https://orcid.org/0000-0003-3317-1319
ABSTRACT
There is a growing political interest in health reforms in Africa, and many countries are choosing national health insurance as their main financing mechanism for universal health coverage. Although vaccination is an essential health service that can influence progress toward universal health coverage, it is not often prioritized by these national health insurance systems. This paper highlights the potential gains of integrating vaccination into the package of health services that is provided through national health insurance and recommends practical policy actions that can enable countries to harness these benefits at population level.
Background
Current health sector reforms across the World Health Organization (WHO) Africa region are causing a paradigm shift toward sustainable health financing, with several countries adopting national health insuranceCitation1. Health financing refers to the process of generating revenue, pooling of funds, and allocation of funds to health care providers so that people can have access to quality health care services without suffering financial hardship.Citation2 It is said to be sustainable if the funding source is predictable and sufficient, and used in a transparent manner to support the provision of quality health services.Citation3 The choice of national health insurance stems from the urgent need for countries in the region to fast-track their progress toward universal health coverage.Citation4
Universal health coverage is a global agenda to make quality health care services accessible to everyone without causing them financial hardship.Citation5 This is why national health insurance schemes are operated by the central government and seeks to cover the entire population using revenues generated through contributions by or on behalf of insured residents.Citation4 They are more advantageous than social health insurance schemes that cover only the formal sector (a small subset of the population).Citation6 As shown in , at least eight countries in the African region (namely, Cote d’Ivoire, Gabon, Ghana, Kenya, Rwanda, Nigeria, Tanzania, and Zambia) have fully established their national health insurance, and several other countries (such as Burkina Faso, Cameroon, Ethiopia, Gambia, Mali, South Africa, Togo, and Uganda) are in the process of establishing one.Citation4,Citation7
Table 1. Health insurance in African countries.
Some countries with national health insurance schemes are already observing progress in some intermediate health outcomes, signifying improvement in the primary health care functions of the health system.Citation14 A study that was conducted in Ghana suggests that the comprehensive benefit package of the national health insurance scheme is improving access to essential medicines and reducing stock-outs.Citation15 Malaria care is one of the health care services that is included in the Ghanaian benefit package, and this has significantly increased care seeking and treatment among childrenCitation16 with associated improvements in service quality.Citation14,Citation17 Women who are enrolled in national health insurance have higher antenatal care visitsCitation18 and hospital deliveries.Citation19 There is also evidence to suggest that national health insurance schemes improve access to child health care.Citation20 Furthermore, there is a positive relationship between possession of health insurance and the health-care-seeking behavior of beneficiaries.Citation21
Although vaccination is an essential primary health care serviceCitation22 and arguably the nucleus of universal health coverage, the extent to which it is financed through national health insurance in the African region is unclear and difficult to track. Investing in childhood vaccination is a good use of public funds because its net return is estimated to be about 44 times higher than the cost.Citation23 Furthermore, it contributes to improving population health outcomes which are central to universal health coverage. In the African region, vaccination alone averted 14.4 million deaths between 2011 and 2020, and is projected to prevent 23 million deaths between 2021 and 2030.Citation24
Vaccination and universal health coverage
Vaccination serves as a bridge between the population and the primary health care system. Therefore, efforts to continuously strengthen equitable access to vaccines and ensure quality vaccination services within the framework of primary health care, as well as guarantee financial risk protection from health care cost associated with common vaccine-preventable diseases can advance progress toward universal health coverage. But the success of these actions is dependent upon community partnership and effective implementation of primary health care interventions as well as the sustainable financing for the primary health care system and vaccination. illustrates how all these elements connect with each other. Linking vaccination to universal health coverage has policy implications for national health insurance. This is because from a political standpoint, “universal coverage” can justifiably be translated to also mean “universal right to vaccines” that people need to attain and maintain good health and optimal wellbeing.Citation2 In this case, it then becomes imperative for national health insurance to diversify from sick child care (which is what is typically covered in most countries) to vaccination.Citation7,Citation20
Figure 1. A conceptual model of the linkage between vaccination and universal health coverage.
