Nambata Angula
The World Health Organisation (WHO) defines Universal Health Coverage (UHC) as a means for all individuals and communities to receive the health services they need without suffering financial hardship. UHC includes a full spectrum of essential quality health services from the promotion of health to prevention, treatment, rehabilitation and palliative care across an individual’s life. It forms part of the International Labour Organisation (ILO)’s social protection floors.
UHC not only focuses on what services are to be provided, but also how these will be funded, managed and delivered. Furthermore, it will require the strengthening of a country’s health system. Therefore, robust funding is of utmost importance. Without UHC, people without medical aid are forced to pay for medical expenses out of pocket, which disadvantages the poor as they are unable to obtain the services they need, and in the same vein, exposes the rich to financial hardship in the event of severe or long-term illness. Therefore, UHC is beneficial to all social classes in society as a strong healthcare sector is one of the cornerstones of a sustainable health system, and is a major driver of economic growth.
Universal Health Coverage is a target under the Sustainable Development Goal 3 of Good Health and Well-being, targeting financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Furthermore, other international legal instruments that underpin UHC are as follows: World Health Assembly (Resolution 58.33); ILO Recommendation 202 Social Protection Floor; World Health Assembly Resolution 69.1 (May 2016). Domestically, the Social Security Act 34 of 1994 establishes the National Medical Benefit Fund with the objective to provide medical benefits to every employee who is a member of the Fund.. [emphasis added]. Therefore, coverage is limited to employees only. This is equivalent to the concept of a social health insurance (SHI) or for the lack of a better description, a National Health Insurance (NHI); whereas the intention of UHC is the coverage of all individuals and communities.
Namibia does not currently have a UHC policy in place, unlike our southern neighbours who adopted a National Health Insurance policy in 2011, albeit lagging in terms of implementation.
A prerequisite for UHC is that the necessary health infrastructure and services must be in place in terms of geographic accessibility and the availability of quality services. It critical that a multisectoral and community-centred approach is adopted in order to ensure that UHC reaches difficult-to-access areas and vulnerable populations and most importantly, the elephant in the room must be addressed: funding.
Financing options & success factors
Namibia has a well-established private health insurance industry with eight active medical aid funds operating, regulated by NAMFISA through the Medical Aid Funds Act 23 of 1995. However, the total population coverage through these medical aid funds is limited at 204,713 members, with fund reserves amounting to N$2.06 billion.
Government employees are covered by the Public Service Employee Medical Aid Scheme (PSEMAS); a fund not regulated under the Medical Aid Funds Act, with a total membership base of 412,125 members. It has a larger beneficiary base than the combined private medical aid sector. However, there is a lack of proper risk pooling as premiums paid by members are at a flat rate, regardless of salary level, and are not based on their risk profile or their ability to pay. The government also heavily subsidises the fund to insure full coverage of claims made to the fund. This makes the contributions to PSEMAS highly regressive.
Other forms of health financing in Namibia are through the Employees Compensation Fund of the Social Security Commission and the Motor-Vehicle Accident Fund. Donor funding has decreased significantly, as donors have transitioned due to Namibia’s upper-middle-income status.
In exploring the financing of UHC, the different stakeholders, such as government, workers, employers, industry players, academia, civil society and development partners will need to coordinate to make a determination in terms of health sector reforms and the resources available as simply introducing a new tax to already constrained workers is not the easy option. A costing exercise needs to be undertaken to determine the real cost of UHC.
Reforms of PSEMAS should be a consideration as to whether the fund will be liquidated and rather utilised for the realization of UHC since the government is already heavily subsidising it, or whether it will be merged with UHC.
A levy from the private medical aid funds is another consideration, with the aim of cross-subsidising the public health sector. Other funding options can also be explored from the Employees Compensation Fund and the Motor- Vehicle Accident Fund. A critical success factor for UHC is political will, which is driven by a need for all stakeholders to speak the same language, particularly lawmakers. The overarching goal of universal healthcare should be driven by these important considerations, namely a healthcare system that is designed to pool funds to provide access to quality, affordable personal health services for all Namibians based on their health needs, irrespective of their socioeconomic status.
A legal framework needs to be developed in order to establish UHC, as the only current legal instrument close enough to UHC is the National Medical Benefit Fund established by the Social Security Act, which is limited to members of the Fund.
The importance of political will cannot be understated as evidence has shown that without political will, good programmes fail. This is also due to changing leaderships, whereas new leadership may not believe in the vision of the previous leadership due to political differences. A case in point is the frequent changing of Ministers of Labour before they reach tangible milestones in extending coverage as per the existing legislation. In the past 32 years, Namibia has been served by no less than nine Ministers of Labour under whose jurisdiction the SSC schemes are administered and implemented. This means that an average time spent by the political head of social security is a mere three years. Therefore, it is important for all stakeholders to put politics aside and work together towards achieving UHC.
Furthermore, the government should make use of the many medical graduates and trained community health workers for the delivery of UHC as health workers are integral to building strong, resilient and safe health systems in urban and rural areas, thus reducing inequities.
Lastly, the Covid-19 pandemic has shown us that countries need to hastily scale up their investments in essential public health functions, or risk large market failure.
*Nambata Angula is the General Manager: Business Development at the Social Security Commission. She is writing in her personal capacity.