Reforms in Africa to extend health insurance coverage

Reforms in Africa to extend health insurance coverage

Extending social security coverage is a key challenge for the quasi-totality of members of the International Social Security Association (ISSA) in Africa. Social security coverage for a diverse workforce is therefore one of four topical priorities for ISSA in the 2023–2025 triennium. This follows from extensive work on extending social security coverage in the previous triennium culminating with new guidelines on extending health-care coverage launched in October 2022.

A successful coverage extension often requires efficient implementation and appropriate regulations. In recent years, several African countries have adopted new laws and amendments to extend health coverage or introduce completely new systems. This article highlights developments in Egypt, Morocco, and Zambia. It also briefly summarises ongoing efforts in Benin, Kenya, Togo and Tunisia, building on ISSA’s online Country Profiles, which offers concise descriptions of social security policies in over 180 countries and territories.

The context

Sustainable Development Goals, Target 3.8

Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

An important part of the global population still has no access to essential health care, defined as access to a full range of quality health services when and where they are needed, without financial hardship (WHO, 2022). Almost two billion people face catastrophic or impoverishing health spending (ibid). Many countries are striving to achieve the Sustainable Development Goals, Target 3.8 to achieve universal health coverage (UHC),  which requires equitable financing that considers everyones contributory capacities. However, within Africa, the International Labour Organization (ILO) estimates that only 23.7 per cent of the population is effectively covered by a social health scheme (ILO, 2021, p. 192).

Health insurance provides an important way to reduce the incidence of ruinous spending by insuring people against such a risk. Generally, UHC is achieved through combined contributory and non-contributory financing and serves as the gateway to social security protection. Opening up contributory health insurance programmes to traditionally excluded sectors, such as rural workers, self-employed workers, and informal workers, enhances their inclusion and participation in the realisation of the human right to social security for all.  

In social security, regulations are crucial in establishing the key characteristics of any system (see Table 1). Just like laws for cash benefits, they establish the organizing principles of the system (programme type), the groups covered, the financing model, the qualifying conditions, the benefits package, and eligible dependents. As they offer in-kind benefits, laws of health systems also need to define other system features, such as the approved service providers, approved service conditions, and the model of cost sharing, among other factors.

Table 1. Key characteristics of health systems established by law (ISSA/SSA, 2019).
Laws or regulations define… For example…
Type of programme Social insurance, social assistance, universal programmes, employer liability, etc.
Coverage Residents, employees, self-employed, public/private sector, etc.
Financing Contribution rates, minimum and maximum insurable earnings, government subsidies, etc.
Qualifying conditions Minimum periods of insurance, residence, employment, citizenship, etc. (e.g. “must have at least 180 days of contributions in the last five years.”), age or other requirements, means tests, etc.
Eligible dependents Children, spouse, dependency requirements, etc.
Benefit packages (i.e. range of medical services covered) Primary or specialist care; inpatient or outpatient services; approved medicines and appliances; maternity care; emergency and rescue services; dental care; psychiatry or psychologist services; nursing services; rehabilitation; etc.
Approved service providers and service conditions Approved doctors and/or hospitals, which conditions (e.g. upon referral, public versus private setting, number of patients per room, etc.)
Cost sharing The amount or percentage paid by the beneficiary, limits per treatment or per year, fee schedules, upfront patient charges, etc.
Administration Defining which organization supervises, regulates, administers records and claims, collects contributions, etc.

Many countries in Africa are making efforts to move towards UHC. Frequently, this extends coverage of existing schemes to include previously uncovered groups, especially informal workers and low-income groups. In other cases, efforts have been made to introduce health insurance schemes where none existed in the past. Below are case experiences of African countries that recently undertook such legal reforms.

Egypt implements health insurance coverage for self‑employed and casual workers

Egypt continues to progressively implement Law No. 2 of 2018 promulgated to extend coverage of the Health Insurance System to provide high-quality medical services to all citizens regardless of their ability to pay. The law extends coverage to new population groups, including self-employed and casual workers. In addition, Egyptians working or living abroad and foreigners working or living in Egypt can choose to affiliate. Individuals are covered regardless of the sector (public and private), contract type (seasonal and permanent), sex, or age. The new law will reorganize health insurance administration and financing by 2032.

