Background
Providing access to health care services and goods to all citizens has long been a cornerstone of modern health financing systems in many countries (World Health Organization, 2000). In sub-Saharan Africa (SSA), this became evident soon after independence in the 1960s: in order to redress the significant levels of inequality and deprivation during the colonial era, most countries introduced free public health care services, as a way of increasing access to (and utilisation of) modern health services and, hence, achieving the equity goal (EQUINET, 1998). However, with the passage of time, countries in SSA have been faced with an increased disease burden and growing demand for quality health care services, amidst limited economic resources, low economic growth, a large informal sector with unregulated labour markets, and high population growth rates (World Bank, 1993a). In order to respond to this crisis, in the 1980s and 1990s, many governments with the influence/support of international organisations undertook health sector reforms, with regard to health financing, which saw the reversal of the policy of the provision of free public health care services (Akin, Birdsall, & De Ferranti, 1987; World Bank, 1993b). User fees for health services at the point of use in public health facilities were introduced in almost all countries in SSA—only a few countries, such as Malawi and Mauritius, resisted the temptation of introducing user fees for public health services at all levels nationally.
Despite user fees once being seen to promote a higher quality of health services, and provide an important source of revenue (especially at lower levels of the health system), nearly all global health
actors now agree that user fees represent an inefficient funding mechanism that negatively affects the utilisation of essential health services, especially among the poor and the vulnerable population groups (Robert & Ridde, 2013). This poses a major financial barrier to achieving one of the Sustainable Development Goal 3 targets of Universal Health Coverage (UHC), including financial risk protection, access to quality health care services, and access to safe, effective, quality, affordable essential medicines for all (Ridde, 2015; United Nations, 2015). It is against this backdrop that countries in SSA and, in particular, the Eastern, Central and Southern Africa (ECSA)-Health Community (Eswatini, Kenya, Lesotho, Malawi, Mauritius, Tanzania, Uganda, Zambia and Zimbabwe) have intensified and prioritised health financing policy reforms in order to achieve the UHC goal of financial protection—reduce direct out-of-pocket payments, and increase equity in health services utilisation.
However, as ECSA-Health Community member states embark on these health financing policy reforms within their context, it is important to document and share experience across the region. This is because there is a need to avoid repeating common mistakes, and to also learn from the best practices across the ECSA-Health Community region. UHC encompasses several dimensions, requiring multiple interventions, and at times there could be both external and internal pressures to adopt such reforms that have not worked well when implemented elsewhere (as it was with the introduction of user fees in public facilities in the 1980s and 1990s). This Policy Brief aims to provide information to policymakers and advisors in the ECSA-Health Community Region that could inform and improve accountability for decision-making, and facilitate the sharing and dissemination of knowledge and experience. This Policy Brief will provide information on two main health financing policy reforms for revenue collection and pooling: 1) removal of user fees in public facilities, and 2) design/implementation of social health insurance (SHI)/community health insurance (CHI) schemes that have been implemented widely in SSA countries, including ECSA-Health Community member states. In addition, it will also examine the search for innovative domestic financing mechanisms for raising additional funds for health implemented in a few SSA countries and beyond.
Published: February 2021