Such change can have substantial benefits for the health system. If pooled funds from national health insurance are harnessed to co-finance the immunization program, it can increase the availability of a broad range of new and underutilized vaccines that are recommended for use in national immunization schedules for insured individuals, thereby expanding vaccination in the primary health care system to cater for people’s needs throughout their life course.Citation25 Furthermore, health insurance already engages providers in the private health sector for primary care services,Citation7 and if vaccination is included in provider contracts, it can promote closer collaboration between the public and private health sectors, thereby aiding private health sector integration into the primary health care system. If achieved, this will not only expand the availability of vaccination services at service delivery points in private health facilities but also strengthen surveillance of vaccine-preventable diseases and reporting of adverse events following immunization. In addition, it can expand the fiscal space for primary health care using domestic resources, which will allow the implementation of evidence-based, context-specific strategies to improve primary health care service delivery at scale and subsequently, immunization coverage. Moreover, available evidence suggests that health insurance is linked with community confidence in the health system, and if extended to cover vaccination,Citation26 can serve as an opportunity to foster stronger community partnerships with primary health care. The convergence of all these gains can have a multiplier effect in the health system.
Immunization expenditure and budget deficits
Most immunization programs in the African region are already underfunded and will certainly require additional domestic financing to be able to meet the global goals indicated in the Immunization Agenda 2030 (IA2030).Citation3 IA2030 is the strategic framework for immunization from 2021 to 2030 adopted by the World Health Assembly.Citation27 On average, the African region spends about US$41 on routine immunization per surviving infant which translates to about US$1.3 per capita.Citation28 In fact, immunization expenditure accounts for only 1.3% of the region’s current health expenditure.Citation28 Immunization is mainly financed through budgetary allocations,Citation29 with additional funding from international development assistance.Citation30 Even when these funding sources are combined, a budget deficit often persists.Citation31
The COVID-19 pandemic disrupted vaccination services and caused an increase in the number of underimmunized and unimmunized children in the African region.Citation32 Overall coverage with three doses of diphtheria-tetanus-pertussis containing vaccine (DTP3) decreased from 77% in 2019 to 72% in 2022.Citation33 The WHO-United Nations Children’s Fund (UNICEF) Estimate of National Immunization Coverage (WUENIC) data suggests that the African region cumulatively gained 29 million zero-dose children from 2019 to 2022.Citation33 Substantial financial investment is urgently needed for countries to reach those that were missed from vaccination during COVID-19, restore immunization coverage to pre-pandemic levels, and strengthen their health system to attain the IA2030 targets.Citation34
Unfortunately, the possibility of securing higher budgetary allocations for immunization is unpredictable as many countries in the region are confronting multiple challenges that are draining their resources. For instance, the rising prevalence of non-communicable diseases is putting additional pressure on the health care system.Citation35 Furthermore, there is a decline in foreign direct investment in many African countries, and this is affecting economic growth in the region.Citation36 Countries have to resort to foreign loans with attendant capital flights during repayment.Citation37 For this reason, many countries in the region are now facing a foreign debt crisis that is complicated by debt accumulation and budget deficits.Citation37 In fact, government debt to Gross Domestic Product (GDP) ratio in 2022 is as high as 127.6% in Mozambique, 106.8% in Zambia, and 90.8% in Angola.Citation38 Also, the conflict in Europe is precipitating a food crisis in the African region,Citation39 thus necessitating quick investment in efforts to improve food security. Additionally, wars and insurgencies in the West African Sahel are forcing more spending on defense.Citation40
Leveraging funds from national health insurance to co-finance vaccination
If countries consider vaccination as a core component of their universal health coverage objectives, it can pave way for their universal health coverage financing arrangements such as national health insurance to be leveraged to fund vaccines and vaccination services. This will increase domestic financing for vaccination and address (to a certain extent) the budget deficit that countries are currently faced with. Indeed, there are concerns about the deficiencies in enforcement of mandatory health insurance to increase their risk pools in countries that use the contributory models.Citation41 There is a need for countries to employ more innovative strategies to stimulate voluntary enrollment or adopt a tax-based model and automatically enroll the entire population.Citation42 Enrollment varies widely in countries with national health insurance in the African region, from less than 10% in Nigeria to almost 80% in Rwanda.Citation43 Nonetheless, this should not necessarily discourage health systems strengthening efforts to position national health insurance to cover critical preventive care like vaccination. After all, enrollment is a journey, and it is subject to the influence of political economy.