Employee contribution rates are set at 1 per cent of income for public- and private-sector employees and civil servants, 4 per cent for casual workers, and 1 to 2 per cent of pensions for pensioners. Employer contribution rates are set at 3 per cent of income for the public sector and civil servants’ employers, and 3.25 per cent for private sector employers (there is no employer contribution for casual workers). For self-employed workers, the contribution rate is 4 per cent of monthly contributory earnings. The Egyptian government will pay a monthly contribution of 5 per cent of the national legal minimum wage on behalf of people who are unable to pay, according to the rules to be determined by the Government. It is estimated that this subsidy will affect roughly 30-35 per cent of the population (UHIA, n.d.).

The implementation of the universal health insurance system is to be carried out by several institutions, including: (1) the Universal Health Insurance Authority, which manages the provision and financing of health service; (2) the Health Care Authority, which supervises hospitals and public-sector service providers; and (3) the General Authority for Healthcare Accreditation and Regulation (GAHAR), which ensures the quality of the health services. Benefits include a comprehensive range of diagnostic and treatment services.

Morocco extends mandatory health insurance coverage to non-salaried and self-employed persons in liberal professions

In July 2021, Morocco adopted Royal Decree No. 121.79, implementing Law No. 30.21 that amends and supplements Law No. 98.15 of 2019 to extend mandatory health insurance to non‑salaried and self‑employed persons in liberal professions. The reform is part of a wider effort to extend health care coverage to all residents.

The Compulsory Health Insurance scheme (Assurance Maladie Obligatoire; AMO), managed by the National Social Security Fund (Caisse nationale de sécurité sociale – CNSS), offers a comprehensive benefits package to insured persons and their dependents. The package includes preventive and curative care, maternity, medical and surgical, health-care costs arising from illnesses, accidents, maternity, and functional rehabilitation. It guarantees the right to reimbursement and eventual upfront payment of curative, preventive and rehabilitation costs (CNSS, n.d.).

As established under the 2021 Finance Act, the self-employed and certain non-salaried persons can contribute through a single unified payment covering tax and social security obligations (this is called the contribution professionnelle unique; CPU). The amount paid varies according to income, with quarterly contributions ranging from 300 to 3,600 Moroccan dirhams (MAD) (29 to 352 United States dollars (USD)). The government covers the remaining cost. Other non-salaried persons pay 6.37 per cent of income (totalling the amount paid by employees: namely, 2.26 per cent by employees and 4.11 per cent by employers).

Additionally, the reform transfers citizens previously covered under the partially contributory social assistance programme, Medical Assistance Plan for Needy Persons (Régime d’assistance médicale – RAMED), to the main health insurance scheme (Assurance maladie obligatoire – AMO). This guarantees that vulnerable population groups have access to the same services and quality of care as their compatriots.

These reforms have been greatly facilitated by developing a unified social registry (Registre social unifié – RSU), launched in 2019 (to be formalized under the project of Law 27-22). The Minister of Health and Social Protection has noted that the RSU allowed for the effective targeting of families and has enabled the extension of coverage to needy segments of the population.

Zambia introduces mandatory national health insurance

In September 2019, Zambia passed Statutory Instrument No. 63 of 2019, implementing the National Health Insurance Act No. 2 of 2018 which introduces a mandatory health insurance scheme (Zambia, 2018). The scheme seeks to provide sound and reliable healthcare financing for Zambian households and the entire health sector. The programme is supervised by the National Health Insurance Management Authority (NHIMA), which also collects contributions and provides accreditation to health-care providers for service provision.

As a scheme guided by the principles of universality and solidarity, contributions made to the scheme cross-subsidize care for the most vulnerable. To be accessible, contributions to the programme are based on a member’s ability to pay, with a rate of 2 per cent of the basic salary for employees (split equally between the employer and employee) and 1 per cent of declared average income for the self-employed. In addition, the government and external actors (loans, grants, donations) subsidize the programme.

The scheme provides access to quality essential health-care services for all citizens and established residents. After four consecutive months of contributions, registered persons and their dependant family members enjoy access to a comprehensive benefits package. The benefits package provided to insured members covers medical care, surgery, maternity and neonatal care, pharmaceutical drugs and supplies, and selected eye care, oral health, and physiotherapy services.

The National Health Insurance Scheme (NHIS) moves Zambia towards UHC, as the mandatory social insurance programme provides essential care through risk pooling, where the contributions of paying members subsidize the care of those unable to contribute.

Other ongoing legal reforms in health

Benin passes a new legal framework for health insurance (implementation pending)

In October 2022, the government of Benin passed a new public health policy and regulations law (Law no. 2022-17 modifying Law 37 of 2020) that seeks to expand service provision and extend coverage as part of a strategy to reach UHC by 2030. The implementation of the law will take place once the government has finalized the details for its implementation. (BéninRévélé, 2023).

