A Framework Policy Analysis of National Health Insurance Policymaking in Sub-Saharan Africa
Roll, Amy Christine
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A large proportion of the world’s low- and middle-income population reside in sub-Saharan Africa where out-of-pocket payment systems have made healthcare inaccessible and unaffordable in many places. Universal health coverage (UHC) means that all people have access to high-quality health services and are protected against financial-risk while using those health services. Financing approaches to UHC include varieties of health insurance and tax-funded systems. National Health Insurance (NHI) is one such financing mechanism established by a national government with the goal of covering all or almost all citizens of the country. This descriptive, qualitative study used policy sources from four countries, Ghana, Kenya, Zambia, and South Africa, that are implementing or transitioning to an NHI scheme. The research goal was to understand how the introduction of an NHI scheme might affect national health policy making and to use the results to inform South Africa and other countries in sub-Saharan Africa that are introducing NHI. A conceptual framework of 16 NHI policy domains was developed. Data were extracted from policy sources and indexed according to the different policy domains. Results revealed that following passage of legislation, NHI bodies were making policy decisions in order to operationalize and manage implementation of the NHI. We found variation in the four countries in terms of the types of policies developed and the decision-making authority around those policies. A key finding was that that Ministries of Health retained decision-making power over the NHIs through regulations and appointment of board members. However, NHIs were often delegated policymaking authority in key areas including financing mechanisms, provider payments, member payments, benefit schemes, accreditation, and relationships with private health insurance schemes. This study helps fill an important gap in research concerning policymaking responsibility in a health system after an NHI is adopted. Lessons from the focus countries can inform the transition to an NHI scheme including introduction of policies and delegation of decision-making authority in countries in sub-Saharan Africa considering NHI as a UHC financing mechanism.
- Global health