African countries have made significant strides towards universal health coverage, which ensures every individual, regardless of economic status, can access quality medical services.
A global rise in the cost of living has been felt acutely across Africa. Universal health coverage can address financial, social, and health-related challenges.
In 2015, the United Nations General Assembly adopted universal health coverage as one of the sustainable development goals (SDGs). Achieving universal health coverage contributes to social inclusion, equality, poverty eradication, economic growth, and human dignity.
Universal health coverage is essential in low- and middle-income countries (LMICs) as it addresses the financial, social, and health-related challenges faced by individuals and communities. It helps ensure equitable access to healthcare services, improves health outcomes, supports economic development, and contributes to the achievement of broader development goals.
The world has faced a series of crises in recent years, ranging from the covid-19 pandemic to the more recent war in Ukraine, which have put immense pressure on healthcare systems and caused damaging economic disruptions. LMICs have not been spared the spillover effects; the global rise in prices and general cost of living has been felt acutely across Africa.
Universal health coverage is essential in low- and middle-income countries (LMICs) as it addresses the financial, social, and health-related challenges faced by individuals and communities.
In this context, medical experts agree that establishing robust and adaptable healthcare systems, with primary healthcare at their core, can enhance health equity, effectively address current health issues, and enhance readiness for future health emergencies in a region that has historically struggled with infectious diseases and outbreaks.
Rwanda’s success story
Rwanda, often regarded as a success story in healthcare transformation, has made remarkable progress toward universal health coverage. Following the devastating genocide against the Tutsis in 1994, the country faced severe healthcare challenges. “In 1995, there were about 30 medical doctors in the whole country. The rest were just foreign humanitarians. And, of course, in the years that followed the genocide, the country was dealing with a lot of diseases and trauma; physical trauma, mental health issues, neonatal issues, maternal issues...” explains Dr Nkeshimana Menelas, vice-president of Rwanda Medical Association.
“But as the years progressed, we witnessed that the system was transforming and providing more and more access to healthcare to people across communities.”
In 2010, the country implemented a comprehensive health insurance scheme known as Mutuelles de Santé, whereby community health workers guide patients on ways to access services at health posts, district hospitals, regional hospitals, and eventually national hospitals. This referral pathway ensures patients receive appropriate care based on the complexity of their condition.
The Ministry of Health oversees 426 programmes of Mutuelles de Santé through a decentralised approach that relies on local community health structures. Within this system, 1,179 health posts are spread across the country to deliver essential health services to communities that lack access.
To join the scheme, individuals pay an annual fee based on their household income category, ranging from FRw3,000 (US$3) to FRw7,000 (US$6). No-cost memberships are offered to people unable to pay. Individuals also contribute 10% of the cost of the healthcare services received.
“An individual [may be] required to pay US$3 for an annual subscription,” says Dr Vincent Mutabazi, director at the Ministry of Health Rwanda. “This may not sound like a lot, but it becomes cumulative, especially in bigger families where you need US$3 for each member. Then it’s not easy to pay.”
But both medical experts agree that the system has found considerable acceptance among the Rwandan population and highlight the importance of community involvement. Community health workers act as a bridge between the population and healthcare facilities, educating and guiding them. The scheme now covers over 90% of the population, making Rwanda one of the few African nations to achieve near universal health coverage.
However, like any ambitious healthcare endeavour, Rwanda's experience, too, is marked by limitations and challenges.
The sustainability challenge
One of the primary challenges facing universal health coverage in Rwanda is ensuring its financial sustainability. The Mutuelles de Santé programme partially relies on contributions from individuals. But as healthcare costs rise and the population grows, sustaining adequate funding for universal health coverage becomes a crucial issue.
According to Mutabazi, this notably means reducing reliance on external funding and increasing domestic funding for health programmes. “Over the last couple of years, we’ve witnessed a decrease in international funding availability. So, in the next couple of years, certain funding programmes may not be available. Context-specific solutions and targeted investments in the health sector are also crucial for continued progress,” he explains.
Menelas emphasises that the healthcare system must remain adaptable to the changing needs of the population and evolving disease patterns. “Within the bottom-up system, at the referral hospital, for example, you’ll come across many patients with advanced cancer,” he says.
“This means the disease is at a high incidence, but also that detection services are misplaced because the health posts across provinces provide rudimentary healthcare. You need them to detect this kind of disease much earlier because treatment for advanced cancer is going to be very expensive.”
According to the experts, the system will eventually be marred by inefficiency if it remains rigid. In other words, bypassing the hierarchy of care for specific conditions or decentralising certain services is necessary to improve healthcare delivery in the long run.
