In 2015, Burkina Faso adopted a law on universal health insurance scheme (RAMU), which is compulsory for all. This blog examines the issue of involving existing insurance mechanisms in the implementation of this scheme.
Health insurance provision is not well developed in Burkina Faso, where about 2% of the population, mostly employees in the public and private sectors have health coverage through private insurance or professional mutual insurance companies. Protection against financial risk for rural populations and workers in the informal sector, who represent a large majority of the population, is dependent on community-based mutual health insurance. With a view to providing financial protection for its entire population, Burkina Faso adopted a law on 5 September 2015 establishing a universal health insurance scheme (RAMU), which is compulsory for all. To achieve this goal, this scheme intends to build on pre-existing insurance mechanisms, including community and professional mutual health insurance as well as private insurance. However, there are challenges in aligning the RAMU with these pre-existing schemes.
Challenge 1 – Ensuring a fair financial contribution for all social classes
As is the case in most developing countries, there is no formal and reliable mechanism in place to determine households’ income and especially, the income of those working in the informal sector in Burkina Faso. Such a mechanism is all the more difficult to put in place because the rate of those using banking services is very low in the country and employers do not declare many employees to the social security fund. This situation makes it difficult to ensure that the contributions of people living in rural areas and workers in the informal sector to community mutual health insurance schemes are commensurate with their income. Moreover, article 48 of the Law provides that the State shall pay the full contribution of the needy people. However, there is no consensual definition of poverty in Burkina Faso and the criteria used to identify the needy cases differ from one structure to another. This therefore poses a real risk of wrongly including or excluding some poor households from the list of those in need. Finally, the contribution rates for members of professional mutuals differ from one mutual to another. However, these differences in contribution rates between mutuals are not related to the income level of members, or even to the health care package that is offered. Ideally, for a fair contribution, the members’ contribution for a given basket of care should correspond to their capacity to pay regardless of the mutual insurance company to which they belong. An inclusive dialogue along these lines between professional mutuals would be necessary to achieve that goal.
Challenge 2 –Defining care packages that meet the health needs of people
The law on RAMU is based on “principles of national solidarity, equity, non-discrimination, risk pooling, efficiency and the general responsibility of the State”. These principles underpin the definition of a basic health care package for all social classes and meeting their needs. In this regard, the Government of Burkina Faso effectively defined a healthcare package during a workshop organized by the CNAMU on 9 and 10 June 2015. However, the challenge that remains is to ensure that this basic package is in line with the basic package of existing insurance mechanisms, in particular that of professional mutual insurance companies and private insurers. Indeed, the healthcare package proposed by the Government does not take into account certain services offered by professional mutual insurance companies, such as the payment of optical expenses by the mutual insurance company covering customs employees, or the payment of national and international medical evacuations by the mutual insurance company covering university lecturers or private insurance companies. How then can these benefits be maintained without violating some of the principles mentioned above, notably equity, non-discrimination and risk pooling? Ideally, the common healthcare package proposed by the State should be gradually extended to take into account the advantages of professional mutual insurance and private insurance, while maintaining a fair financial contribution for the entire population.
Challenge 3 – Putting in place effective contracting mechanisms
Article 40 of the RAMU law provides for the possibility of CNAMU to delegate certain technical functions such as affiliation and registration of persons entitled to benefits, collection of contributions, monitoring and purchasing of care services to delegated management bodies. However, owing to the multiplicity of these bodies, there is likely to be challenges harmonizing the different interests involved since they may differ from one another or have their own specific operating procedures. Therefore, in the contracting process with these bodies, particular emphasis should be placed on collective negotiation of specifications with their umbrella organizations (e.g. the Federation of Professional Mutuals and the Solidarity Fund of Burkina Faso, ASMADE, RAMS) in order to iron out possible differences. In addition, this contracting process should include strong accountability mechanisms to ensure compliance with the specifications, as well as clauses guaranteeing a fair financial contribution and an accessible, equitable and quality health care system. This is how the RAMU would achieve its objectives of protecting the public against financial risk and contributing to the improvement of their health.
Challenge 4 – Adopting good governance measures to facilitate uptake of the RAMU
Currently, there is a lack of trust between the State and citizens in Burkina Faso due to the management of public assets by the former, which is sometimes considered by the latter to be lacking in propriety. In fact, the poor management of public goods that is often reported in the press and social networks has exacerbated the population’s mistrust of those in power; in the eyes of citizens, this has undermined the ability of those in power to ensure the sound management of the RAMU. As an illustration, the workers’ unions under the umbrella of the Trade Union Action Unit (UAS) are expressing concerns and complaints about the process of implementing the RAMU. Indeed, the UAS fears that contributing to the RAMU will further reduce the already very low purchasing power of workers, without guaranteeing them quality care in case of illness due to recurrent problems in the health system which the State would be slow to solve. Furthermore, the UAS would not have been involved in some key decisions relating to the RAMU, such as its adoption and the definition of the healthcare package, even though its advocates would have been major contributors. In order to restore and maintain trust between the State and the UAS and thus overcome resistance to the implementation of the RAMU, strong transparency and social as well as financial accountability mechanisms would need to be put in place to govern the actions of the RAMU. With regard to social accountability, the civil society should be strengthened and given a mandate for citizen monitoring. As for financial accountability, this should be based on the action of credible and independent control structures such as the Higher State Control and Anti-Corruption Authority (ASCE-LC). The challenges outlined in this blog are not exhaustive but could constitute obstacles to the implementation of the RAMU. Therefore, addressing these challenges in an appropriate manner would ensure that the scheme is acceptable and sustainable.
Orokia Sory is a research assistant at RESADE (Ouagadougou, Burkina Faso). She is a macro-economist by training and an expert in public health, specifically health policies and systems.
Yamba Kafando is a health geographer, expert in health financing, health policy and systems analysis. He is currently Director of Operations and Researcher at RESADE.
Charlemagne Tapsoba is a researcher at the Centre de Recherche en Santé in Nouna (Burkina Faso) and an associate researcher at RESADE (Ouagadougou, Burkina Faso). His main field of interest is health policy and systems research. He has conducted several studies in the field of strategic purchasing.
Issa Kaboré is a medical doctor and research assistant at Recherche pour la Santé et le Développement (RESADE) (Ouagadougou, Burkina Faso). He was a front-line worker in the fight against COVID-19 in Burkina Faso.
Joël Arthur Kiendrébéogo is a doctor, health economist, lecturer at the Joseph Ki-Zerbo University and associate researcher at RESADE (Ouagadougou, Burkina Faso). He is currently doing a PhD thesis in public health at the Institute of Tropical Medicine (ITM) in Anvers (Belgium) and the University of Heidelberg (Germany) on learning processes in health financing policies and, more specifically, strategic purchasing in Burkina Faso’s health sector.