Health Insurance Systems in Five Sub-Saharan African Countries: Medicines Benefits and

Data for Decision-Making

Carapinha, Joao (1); Ross-Degnan, Dennis (2); Tamer Desta, Abayneh (3); Wagner, Anita (2)

joao@carapinha.com

1: Northeastern University, United States of America; 2: Harvard Medical School and Harvard

Pilgrim Health Care Institute; 3: World Health Organization, Regional Office for Africa

Problem statement: Medicines benefits through health insurance programs have the potential to

improve access to and promote more effective use of affordable, high-quality medicines.

Information is lacking about medicines benefits provided by health insurance programs in Sub-

Saharan Africa.

Objectives: To describe the structure of medicines benefits and data routinely available for decision-

making in 33 health insurance programs in Ghana, Kenya, Nigeria, Tanzania and Uganda

Design: Survey data of the program structure, characteristics of medicines benefits, and availability

of routine data for decision-making in health insurance systems is described, by country, with

tables and figures.

Setting and study population: A convenience sample of 82 health insurance programs in five Sub-

Saharan African countries (Ghana, Kenya, Nigeria, Tanzania, and Uganda) were identified and

surveyed, of which 33 (40% of total) submitted data complete enough to be analyzed.

Intervention: No intervention was applied and assessed.

Policy: No policy change was evaluated.

Outcome measure(s): Measures covered program structure, characteristics of medicines benefits,

and data available for decision-making.

Results: Most programs surveyed were private, for-profit schemes covering voluntary enrollees,

mostly in urban areas. Almost all provide both inpatient and outpatient medicines benefits, with

members sharing the cost of medicines in all programs. Some programs use strategies that are

common in high-income countries to manage the medicines benefit, such as formularies,

generics policies, reimbursement limits, or price negotiation. Basic data to monitor performance

in delivering medicines benefits are available in most programs, but key data elements and the

resources needed to generate useful management information from the available data are

typically missing.

Conclusion: Many questions remain unanswered about the design, implementation, and effects of

specific medicines policies in the emerging and expanding health insurance programs in Sub-

Saharan Africa. These include questions about the most effective medicines policy choices,

given different corporate and organizational structures and resources; impacts of specific benefit

designs on quality and affordability of care and health outcomes; and ways to facilitate the use

of routine data for monitoring. Technical capacity building, strong government commitment,

and international donor support will be needed to realize the benefits of medicines coverage in

emerging and expanding health insurance programs in Sub-Saharan Africa.

Funding source(s): The WHO Department of Essential Medicines and Pharmaceutical Policies in

Geneva funded the development of the survey. The WHO Regional Office for Africa organized

and funded data collection and analysis.

1

BACKGROUND

• Medicine prices vary significantly

across Sub-Saharan African

countries

• Strengthening health insurance

programs could improve the

availability and affordability of

essential medicines

• Many types of national, social,

private, and community-based

health insurance schemes are

emerging

• Health insurance is intended to

reduce the financial burden of

purchasing medicines and improve

access 2

STUDY AIMS

No published information exists on:

1. the scope of medicine benefits

provided by Sub-Saharan Africa

health insurance programs

2. what data these programs have

available to monitor performance

or evaluate effects of changes in

medicines coverage

We therefore:

- describe health insurance

programs in Ghana, Kenya,

Nigeria, Tanzania and Uganda,

their medicine benefits, and the

routine data available to them 3

METHODS

• We developed a survey to:

– assess program structure,

– characteristics of medicine benefits,

– availability of routine data for

decision making.

• Distributed through National

Program Officers in WHO AFRO

• Sampled 82 health insurance

programs, 33 (40%) returned

completed survey

• Responses presented in aggregate

with no individual program

identified.

4

METHODS

• Data entered and checked in MS

Excel® 2007

• Summary tables produced using

SPSS ® version 16

• We describe by country:

– characteristics of the responding

insurance programs,

– medicine benefits provided,

– routine enrollment and utilization

data available,

– perceived barriers to using these

data for policy decision making.

5

Ver

y f

ew h

ealt

h i

nsu

rance

pro

gra

ms

cover

the

poor,

the

unem

plo

yed

, an

d p

ensi

oner

s

6

Tota

l res

po

nse

s: 2

3

Most

pro

gra

ms

requir

e th

at i

npat

ient

and

outp

atie

nt

med

icin

es b

e dis

pen

sed a

s gen

eric

s

7

Tota

l res

po

nse

s: 2

3 (

Blu

e), 2

3 (

Red

)

Del

ays

in p

aym

ent

and f

raud a

re s

erio

us

pro

ble

ms

wit

h m

edic

ines

ben

efit

8

Tota

l res

po

nse

s: 1

7 (

Blu

e), 1

8 (

Red

)

Medicine codes, generic vs. brand

status, & patient charges are not

typically available

9

Medicines data elements (always on claim)

Total responses: 29

Most programs routinely

collect and computerize data

Total responses: 27

Data routinely collected and computerized

Programs reported the three

most important questions they

would like answered

• Some medicines policy or coverage issues included:

– concern about expanding pharmacy budgets and controlling medicines prices,

– addressing product selection, cost, and cost-effectiveness of medicines,

– combating counterfeit medicines,

– implementing specific medicines management approaches,

– improving adherence to generic prescribing,

– responding to quality concerns of patients and providers about generic medicines,

– assessing the effectiveness of newer, costly therapies, and

– implementing computerized data management.

11

SUMMARY

• There is a lack of comprehensive

information on medicines benefits in Sub-

Saharan Africa

• There are challenges with providing effective

and efficient medicines benefits

• Fraud is a serious issue which requires

improved record management systems and

provider/member education

• Questions about the design, implementation,

and outcomes of medicines benefit policies

remain unanswered

• Questions about the impacts of corporate

status, revenue sources, structural

relationships with health care facilities and

dispensaries, and membership profiles remain

unanswered

POLICY IMPLICATIONS

• Strengthen transparency through improved

record management systems, provider and

member education.

• Mechanisms to integrate local population

ownership and joint decision-making are

needed.

• Expanded risk pooling that could mitigate

the effects of adverse selection.

• Capacity building for medicines policy

decision making is needed to strengthen

existing systems.

• Strong government commitment and

international donor support is needed to

expand medicines coverage through health

insurance systems.