Breaking the Deadlock Using Private Health Insurance Schemes Chris van der Vorm & Joep M.A. Lange Health Insurance Fund PharmAccess Foundation Center for Poverty-related Communicable Diseases Academic Medical Center / University of Amsterdam

Price reduction of antiretrovirals (Accelerating Access Initiative, etc) (2000) Declaration of Commitment of the UN General Assembly Special Session on HIV/Aids (2001) $48bn US grant for Aids, tuberculosis and malaria over a period of five years (2008) Milestones in Bringing HAART to Resource Poor Settings

Aids Response Creates Island of Sufficiency in a Swamp of Insufficiency * Gorik Ooms, MSF

Major Challenges Limited capacity local governments 50-70% of healthcare expenditures financed out-of-pocket * –Leads to financial shocks –Minimal risk sharing –Limits investments Crowding out effect * WHO, 2006

Health Insurance Risk- pooling Risk sharing between different population groups Limit financial shocks Pre-paid financing Predictable and sustainable financing Reduced financial risk  facilitation of investments Prevent crowding out Utilize existing out-of-pocket resources

Health Insurance Fund Not-for-profit, established in 2005 –Subsidized Community Health Schemes –Executed locally by HMOs/Insurers Board of Directors chaired by Kees Storm –Others include former Dutch Minister and CEO’s of 5 largest Dutch insurers and banks PharmAccess contracting agency €100m grant from Dutch Ministry of Foreign Affairs –6 years / 4 African countries Potential Grant from World Bank –Further funding sought Operational Research

Our Vision Sustainable systems of healthcare delivery and financing, by introducing private health insurance for people with low / medium income in Africa

Key Characteristics Subsidized Premiums Stimulate demand Decreasing premium/ co-payment over time Delivery Quality and Capacity Upgrading of clinics and hospitals Ongoing monitoring and evaluation Local Embedding Commitment local champions Coordination public programs Data Collection/ OR Medical and financial data Program improvement Output-based Contract Accountability Transparency

Health Insurance Fund in Nigeria Target population > 200,000 people –75,000 farmers in Kwara State –40,000 market (wo)men in Lagos –70,000 farmers in Kwara State* –30,000 ICT workers in Lagos* Current scheme enrollment –> 40, clinics and hospitals –14 upgraded to date; others to follow –Three rounds of monitoring and evaluation conducted * In development

“Before”

“After” Increase in utilization from 1,500 patient visits per month (Shonga Clinic, Kwara State)

Enrolment Station in Lagos, Nigeria

Community Enrollment

Acknowledgements PharmAccess Foundation Onno Schellekens Max Coppoolse / Mayte Oosterveld Michèle van Vugt Hygeia HMO Professor Elebute Fola Laoye Kwara State Government Center for Poverty-related Communicable Diseases Professor Joep Lange Amsterdam Institute for International Development Professor Jacques van der Gaag Dutch Ministry of Development Corporation Aaltje de Roos Representatives of DDE and DSI