The framework law will require private- and public-sector employers to provide coverage to their employees. Self-employed workers will need to arrange their own coverage. The minimum health benefit package will be defined by the Council of Ministers.

Kenya amends its health insurance law to extend coverage (implementation pending)

In January 2022, the National Hospital Insurance Fund (NHIF) Amendment Act was signed into law. Under the new NHIF (Amendment) Act, 2022, any resident of Kenya who has attained 18 years of age with an income will be required to register with the NHIF. The law will also increase the self-employed contribution rate from 30 to 500 Kenyan shilling (KES) (0.2 to 3.8 USD) monthly. The full implementation of the law is stalled due to legal challenges, such as the Employment and Labour Relations Court ruling, which stated that employers do not need to match employee contributions (as set out in the NHIF (Amendment) Act, 2022).

Togo passes a new legal framework for health insurance (implementation pending)

The Government of Togo passed the Law of 12 October 2021 to establish UHC in the Republic of Togo. The Law established the general framework for the future health-care system and prepared for the creation of the National Institute of Health Insurance (Institut national d’assurance maladie – INAM). The benefits package and contribution rates are still being determined.

Tunisia improves targeting by unifying two social assistance programmes

In November 2022, the Government of Tunisia passed Decree No. 2022-919, implementing the Organic Law No. 10 of January 30, 2019, to create the “Amen Social” programme. Amen Social merges the poverty-targeted household transfer programme, National Programme of Assistance to Needy Families (Programme National d'Aide aux Familles Nécessiteuses, PNAFN), and the Free Medical Assistance programmes (Assistance Médicale Gratuite, AMG). Merging the two programmes enables better identification of eligible beneficiaries for subsidized or free medical assistance. The aim is to expand social assistance and access to basic health services to more qualifying households.

Final remarks

Achieving universal health coverage has been both a priority area  and a challenge in Africa over the past four years. In countries like Egypt and Morocco, this has meant expanding coverage of well-established schemes, while in Zambia for example, it has meant pioneering new health insurance schemes. While these countries have begun implementation, others are currently working on similar reforms, as seen in the effort to extend coverage of health insurance in Kenya and create new social insurance systems in Benin and Togo.

To extend effective health coverage, legal reforms need efficient implementation, for example, coordination between various organizations. The reforms discussed in this article often relied on multiple organizations, simplified registrations, and targeting or financing. Regarding financing, there is wide variation in the type of contributions required from self-employed workers. In Morocco, for instance, they benefit from a unified quarterly payment; in Egypt and Zambia, contributions are tied to declared income, while in Kenya contributions take the form of a fixed sum. Members’ contributions are often supplemented by government contributions subsidizing care for the most vulnerable sectors, as shown in the programmes implemented in Egypt, Morocco, and Zambia.

The reforms undertaken in these countries vary widely, but all form part of a larger trend aiming to move towards UHC. Other countries are currently preparing laws moving in the same direction. For example, Ethiopia and Uganda are also working on laws to strengthen health provision. Uganda’s Ministry of Health drafted a bill to introduce the National Health Insurance scheme, while Ethiopia is engaged in securing a legal basis for its community-based health insurance programme, which has existed as a non-statutory programme since 2011 (the bill was approved by the House of Representatives in 2022 and is currently awaiting its final passage).

Regulating health coverage also involves managing the quality and accessibility of the health care procedures and products provided, ensuring the financial stability of the system in a context of ever-increasing expenses linked to chronic diseases and population ageing, promoting innovation and managing pandemic-related episodes. These multiple objectives go beyond the mere control of health expenditure and create a need for regulatory policies that continually set a balance between health care supply and demand.

Considering the specific nature of certain regulatory strategies in the field of health coverage, the ISSA Guidelines on Administrative Solutions for Coverage Extension (ISSA, 2022) support institutions as they move towards providing high-quality care to all without major financial or societal barriers. Notably, the new Part B of the Guidelines, Defining a Regulatory Strategy to Ensure the Sustainability of Health Coverage and Build Confidence across the Population, provides tools to build an effective regulatory framework for institutions in their efforts to extend quality health coverage that is accessible to all. The extension of coverage will also be on the agenda at the Regional Social Security Forum for Africa, taking place in Côte d’Ivoire in May 2023, and treated in the corresponding ISSA regional report.


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