Potentials of a ten dollar pre-paid public health plan for rural health in Sub-Saharan Africa

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Dear Editor

It is often said that for public health policy to be credible and acceptable it has to satisfy the criteria of equity, quality and efficiency. However, some studies indicate that many Sub-Saharan African (SSA) countries are unlikely to internally generate the required funding to provide efficient and quality health services^1-3. Such countries may be unable to guarantee the required equity in financial contribution to enable universal health coverage (UHC)^4,5, leading to increasing private spending on health care.

Related studies show that episodic treatment for diseases such as malaria may cost families in SSA between US$17 and US$93 per household^6,7, with the impact being greater on rural and remote populations where household income will often be inadequate to meet such expenditure. However, even with private contributions, the quality of SSA health services will be inadequate due to the endemic financial and management challenges such as personnel retention⁸, quality assurance⁹, stewardship¹⁰ and technical inefficiency¹¹.

Differing approaches have been considered to enable UHC, such as sustainable funding models and advocacy for revenue from hypothecated, sector-specific and excise taxes¹². However, because private expenditure on health continues to exceed government expenditure in most SSA countries, to ensure the sustainability of UHC in the rural and remote regions of 6 SSA countries (Table 1) a '$10 dollar prep-paid plan' for free basic health services is suggested, with the following assumptions:

• Although $10 is less than the World Health Assembly (Resolution WHA 58.33) ideal, it is better than no contribution.
• Subscribers will be willing to pay this in order to receive better quality health care¹³.
• Subscription contributions can be made easily via dedicated GSM (Global System for Mobile communication ) pre-paid cards/starter packs, with postal confirmation certificates to reduce administrative costs.
• The funds generated will increase the sustainability of rural health services provided there are explicit mechanisms to ensure expenditure for specific purposes, such as access to medicines and rural personnel retention.
• All enrollees, including those paid for by family, community members or purpose-specific social welfare grants, are covered irrespective of their demographic characteristics.

Table 1: Potential revenue streams for a 'US$10 pre-paid plan' if 30% of estimated total and rural populations
voluntarily enroll for 6 Sub-Saharan African countries^14-17

Analysis using 2009 total and rural populations¹⁴ for the 6 SSA countries (all with an out-of-pocket health expenditure as a percentage of private expenditure on health of 70% or more, as well as private pre-paid plans less than 20% coverage by 2006)¹⁵, shows that if 30% of the total and rural estimated populations in several SSA countries enroll in such a scheme, the revenue stream would be significant, compared with total government expenditures^16,17 (Table 1). Therefore, if appropriate mechanisms ensure the retention of such funds for dedicated expenditure on rural health services, and wider managerial issues are addressed⁹, a significant impact will be made on the sustainability of rural health services, including access to medicines¹⁸ and improved personnel retention⁷.

Anthony Umunna, MA
Ministry of Health & Social Welfare, Lesotho

References

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