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Africa Policy Journal

Topic / Health

What Public Health Insurance Agencies Can Learn from Private Health Insurance Firms

The COVID-19 pandemic and the health inequities it revealed strengthened the case for universal health coverage (UHC), a discussion that was already topical pre-pandemic, with many countries in sub-Saharan Africa launching health insurance schemes as their vehicles for achieving UHC. Although there are success stories from countries like Rwanda, questions have been raised about the potential of these schemes to achieve UHC goals,  partly because they remain voluntary, contributory and oftentimes tied to employment. 

As these discussions continue, it is critical that the health insurance schemes that already exist become more efficient. Not less than 36 countries in Africa have health insurance schemes, many of them with financial deficits. As one who worked in private health insurance firms for many years and can attest to the profitability of those schemes, I explore lessons that public health insurance schemes can learn from them to improve their sustainability, without sacrificing the UHC goals of equity, financial protection and quality. 

In the private sector, there is a deep culture of customer engagement to encourage enrolment and understand what works, when and why. To bring the same culture into public sector insurance, member engagement and mobilization should be stepped up using already existing structures like townhall meetings. Apart from discussing the successes and challenges of the scheme, these platforms can be used to share success stories to encourage enrolment. Customer service surveys can help understand members’ perceptions of the scheme but are typically expensive to deploy. Phone surveys on a representative sample of the population can serve as a substitute. 

Data is the lifeline of private health insurance. Leaders at multiple levels receive up-to-the- moment data and course-correct in real-time. To generate and analyse these data, private firms have underwriting and data analytics units, who consistently review utilization and medical spend, alerting managers about changes in trends that should trigger operational actions. To recreate this in the public sector, carve out a team devoted to analysing data and adopt a culture of data use for decision-making. There should be a careful consideration of indicators that provide a picture of operations and strategy and an understanding of how to derive these data. Ensure that all stakeholders have the right incentives to submit data and consider different sources of data together to create a full picture, whenever possible e.g. HMIS data combined with claims data to better understand disease patterns. Dashboards should be developed to show trends. A simple step to move from a manual to digitized system, would be to use Excel or Access forms with simple validation rules to capture data from the lowest level of the health system, possible. This can be a game-changer, giving managers visibility over their data. There should be frequent reviews of the data with immediate actions taken to address identified challenges and feedback provided on data quality. Countries should consider the adoption of a data timeliness benchmark that will specify timelines for data generation and analysis, review, identification of disruptions, initiation of investigations and response to disruptions. 

The real-time data mined by private health insurance firms are used to course-correct in real-time. Case management and health promotion teams address issues that arise e.g. a spike in malaria cases would warrant an investigation by the health promotion team to track the population most involved and target them with health promotion activities. In the public sector, this can translate to working more closely with the Ministry of Health – which is notified as disruptive disease trends are observed. Potentially, this can help identify and better respond to the next pandemic, especially if benchmarks on data timeliness are adopted. 

Private health insurance firms typically contract providers who can provide services of a specific quality and failure to do so, leads to sanctions including de-listing from the provider network. With public health insurance agencies, enforcing this with public providers is tricky because in some instances, these providers do not have the autonomy to make financial and other decisions. It then becomes difficult to hold them accountable for failing to meet quality indicators. This is one area of ongoing debates and discussions – how governments can grant more autonomy to public sector providers and still ensure accountability. There’s no ‘one size fits all’ answer. Solutions will have to be context-specific. 

To understand new trends in healthcare and changes in the tastes of their market, private insurance firms are always scanning the environment. The result of this is a regular review of benefit packages. For public firms, this should translate into a process for the periodic review of benefit packages to ensure that they still address the healthcare needs of the population. 

Learning from the private sector is one area of private sector engagement that is not being fully exploited. There is a lot that existing public institutions can learn from the private sector to become more innovative and efficient. As these reforms are implemented, it is critical to continue to explore the use of tax funding to better finance the ‘health insurance function’ in every country, irrespective of institutional or organizational arrangements.