot of discussions with companies who do feel and see HIV and AIDS. So we have started with the HIV and AIDS benefits. That way they start budgeting for it. Then perhaps next year they can start with the general health care benefits. It’s not ideal, but it’s better than companies sitting back and doing nothing. If people who are HIV-positive can access treatment, it will make a difference in their lives. So let’s start there.

What are the main lessons learned so far? 
The key lesson we have learned is that it doesn’t work to support any one product in a country like Namibia. We have a very small community, we have a lot of people who have built relationships over many years, which is why it’s important to partner with various organisations. One of the other most important lessons is that … and I don’t want to sound like a propaganda slogan … but you need to keep access to health care on everyone’s agenda. It’s a process, not an activity. It’s a perception change that happens over time, and one that you need constantly to reinforce – how important it is for people to be able to access affordable health care, whether it’s through the public or the private sector. But you have to be extremely flexible, keeping your objective in mind, but tailoring it to the organisation or institution you are talking to. A one-size-fits-all approach definitely doesn’t work.

Where do you see the medical aid industry in five years time?
Namibia is such a large country with such a small population. We should be able to deal not just with HIV and AIDS, but all health-related conditions. What I would love to see is a platform through which the pubic and private sector can share in resources, skills, knowledge and infrastructure to be able to provide health care to the entire population.
Is that achievable in five years?
Well, a year ago I didn’t think we would have a risk equalisation fund, so I don’t see why not! It will take a concerted effort, but I think it’s possible. And then what about employee groups like domestic workers, security guards and commercial farm workers? Any effort to get these groups insured will require investment in health care infrastructure. And that’s a natural second phase to expanding access to health care. Sometimes we find under-utilised public infrastructure that, through public-private partnership, could be jointly used. By creating low cost medical aid products, you’re going to create a demand, but you’re going to have to deliver the services too.
Copyright © 2006 Insight Namibia