The Gambia National Health Insurance Scheme: A Panacea for Our Healthcare Worries, Or Another Money-wasting State Enterprise?

By: Malamin Barrow, Biomedical Scientist and Healthcare Specialist

The National Health Insurance Act 2021 (NHIA), which has as its main objective: “To ensure the attainment of universal health coverage in The Gambia,” will go down in history as the most important act of parliament to impact healthcare delivery in the country.

The Hon Minister of Health Dr Amadou Samateh, responsible for initiating and steering the bill through the arduous parliamentary process, will forever be associated with the success or failure of this key healthcare legislation.

The NHIA is an ambitious effort to bring healthcare to all at an affordable cost. In terms of intention, nothing can be more laudable. However, because of its far-reaching impact on the health and well-being of all citizens, we are obliged to subject the Act to scrutiny against the background of intention versus applicability.

Background of Healthcare infrastructure in The Gambia: 

While the majority of healthcare workers are doing their utmost to maintain a semblance of healthcare services, it would not be wrong to say that healthcare delivery in the country has experienced progressive deterioration over the years. From the lack of diagnostic infrastructure, and the unavailability of medicines and medical accessories, to the scarcity of medical consultants, the “minimum standard of medical care” referred to in the act is currently the barest minimum.

It will be inconceivable to ask the public to pay premiums for the existing status quo, which has been variously described as at best deficient, or at worst a “deathtrap”.

Against this background, we are informed that the government of the Gambia has secured a massive 80 million US Dollars for the enhancement of Gambia’s healthcare sector. This is good news, a once-in-a-lifetime opportunity to tackle the healthcare crisis head-on. Every effort must be made to modernize the sector; that is invest in modern diagnostic and therapeutic devices, introduce new sub-speciality clinics, reform the chaotic medical procurement system, improve access for the vulnerable, and introduce modern management systems to ensure continuity of all the improvements.

THE ACT AND ISSUES

A National Health Insurance Authority with all the powers, perks and trappings of a full-blown state-owned enterprise will be created.

PART V 32. Membership of the Scheme 

A resident in The Gambia, who is not a member of a private health insurance scheme, shall be a member of the Scheme. This means access to healthcare in the Gambia will be available to only those who are members of the National Health Insurance Scheme or hold private Health Insurance.

PART V 34. Contributions and Healthcare Equity

1. Except as otherwise provided for in this Act, every resident of The Gambia shall pay the annual contributions determined by the Authority.
2. The Accountant General shall deduct from every public officer an amount equivalent to twenty per cent of the premium based on the net salary.
3. The Government of the Gambia shall meet the cost of the premium, under this Act allowing for contributions referred to under sub-section (2).

This section imposes an annual membership contribution to be determined by the Health Insurance Authority. However, it goes further to say that public sector employees will only pay 20% of the annual contribution which will be deducted from their salary by the Accountant General. The remaining 80% will be subsidized by the government.

Unless refuted by the competent authority, this appears to be creating a discriminatory two-tier access system. The relatively well-off minority receive a subsidy, while the majority, many living on less than a Dollar a day, will receive no subsidy from the government. Furthermore, the act does not appear to address the issue of state-owned enterprises already enjoying lucrative health insurance benefits and yet being allowed to use public sector facilities.

PART VI   48. Sources of money for the Fund

1. The sources of money for the Fund are:
2. Two percentage points of the value of all goods and services purchased in The Gambia.
3. A reasonable amount on the cost of mandatory international health insurance for every air traveller to The Gambia.  

It is unclear from the Act whether the 2% will be in addition to the current 15% VAT levied on goods and services, or whether the state will be content to relinquish the 2% from the 15% VAT for the benefit of the fund.

The Act introduces mandatory Health Insurance for all travellers to the Gambia. This may be fair if the healthcare expectations of the visitors are going to be met. It is worth mentioning that travellers to the Gambia are already paying an unpopular airport security tax of $20 for each inbound and outbound flight. An additional mandatory health insurance charge to the cost of travelling could be the last straw for a struggling tourist industry.

Ethics and conflict of interest: Potential impact on the NHIA

This is a difficult area that many of us tend to shy away from because of our cultural aversion to saying things as they are; in fear of offending a friend, a relative or an elder. I believe that in matters of national importance, we must say and do the right thing irrespective of the consequences.

The NHIA will create a powerful State-Owned Enterprise (SOE), with enormous wealth and key decision-making authority over our health and welfare. Therefore, it must be made to function for the greater benefit of members, and not create a new “fuel coupon” bureaucracy that will spend most of the wealth on administration and management issues.

In that regard, we must face all the moral challenges that confront us in our stride to implement a modern healthcare delivery system. In an environment where a majority of public healthcare employees run their own competing healthcare establishments, some in close proximity to, or even embedded in major public Hospitals; the lack of clear guidelines regarding possible conflict of interest will lead to future complications in the implementation of the NHIA.

Persistent allegations of senior personnel using their roles in public hospitals to poach patients towards their private institutions cannot be ignored. Nor can the fact that the healthcare licensing authority, the MOH, are conflicted by having to make licensing decisions of private institutions and their own possible clinics.

The recent controversy over the alleged paracetamol poisoning of children has shown that regulations relating to the importation of medicines need to be revisited. The proliferation of medicine and drug importers allegedly backed by regulatory authorities has created an environment where the monitoring of fake and counterfeit medicines has been practically abandoned.

With these concerns in mind, it is suggested that senior management of the authority and all personnel with healthcare regulatory authority should be obliged to sign a CONFLICT DECLARATION FORM going forward.