1. 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

2. 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

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

4. 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

5. 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

6. 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

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

8. 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

9. 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 –> 40,000 23 clinics and hospitals –14 upgraded to date; others to follow –Three rounds of monitoring and evaluation conducted * In development

10. “Before”

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

12. Enrolment Station in Lagos, Nigeria

13. Community Enrollment

14. 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