By Cons Karamata
The Namibian Government recognizes health and social well being as a fundamental human right.
The Report of the Presidential Commission of Enquiry on the Health Sector states that given this fact, “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.”
In accordance with the above, the Namibian Government has since independence prioritized 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 percent of government expenditure over the past 10 years.
While still falling short of the 15 percent target of the Abuja Treaty, regional comparisons show that Namibia’s public spending on health is relatively high as it compares favorably with the SADC average of 9,6 percent.
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 advanced private health sector, and an overstretched and inadequate public health system.
Only about 15 – 16 percent of the Namibian population, the portion covered by health insurance, has regular access to private health services. The rest of Namibia’s population (84 – 85 percent) is dependent on a public health system.
What is Universal Health Coverage (UHC)?
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.” This was also endorsed as part of the World Health Assembly Resolution 58.33 (2005) that urges member states to “ensure that health financing systems include pre-payment methods with views to sharing risk among populations and avoiding catastrophic health care expenditure.” 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 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. It is thus the hallmark of a government’s commitment to improve the wellbeing of its citizens.
Various financing models are used to achieve the above 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.
Can Namibia afford UHC?
It has often been asked whether the Namibian economy can afford to implement UHC. In answering this question it should to 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.
Health financing systems that are moving towards UHC seek to raise sufficient funds for health care, and use such funds in the most equitable and efficient way possible. These systems have very different starting points and country contexts. Thus, each country will need its own road map in order to achieve the core principles of UHC.
Nevertheless, 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 US$644 (as opposed to Namibia’s US$4 328), has achieved near universal coverage within 8 years, using a modified version of social health insurance.
Thailand, with a per capita health expenditure almost half that of Namibia (US$385 compared to US$619 in Namibia), reached universal coverage in 2010. With a great deal of popular support, the Thai government passed the National Health Security Act in 2002 which established the Universal Coverage Scheme (UCS), combining the already existing Medical Welfare Scheme and the Voluntary Health Card Scheme to expand coverage to an additional 18 million people. In total Thailand has expanded coverage to 65 million people, or roughly 98 percent of the population.
Namibia’s Response and the Role of the SSC
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 realizing the importance of UHC however, the Ministry of Health and Social Services (MOHSS) allowed the 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 advisory committee, the Universal Health Coverage Advisory Committee of Namibia (UHCAN) to provide advice 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 roadmap 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 the Act?
This measure would be crucial to avoid the phenomenon of adverse 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. Internationally, such systems have proven to be the most effective tools in reaching the objectives of universal health coverage.
It has further been established that there is no one-size-fits-all model in this area. Namibia should therefore determine its own path, reflective of local realities, in choosing a health financing model.
The main objective should however remain the equitable provision of quality health care to all Namibians. This would ensure that all Namibians, irrespective of their income level, lead socially and economically productive lives.
In doing this Namibia will achieve the necessary pre-conditions for the country to attain economic growth and reach its national development objectives. Also, by taking steps towards Universal Health Coverage, Namibia will go a long way in meeting the Millennium Development Goals (MDGs) related to health and social welfare.
• Cons Karamata 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."