Universal Health Coverage – a Solution for Namibia? [opinion]

THE NAMIBIAN government recognises health and social well-being as a fundamental human right.

The report of the Presidential commission of enquiry on the health sector states that “the goal of government is the attainment of a level of health and social well-being by all Namibians, which will enable them to lead economically and socially productive lives.”

This echoes the World Health Organization (WHO) constitution and the ‘Health-for-All’ agenda set by the 1978 Alma Ata Declaration, which holds that “health is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal”.

The government has, since independence, prioritised the improvement of health provision to its citizens. This is observed in the relatively high budget allocations this sector receives annually, which averaged about 11% of government expenditure over the past 10 years. In the 201415 budget this share has increase by about N$850 million from the previous year to reach the N$6 billion mark. While still falling short of the 15% target of the Abuja Treaty, regional comparisons show that Namibia’s public spending on health is relatively high as it compares favourably with the SADC average of 9,6%.

Notwithstanding these generous budget allocations, the country’s health care system continues to face enormous challenges. Chief among these are the stark inequalities in the provision of health services in the country. Namibia faces a disturbing dichotomy between a highly efficient and aanced private health sector, and an overstretched and inadequate public health system.

Only about 15-16% of the Namibian population have regular access to private health services. The rest of Namibia’s population (84-85%) is dependent on a public health system, which by government’s own admission, is beset with various shortcomings which often compromise the quality of health care, leading in some instances to preventable loss of life.

In response to similar challenges internationally, social health protection has been regarded as a priority area by the UN for years, and has reached prominence after the international financial crisis in 2008. This has led to a heightened global momentum for calls on countries to establish Universal Health Coverage (UHC), a theme which was the focus of the 2013 World Health Report.

Below, we will take a closer look at the Namibian health (financing) system in light of these global debates and offer some anecdotes on social health protection, which may stimulate public debate and help guide the national perspective on establishing UHC in Namibia.

The WHO defines UHC as “access to key promotive, preventative, and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access”. Generally, UHC is based on the following three pillars: Reduced out-of-pocket spending, the reduction (minimisation) of direct payment for health care at the point of service prepayment, which may be effected through general taxes, member contributions and donor support and finally, risk pooling, denoting the pooling together of financial risk such that the financial cost of health care is spread across the entire pool of persons who are part of the system. The goal of UHC is to ensure that all persons within the system obtain the health services they need without suffering financial hardship when paying for services provided. A key principle in this regard is “service according to needs, and payment according to means.”

As such, UHC fosters people’s equitable access to health services while preventing them from being pushed into poverty when having to pay for such services. UHC is thus a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities.

Various financing models are used to achieve the above-mentioned objectives. Some countries follow a Bismarck-type Social Health Insurance (SHI) in which health expenditure is financed through member contributions, while others use the Beveridge-type National Health Insurance (NHI), a tax-based health financing system. A mixture of the two is also found in some countries.

It has often been asked whether the Namibian economy can afford to implement UHC. In answering this question it should be noted that international experience shows that all countries, irrespective of their level of national income can take concrete steps related to the objectives of UHC.

WHO data shows that countries at all income levels have recently made important progress towards that goal.

Rwanda, for instance, a country with a per capita income of merely USD644 (as opposed to Namibia’s USD4,328), has achieved near universal coverage within eight years, using a modified version of social health insurance.

Thailand, with a per capita health expenditure almost half that of Namibia (USD385 compared to US 619 in Namibia), reached universal coverage in 2010.

Through the Social Security Act, the Social Security Commission (“SSC”) is mandated to establish a “National Medical Benefit Fund” (“NMBF”), a type of SHI aimed at providing “payment of medical benefits to employees”. As such, the NMBF can serve as a sub-set to a broader NHI and pave the way for achieving UHC.

In 2011 SSC commissioned a strategic study on the design and implementation of NMBF, which was completed in July 2012. Stakeholder input was solicited and some input was received. However, some important stakeholders still have to make input according to SSC.

In realising the importance of UHC, however, the Ministry of Health and Social Services (“MOHSS”) allowed SSC to move beyond its current legal mandate and spearhead efforts towards establishing UHC in the country.

As a result, and parallel to the process of establishing NMBF, SSC has instituted a multi-stakeholder aisory committee, the Universal Health Coverage Aisory Committee of Namibia (UHCAN) to provide aice and leadership on broader UHC matters in the country.

UHCAN has thus far brought together key government agencies and captains of industry and, under an MOHSS-appointed chairperson, is in the process of laying down the necessary groundwork aimed at finding the most suitable road map for the country to establish UHC.

Key questions in this regard remain unanswered. Should the Public Service Medical Aid Scheme (PSEMAS) become part of a national health financing arrangement, such as the NMBF? This would be an important step in ensuring the necessary critical mass to make such an arrangement financially viable. Should the NMBF be compulsory for all employees as provided for under Act? This measure would be crucial to avoid the phenomenon of aerse selection. These and other questions need to be answered at UHCAN level for the country to move forward in this area.

The way forward

It is clear from the above that given current inequities in social health provision in the country, and in light of global trends in health care financing, Namibia cannot sit idle and continue with business as usual. The country should be compelled both by conscience and good socio-economic sense to move towards establishing a national health care financing system.

The author is a researcher employed by the Social Security Commission. The views expressed in this article are however his own and do not necessarily reflect those of his employer.

Source : The Namibian