People expect their health systems to be equitable. The roots of health inequities lie in social conditions outside the health system’s direct control. These root causes have to be tackled through intersectoral and cross-government action. At the same time, the health sector can take significant action to advance health equity internally. The basis for this is the set of reforms that aims at moving towards universal coverage, i.e. towards universal access to health services with social health protection. Health inequities also find their roots in the way health systems exclude people, such as inequities in availability, access, quality and burden of payment, and even in the way clinical practice is conducted.
The fundamental step a country can take to promote health equity is to move towards universal coverage: universal access to the full range of personal and non-personal health services required, with social health protection. The technical challenge of moving towards universal coverage is to expand coverage in three ways (see figure).:
- The breadth of coverage – the proportion of the population that enjoys social health protection – must expand progressively to encompass the uninsured, i.e. the population groups that lack access to services and/or social protection against the financial consequences of taking up health care.
- The depth of coverage must also grow, expanding the range of essential services that is necessary to address people’s health needs effectively, taking into account demand and expectations, and the resources society is willing and able to allocate to health. The determination of the corresponding “essential package” of benefits can play a key role here, provided the process is conducted appropriately.
- The height of coverage, i.e. the portion of health care costs covered through pooling and prepayment mechanisms, must also rise, diminishing reliance on out-of-pocket copayment at the point of service delivery. Prepayment and pooling institutionalizes solidarity between the rich and the less well-off, and between the healthy and the sick. It lifts barriers to the uptake of services and reduces the risk that people will incur catastrophic expenses when they are sick. Finally, it provides the means to reinvest in the availability, range and quality of services.
This section on Universal coverage is structured as follows:
The public and private not‐for‐profit health‐care system serves 85% of the Namibian population and is accessed by the lower income population. The private for‐profit health‐care system serves the remaining 15% of the population, consisting of the middle and high income groups.
Organizational framework of universal coverage
Overview of main actors and arrangements related to universal coverage
The 2008 HSSR recommended a feasibility study for universal coverage (free health services through universal insurance scheme), which is one of the principles of the government’s Primary Health Care approach to public health.
Universal access to HIV prevention, treatment, care and support services has been a development priority for the Namibian government for the last 10 years, and is still a goal.
Specific regulatory framework
- Health mapping and geographical coverage
- Health financing strategy towards universal coverage
- Breadth – extending the target population
- Depth – expanding the package of services
- Height – reinforcing protection against financial risk
- Transversal challenges of universal health financing
- Other initiatives towards universal coverage
Barriers on access to health services
The vastness of country causes geographical accessibility challenges, high opportunity cost and lack of transport. Out of the 295 clients interviewed upon exit from the 76 health facilities, 41.5% had travelled for less than 5 kilometres, 27% travelled for 5-10 kilometres, 8% 11-20 kilometres and 13% travelled for greater than 21 kilometres.
Although Namibia is an upper middle‐income country, the socioeconomic inequalities are significant. Policies that remove financial barriers to access to health care exist but need to be strengthened.
Fees vary between different health facilities and range from N$ 4 (clinic level) to N$ 30 (national referral) for state outpatient patients, inclusive of all services received. Foreigners are classified as private patients and this has become problematic especially in regions bordering other countries as people visiting the nearby facilities from our neighbouring countries do not have the means of payment for private services.
Exemption for the payment of user fees is provided for certain services i.e. notifiable diseases, preventive and promotive services and for vulnerable groups such as children under five and pregnant women. Furthermore, its government policy not to turn away patients that are unable to pay and waiver mechanisms is in place. However, the implementation is problematic as the mechanisms for waiver are cumbersome and may deter patients in need of care.
The data series in the 2010 NHA reveal the burden of financing and illuminates fairness of health financing and financial protection particularly with regard to household out-of-pocket expenditures. There is an insurance scheme providing health insurance for public sector employees. Private insurance companies provide health insurance policies for private sector employees. Endnotes: sources, methods, abbreviations, etc.