Equity through public health insurance
In West Africa, a number of countries have built a mixed universal health coverage system that includes contributing and non-contributing recipients. Since 2013, the Senegal government has set up a programme to democratise health insurance—those with low income are offered health insurance to access healthcare. Today, about 53% of Senegalese are covered by the universal health programme, according to the latest survey by CMU, Senegal’s national agency for universal health coverage.
“The idea was to reach the informal sector and rural Senegal. These communities today make up more than 90% of those with health insurance,” says Dr Mamadou Selly Ly, director of legal affairs and partnerships at CMU.
"The poor, who are supposed to be 100% covered, are not fully protected and still have to go through administrative complexities. They end up paying something too.”
The Senegalese model is a community-based health insurance scheme that includes a general scheme that is partially subsidised, and a special scheme for low-income people that is fully financed by the state for registration and care. As in a few other African countries, this special health insurance scheme for low-income people is supported by the World Bank.
However, Selly Ly believes such a system does not achieve what it sets out to do. “What we're experiencing today in all the countries that have moved towards community-based insurance systems, inspired by the Mutuelles de Santé, is fragmentation,” he says. “In effect, the poor, who are supposed to be 100% covered, are not fully protected and still have to go through administrative complexities. They end up paying something too.”
When a person moves or travels to a different location, for example, they may encounter challenges in accessing the same level of coverage and benefits that they did in their original location. Other issues include increased out-of-pocket expenses and potential disruptions in continuity of care, particularly for people who frequently travel or relocate.
A recent study co-authored by Selly Ly and published in the British Medical Journal found that fragmentation of insurance schemes and differences in coverage packages across localities and income groups were hindering universal health coverage across the continent. As a result, it recommended financing universal health insurance through taxes, such as consumption taxes.
“The poor in many African countries represent around 40% of the population, and live on very little income. We should make sure that these people don’t have to pay any medical expenses because they simply cannot afford it. We need a complete paradigm shift,” Selly Ly says.
Overall, his literature review indicates that public health insurance is more likely to contribute to universal health coverage objectives over community-based health insurance due to factors that include cost efficiency, care portability, transparency, and reduced fragmentation. Nevertheless, more research, including comparative studies on the impacts of coverage schemes in different countries, is necessary to further validate these findings.
Universal health coverage alone is not the solution
Experts agree that achieving universal health coverage alone will not translate into health equity.
As such, the West African country of Ghana has placed technology at the centre of its healthcare reforms. It has, for example, leveraged innovation to streamline service delivery, improve diagnostics, and reduce fraud.
For the last few years, healthcare tech company Redbird has been working to ease the burden on hospitals in Ghana, helping pharmacies diagnose and monitor chronic and tropical diseases by storing user information on an app.
At the height of the pandemic, drones transported test samples of suspected covid-19 cases to laboratories in major cities. This aimed to speed up diagnosis and assist authorities in monitoring and responding to potential outbreaks.
Ghana has placed technology at the centre of its healthcare reforms, helping to streamline service delivery and improve diagnostics.
Leveraging technology to enhance healthcare delivery, data management, and telemedicine remains crucial across Africa. Rwanda has been actively pursuing partnerships and adopting digital health solutions to bridge gaps and expand universal health coverage.
The East African country is also tackling the issue of shortage of healthcare professionals, which is faced by other African countries too. Many highly skilled healthcare professionals from Africa migrate to other countries, primarily due to better opportunities, working conditions, and higher salaries. This brain drain depletes the pool of qualified healthcare workers in Africa.
Furthermore, the scarcity of training institutions for healthcare professionals contributes to the shortage. There is a lack of medical schools, nursing programmes, and other healthcare training facilities, particularly in rural areas.
“The Human Resources for Health programme in Rwanda was designed to build clinical capacity, train specialist doctors, and ensure that their skills are applied and remain within the country,” Mutabazi says.
“Traditionally, what has been happening is that people went outside to study and came back. But there's been a push to have a number of these specialised health practitioners train within the country as well, because that is within the scope of attempts to build not only a wider base for healthcare providers, but also improve the quality of services.”
Through the Human Resources for Health programme, efforts have been made to increase staff numbers through initiatives such as graduate programmes and strategic placement of staff.
The journey towards achieving universal health coverage in Africa is complex, but there has been progress across the continent. Rwanda's success in near universal coverage, Ghana's focus on innovative digital solutions, and other countries’ experimental approaches demonstrate that political will, community engagement, technological innovation, and efforts to address systemic inequalities are critical factors in advancing universal health coverage.
As African nations continue their efforts, it is crucial for international partnerships, knowledge sharing, and sustainable financing mechanisms to support the continent's quest for comprehensive healthcare for all.