Channeling the revenues that are generated through contributions (i.e., pooled funds) for national health insurance to vaccination will require a set of policy levers collectively known as strategic health purchasing to be operationalized.Citation44 Strategic health purchasing is not a new concept in Africa, as there is evidence to suggest that national health insurance schemes in countries like Cote D’Ivoire,Citation45 Gabon,Citation46 Ghana,Citation47,Citation48 Kenya,Citation9,Citation49–53 Rwanda,Citation11,Citation54 Nigeria,Citation10,Citation55,Citation56 Tanzania,Citation57 and ZambiaCitation58 are using it to achieve their objectives of improving access to quality health care services. These policies are required to enable the purchaser (national health insurance) to determine the services to buy (e.g. including vaccines and vaccination services in the health benefit package), who to buy it from, and how to pay for it.Citation59
What to buy
National health insurance schemes in the African region have benefit packages.Citation60 The health services that are specified in these benefit packages vary between countries, but typically have a combination of the priority primary and secondary care that is needed by the people.Citation9,Citation11–13 However, there has been poor progress toward specification of services that are covered by vertical health programs in benefit packages.Citation61 Considering the public health value of immunization,Citation24 it is recommended that it should be prioritized in all the benefit packages of national health insurance schemes in the African region. Critical decisions on which vaccines to deliver should be made jointly with the national immunization program and guided by the national immunization strategy of the country and WHO recommendations. Indeed, several vaccines are recommended for use in the national immunization schedule which offer protection from various vaccine-preventable diseases at every stage of people’s lives. However, in settings where health insurance coverage is not yet optimal,Citation43 the schemes can prioritize routine childhood immunization to maximize the allocative efficiency of available funds. Of course, it is essential to do a cost assessment for vaccines and vaccination services before specifying it in the benefit package to have a good understanding of its financial implication vis-à-vis the existing pool. Some countries have made progress in this regard as they have already specified routine immunization in their benefit packages. Examples of such countries in the African region include Nigeria,Citation10 Kenya,Citation9 and Rwanda.Citation11 To ensure that this benefit package specification translates into actual service provision, contracting arrangements and payment mechanisms must also be put in place.Citation44
From whom to buy
Once vaccination is included in the benefit package, the health insurance scheme will need to decide on the modalities for purchasing recommended vaccines and vaccination services. For services like malaria or diarrhea, schemes have contracting arrangements in place with selected providers to offer the needed care as specified in their benefit packages.Citation47,Citation53,Citation57 These providers can then source for the medicines and other consumables that are required to offer quality services. However, vaccines, which is the main input for vaccination services, are procured in bulk for the country and distributed to health care providers through the immunization program.Citation62 National immunization programs receive funding through national budgets and donors, albeit inadequate to perform these functions. This means that frontline health workers rely on the program for the vaccines that they administer. Considering this preexisting structure, and the fact that national health insurance in most African countries is still evolving, it might be more feasible for national health insurance to purchase vaccines and vaccination services from the national immunization programs. Of course, this will need to be operationalized through contracting agreements. The terms of the contracting agreement can specify the kinds of incentives that should be transferred to frontline providers who administer the vaccines. This will effectively establish national health insurance as a co-financing mechanism for vaccination.
How to buy
A tailored provider payment system for vaccination will need to be established. This payment system should specify the payment mechanisms that will be used to transfer funds to the national immunization program for vaccines and frontline health workers for vaccination services. In addition, it should encompass a performance management information system to enable the tracking and monitoring of all levels of payments, service utilization, quality of care, client feedback, and accountability processes.Citation44 Where possible, this should be integrated into the existing health management information system within countries. The payment method should be differentiated for vaccine procurement and supply at the national level and vaccination service provision at the health care facility level. A prospective payment method like global budget can be used for vaccine procurement and supply, but at provider level, payment should be retrospective and output based. Pay-for-performanceCitation63 may be considered for service providers to incentivize efficiency, quality services, and utilization. This can motivate health care facilities to integrate vaccination with other primary health care services, and deploy strategies like active review of vaccination history at every service delivery point to identify and vaccinate unimmunized and underimmunized children.
