The importance of coordinated and unified approaches towards poverty identification and targeting
Kenya's takeways from the JLN Workshop in Marrakech
Countries all over the world have been working to halve the number of people living in extreme poverty, as set out in the Millennium Development Goals (MDG). This is a daunting task for many developing countries, including Kenya, where 20% of the population lives in absolute poverty. The extremely impoverished are disproportionately affected by ill health and natural disasters among other shocks. As a result, they become sick more frequently. This is further aggravated by the lack of access to health services.
On 24-27 September 2012, several developing countries were invited to a workshop – co-sponsored by the Joint Learning Network for Universal Health Coverage (JLN) – in Marrakech, Morocco to present and discuss the new and innovative mechanisms and strategies they are using to ensure access to essential health services for their poorest populations, and achieve universal health coverage (UHC). Some of the highlights of the workshop were the case studies presented by various countries including; Cambodia, Vietnam, Ghana, Senegal and Benin. Each country addressed the issue of universal coverage according to specific social, cultural, political and economic contexts. These are important considerations for any country that seeks to achieve UHC.
The Moroccan government gave a presentation on the roll out of their medical assistance scheme, RAMED, that aims to cover secondary and tertiary care fees for about 8.5 million Moroccans, according to the official poverty and vulnerability lines of 2004. The scheme was piloted in 2008 and about 60% (420,000) of the eligible population was registered. It was a bold move for the Moroccan government to agree to host the JLN Workshop and open itself up to scrutiny of its newly scaled-up scheme (March 2012) to reach the poorest. However, this afforded them the opportunity to receive feedback and hear from other country experts what they saw as the challenges of the scheme, and where possible, rectify problems to ensure smooth implementation of the scheme.
The issue of universalism vs. targeting approaches to the poor has been a subject of debate in the global arena and was also widely discussed during the workshop. In my view, the approaches are country specific although a mix of the two is possible. For example, in Kenya where political will is not easy to come by, the national health insurance scheme has achieved 100% coverage of the formal sector; the next frontier is the informal sector and the indigents. Considering that the latter categories are moving targets, innovative ways to reach them are being adopted. Case in point, for the informal sector the introduction of innovative revenue collection mechanisms (like mobile money transfers) has proven to be a very successful way of reaching the sector. As for the indigents, a Health Insurance Subsidy Program, funded by Rockefeller Foundation and other development partners, will provide fully subsidized coverage for outpatient care.
The morbidity and mortality ratios in Kenya indicate increased utilization of outpatient services and increased out-of-pocket expenditure by the poorest segments for these services. Thus, the principle of solidarity needs to be embraced to ensure that the national scheme is able to enhance the current benefit package to include a comprehensive outpatient cover. However, considering the backlash that the national scheme faced when new rates were introduced, the available solution is to spur the successful implementation of the Subsidy Program through the involvement of key stakeholders and ensure sustainability of the scheme. This endeavor will be complimented by the Health Bill which was recently approved and it is anticipated that it will be passed into law to bolster the efforts of the national scheme in providing universal health coverage.
A key take away from the workshop for Kenya is the importance of a coordinated and unified approach towards poverty identification and targeting in order to avoid systemic challenges such as leakages in programs. This resonates well, considering that the county governance structure will be implemented after the next general elections in 2013. It also reinforces the need to consider the establishment of an Indigent Health Fund/Health Equity Fund that is financially supported by the Government of Kenya, development partners and contributions from the national scheme.