Towards universal health coverage (UHC): Government of Benin expanding health coverage to the extreme poor

Before “Assurance pour le renforcement du capital humain” (“Insurance for strengthening human capital”) or ARCH was launched in 2019, the national health insurance scheme in Benin was characterized by a user-fees policy which had adverse effects on the demand for health services. This led to the poorest being unable to access and/or pay for such services when they needed them most. To combat this, the ARCH programme was set up with the ultimate goal of stimulating socioeconomic growth. The programme entails a package of four integrated services including training, credit and retirement insurance, with health insurance as the programme’s main component. WHO Benin supported the national authorities to design a more holistic approach for social insurance by assessing the one-year pilot phase of the health insurance component and formulating recommendations for its scaling up. As of December 2022, a total of 867 944 individuals from the poorest strata had been identified and enrolled into ARCH and now benefit from free treatment in public health facilities in Benin. The state subsidizes up to 100% of contributions for this population.

How did Benin, with the support of the WHO Secretariat, achieve this?

Health insurance is a mechanism by which individuals can access a range of quality health services without incurring serious financial hardship. This is a critical element for Universal Health Coverage (UHC). Every country adopts a different path towards UHC after considering which health services to cover based on population needs and in the light of available resources. However, the importance of access to health services as a basic human right is universal. In Benin, prior to development of the ARCH, the health financing system was severely fragmented and not yielding the expected outcomes. Contributary schemes for the salaried formal sector coexisted with voluntary community-based health insurance, but these schemes proved to be non-synergistic. Before 2016, only 8.4% of the population was covered by health insurance, which was mainly addressed to civil servants and other salaried staff. It was inefficiently managed by the state often with exorbitant transaction costs 1. There were no compulsory schemes for the private sector and no large-scale, operational social protection mechanisms in place for the informal sector. Although the informal sector contributes about 68% towards gross domestic product, it is typically composed of people in the lowest socioeconomic strata who have difficulty accessing basic social services.

In 2020, the WHO Benin Country Office and Regional Office for Africa supported the national authorities to conduct a review of the pilot phase of the health insurance component of the ARCH programme. This was done by screening key UHC aspirations and targets in collaboration with the Regional Public Health Institute (Institut Regional de Santé Publique Comlan Alfred Quenum or IRSPCAQ). This assessment identified key challenges and formulated recommendations for effective scaling up of the health insurance component, which included:

• the importance of extending the access to health insurance benefits to the most vulnerable groups such as the extremely poor in order to reduce out-of-pocket costs as a significant barrier to care-seeking in this group;
• the necessity of expanding the fields of service to be included in the basket of health care services;
• the need to put in place timely and responsive reimbursement mechanisms for health facilities; 
• and the requirement to improve communication about the health assurance component at the community and grassroots levels.

With the support of other technical and financial partners, the scaling up phase for ARCH’s health insurance component was expanded to the most vulnerable groups, in line with the assessment recommendations. Early successes of this scaling up phase include extension of the scheme from three health zones in seven municipalities to all 34 health zones in the 77 municipalities of the country to achieve greater financial protection against the impoverishing cost of illness and reduce social exclusion from organized health financing instruments. As of December 2022, a total of 867 944 extremely poor persons have been identified out of a target of 1 000 000 (representing 86.79%), enrolled in the health insurance system and given a health insurance card. They are now able receive free treatment in public health facilities in Benin. The state subsidizes up to 100% of their contribution.

I was involved in a serious car accident “ with multiple fractures and my family could not afford emergency care. But thanks to the health insurance card, I was able to be taken care of immediately and free of charge. During the days following my treatment, I had to undergo surgery due to complications. Both the surgery and the prescribed medication were free.” - Ms Laurence KPAKPO, 20-year-old beneficiary.

Thanks to the leadership of the government through the Ministry of Social Affairs and Microfinance and ongoing reform of the health sector through the Government Action Programme 2021–2026, national laws governing social and health protection have been amended (Law 2022- 07 of 4 October 2022 amending Law 2020-037 of 3 February 2021) to include compulsory subscription in insurance mechanisms for all workers in the formal and informal and public and private sectors as of 1 January 2023. This was made possible due to the findings of the pilot-phase assessment of the ARCH programme. In addition, the institutional organization of the Agence Nationale de la Protection Sociale (National Agency for Social Protection) or ANPS, created in 2019, was revised to lead the practical implementation and governance of the ARCH programme. 

The basic basket of health care services has been extended, based on WHO guidance, to cover 22 medical conditions including diarrhoeal diseases, intestinal parasitosis, malaria, dermatological treatments, respiratory infections and other infections for children under age five, birth control, abdominal surgery, surgical emergencies and trauma. These represent 75% of the most common health problems affecting the Beninese population.

“ Regarding this basket there are three levels. The basic health care basket is about primary health care and has been accessible to the identified extreme poor from the pilot phase to the extension phase.” - Dr Atade NAWANA, Coordinator of the Health Zone Abomey Calavi/Sô-Ava

For its next steps, the government is planning to extend health insurance coverage to persons in the informal sector including farmers, merchants, carriers, craftsmen and artists in order to move towards universal health insurance for all. WHO Benin will be implicated in helping to identify these populations prior to their enrolment.

Knowledge

WHO country stories: delivering for all

“This impact story was published as part of the WHO country stories: delivering for all report, which presents a snapshot of how WHO has delivered on its mission in countries and contributed to health outcomes across a wide range of issues during 2022-2023.”