A proposed collaboration framework for vaccination co-financing by national health insurance
Accomplishing all these strategic purchasing functions for vaccination requires complex interactions with multiple stakeholders, which can be somewhat difficult to navigate. Therefore, a collaboration framework is required to provide general guidance on points of synergy, accountability, and fund flow when effecting intergovernmental fund transfer between national health insurance and the immunization program. Countries need to contextualize their framework to fit their system. A general blueprint that outlines the linkages and responsibilities of the various health systems components that interact to provide routine immunization is shown in . It builds on the existing operational models for immunization programs, but expands the financing options beyond national budgets and development assistance, to include national health insurance. It recognizes budget constraints, low health insurance coverage, and weak public financial management systems as the critical proximal determinants of the fiscal space for primary health care and vaccination. The national immunization program functions as a coordinating agent as it receives funds through multiple sources and transfers them to intermediary agents. These intermediary agents include platforms where vaccines and consumables are procured, and sub-national institutions that directly manage primary health care facilities. The institutions that manage primary health care facilities should be responsible for handling the provider's performance-based payments. Fund flow should be accompanied with a clear technical guidance for fund use. An accountability feedback process from health facilities to the national immunization program is specified as it will ensure that funds are used for what they are meant for. This proposed conceptual framework should be tested and refined according to country context before use.
Figure 2. Proposed NHI-NIP collaboration framework for financing vaccination.
Recommendations
There is an opportunity to increase domestic financing for vaccination through national health insurance in the African region. Countries with national health insurance are already allocating pooled funds to essential health care services.Citation7 With political will, these funds can also be extended to cover recommended vaccines and vaccination services. Countries need to urgently initiate feasibility studies to gain a better understanding of how to operationalize this funding option for vaccination, taking into consideration their health insurance coverage.Citation43
Countries that have already specified routine immunization in their health benefit packages should intensify efforts toward implementing the other relevant policies to enable the immunization programs to actually access funds from national health insurance. This is even more urgent for countries like Kenya and Nigeria that are in Gavi’s accelerated transition phase, to avoid disruption of vaccination services in the post-transition period.Citation64 Countries can learn from Thailand, which has made significant advancements in positioning its national health insurance scheme as the main purchaser of vaccines and vaccination services.Citation65
Core immunization partners in the African region such as Gavi, WHO, and UNICEF among others have an important role to play in advocating for high-level policy reforms to explicitly position vaccination as part of the UHC objectives for countries. These partners can also enhance the technical capacity of immunization program managers on strategic health purchasing within the context of national health insurance so that they can effectively contribute toward advancing strategic purchasing functions for vaccination in their countries. This necessitates more investment and technical focus on health systems strengthening and financing for vaccination.
Within countries, there is a need for stronger engagement between national immunization programs and national health insurance schemes, and this requires the commitment of high-level political leadership. National health insurance should be considered a core stakeholder in the planning and design of national immunization strategies to ensure a common understanding of the immunization vision of the country. In fact, immunization forecasting and costing should be done collaboratively with national health insurance to ensure familiarity with the financial and costing tools that are used for immunization as well as gain a better understanding of the immunization market structure. This level of engagement can sway the political economy in favor of routine immunization.Citation66 If successful, countries with active national health insurance that did not include routine immunization in their benefit package will begin to revise such decisions using evidence that is provided by the national immunization program. Schemes that are in the creation phase will be open to receiving technical support throughout the benefit package design process to ensure inclusion of routine immunization. Also, national health insurance will begin to explore ways to improve contracting modalities with the national immunization programs and instituting appropriate payment systems for vaccines and vaccination services.
Going forward, a representative of the national health insurance should be integrated into the National Immunization Technical Advisory Group (NITAG) as a non-core member to serve as a link between the group and the scheme. A health technology assessment (HTA) sub-committee for consideration of life course immunization in UHC-priority benefit package should be created within NITAG to purposefully guide priority setting and decision-making regarding the new and underutilized vaccines that should be included in the national immunization schedule so that individuals can access them through national health insurance.
Conclusion
As countries in the African region create national health insurance schemes as the financing mechanisms for their universal health coverage aspirations, it is important to know that these insurance schemes can fund vaccination just like any other priority health service. But there must be a deliberate attempt to deploy all the necessary policy levers in favor of vaccination. Policymakers in countries that already have national health insurance or are in the process of establishing one must be conscious of the fact that although vaccination is funded by government and sometimes donors as a vertical health program, it does not preclude its consideration in broader health sector reforms. After all, sustainable financing for vaccination invariably promotes universal health coverage. Moreover, countries that are transitioning from donor support need to identify other sources of funding to domestically finance their immunization efforts. Research is needed to understand the implementation aspect of modalities for accessing funds from national health insurance through the national immunization program.
Authors’ contributions
AAA conceptualized the article. AAA, RIJ, IDM, TAE, DN, and CSW reviewed and edited all the drafts. CSW supervised the work.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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