Neglected Poor in Africa Make Their Own Safety Nets
Tuesday, August 30, 2005
Nogaye Sow is a humble street vendor in a rough patch of urban Africa, but hidden in her flowing robe is a weathered piece of cardboard that helps put her on equal footing with those who work in air-conditioned offices instead of at the curb.
It is a makeshift health insurance card, with photographs of her, her seven children, her granddaughter and two other relatives pasted inside. When they get sick, they receive free consultations at the clinic down the road, cut-rate medicine and peace of mind. The chances are lower now that a bout of illness will bring the family to total ruin.
In most of Africa, there is no such help for informal workers like Ms. Sow, who sells ndambe, a hearty bean paste that she mixes with tomatoes and onions and slathers on bread. Across the continent, fewer than 10 percent of working people have health insurance, pension coverage or other forms of social security, according to the International Labor Organization, the United Nations’ oldest specialized agency.
But that is slowly changing, and not just because some African governments are expanding their ailing social security systems, vestiges of the colonial days and geared mostly to the vast number of people on the government payroll.
The bigger push is coming from everyday Africans who are tired of waiting for politicians to address their needs and have begun spinning their own safety nets.
Plans in which neighbors come together and create their own makeshift health coverage are the rage in Africa, particularly in the continent’s west. Here, the plans now have a significant presence in 11 countries and membership has grown beyond 200,000 people.
Some of these mutual health organizations, as they are known, include fewer than 100 beneficiaries. The tiny group negotiates with a local clinic and forges a better price for care. Others have linked dozens of community groups to produce sophisticated plans that cover 10,000 or more people and offer an array of services.
“Every day there’s a new group,” said Olivier Louis Dit Guerin, who helps set up these microinsurance plans as part of a program run by the Labor Organization. “They’re growing and growing to fill the big gap.”
Not all African governments are sitting on the sidelines. Nigeria, Africa’s most populous country, started a national health insurance plan in June that aims to extend coverage to some of the four of five workers who labor informally. But many Nigerians still fear it will end up enriching politicians instead of helping the poor.
And those African workers lucky enough to be part of a social security plan are not guaranteed comfort. The AIDS epidemic has left many national plans on shaky financial footing because there are more payouts for medical care and death benefits but not as many contributions.
Simply prying the benefits from bureaucrats can be a job in itself.
Charles Owala, 56, a retired Kenyan civil servant, has spent nearly two years trying to get his pension money.
“First when I came here at the beginning of 2004, the officers told me to wait because my membership card number was nowhere to be seen,” he said, camped outside the National Social Security Fund offices in Nairobi. “It took a lot of time for it to be traced. Now I’m being told there are some other contributions that my employer has failed to remit. What can I do? Wait again.”
Those without an employer to contribute to a formal plan – those who, to make ends meet, sell food from the curb, iron clothing, dig ditches, harvest crops or perform any number of the other small-scale tasks that keep Africa going – have long been left out completely.
They are particularly vulnerable to illness because of poverty and exposure, but often put off doctor visits as long as possible. They try traditional medicine because of its lower cost. And they often end up flat on their backs as the price of staying alive soars out of reach.
The fact that many manage to get by is largely because those who have little share with those who have even less.
The community insurance initiatives build on this poor-helping-poor philosophy. They differ from private insurance companies in that they are run by the beneficiaries and not intended to make a single franc. Their target population is people like Ms. Sow, a 40-year-old grandmother who struggles day to day.
For her, a good day of selling ndambe might earn enough to feed her family breakfast. She also runs her own phone booth where her neighbors can place calls, which can bring in enough to cover dinner. And she works at a play group for children; that pay barely covers school fees and other incidentals. Her absentee husband helps, sending money from time to time from Italy, where he lives illegally. None of this gives her health benefits.
But her community plan takes anyone from the neighborhood who can pay the modest fees. Ms. Sow struggles to pay the 200 francs a month – less than half a dollar – that she must come up for herself and for each of the other 10 beneficiaries on her card. With little cash coming into such plans, keeping the books balanced is always a challenge. In some cases, shady bookkeeping has also whittled down the funds.
But the funds tend to regulate themselves. One requires members to visit fellow members who are hospitalized, in both a measure of solidarity and a double check that the person in the hospital bed is the one on the insurance card.
Collecting premiums is not easy, those who run the plans say. But with no rules to follow, the plans can be innovative. In some rural communities in Mali, the health insurance fees are due once a year around cotton harvest time, when most farm families have spending money.
Still, in the three years since it was created, Ms. Sow’s plan has had to drop several hundred people who did not pay. Before the plan, when her children became sick with malaria – as common as a cold in the mosquito-filled single room she shares with her parents and other relatives – she had to wait to take them for treatment until she could raise the money, a delay that allowed the parasites to sap the children’s strength and endanger their lives.
Now, her insurance card means she can head straight for the doctor. She can also more easily afford the drugs she needs.
Like so many other newly insured Africans, she rarely finds herself forced to decide between health care and food. But there is much that these microinsurance programs do not cover. Ms. Sow’s plan offers no reimbursement for ultrasound examinations or X-rays.
One novelty of community insurance plans, though, is that the beneficiaries can come together and make changes. So soon Ms. Sow’s premium will increase 50 francs, which is about 10 cents, but she will be able to choose from more than the two health clinics now available and will be covered for more specialized procedures.
But even those changes will not make the pain in her mouth go away. She visited the dentist recently and he told her that her teeth were rotting away and that she needed 10 of them extracted. The fee, together with dentures, is far more than she can afford, and none of that will be covered by her neighborhood insurance plan.
“Maybe we ought to include dentists as well,” she said, rubbing her sore jaw.