**6.2 Insurance health system of African countries**

CVDs are very burdensome to manage in Africa due to a lack of a national health insurance policy in most SSA countries [30]. Health systems insurance is primordial for achieving universal healthcare by providing financial protection to patients. It helps protect people from high healthcare costs by pooling funds to allow a cross-subsidization between the rich and poor and between the healthy and the sick [31]. Healthcare insurance coverage is still inexistent or at an embryonic stage in most African countries. This has largely contributed to poverty, poor cardiology service delivery and mortality from CVDs in Africa. Implementing an African health system insurance remains an important goal to improve the health status of individuals in Africa [4]. Reports illustrates that in the several SSA countries, direct out-of-pocket payments as a share of total health expenditure are still above 40%, exorbitantly high above WHO 20% threshold level of the total health expenditure below which financial risk protection can be ensured, and thus leading to poverty in Africa [32]. There is a serious handicapping sparsity of health systems insurance in most African nations where only about 15% of the 55 countries have national comprehensive health insurance schemes [33]. Evidence abounds that in SSA, the poor bear the highest burden of diseases and subsequently, experience very high expenses on healthcare costs [34]. Hence, the development of a health system insurance scheme should be advocated in public health and financial planning within African countries for better healthcare delivery in general. A universal healthcare system with national-level health insurance scheme would probably be more efficacious to avoid the low-socioeconomic class of the population from being marginalized. Strategies such as compulsory taxations from employees, deductions from sales taxes, and an increment on tobacco taxes have been shown to be effective in

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

was on the prevention of CVDs. The conference was endorsed by the Minister of Health of Tunisia, highlighting the importance of governmental collaborations in attending 'health-for-all'. Themes arising from the conference included the management of various cardiovascular risk factors, legislation of these cardiovascular risk factors, and using the leverage of other local and international organizations to improve cardiovascular health in Africa. Cited cardiovascular risk factors to be urgently cared for in Africa include diabetes mellitus, hypertension and dyslipidaemia. There is therapeutic inertia in the therapeutic algorithms of these conditions especially hypertension. The AHN emphasized on the importance of the timely treatment of resistant hypertension. Obesity was highlighted as the main driver of the diabetes epidemic in Tunisia as well as Africa, with 75% of patients with Type 2 diabetes mellitus dying from CVDs. A 1% improvement in glycosylated hemoglobin was shown to decrease mortality from ischemic heart disease by more than 14% in the Tunisian population although glycemic control is not often achieved in the African continent due to low awareness, treatment and control of diabetic patients who often present late with acute complications of diabetes mellitus such as hyperglycemic comas. Various barriers to control had been identified, namely the inability of clinicians to apply treatment guidelines, inadequate monitoring or surveillance of blood pressure and glycaemia, lack of community education and empowerment, and most importantly, the cost of accessing healthcare. There is also a poor awareness of the cardiovascular risks associated with dyslipidemia in SSA. The South African perspective displayed an increase in the burden of dyslipidemia due to anti-retroviral therapy (ART) induced dyslipidemia in patients living with HIV/AIDS and treated with ART. This needs to be promptly managed in order to prevent CVDs. Previous studies have identified the huge burden of premature ischemic heart disease partly due to dyslipidemia in Africa compared to other regions [26]. This reflects a lack of prevention, early detection and effective management of CVDs in Africa. Preventing CVDs remains a major challenge for development within the region as it results in significant health, financial and social consequences for individuals and government. Likewise, the control of tobacco use, known a risk factor of six of the eight leading causes of CVDs death was highlighted as being important. The role of healthcare providers and health authorities in preventing CVDs due to tobacco use was addressed through a governmental vote on the increment of tobacco taxation as there remains a discrepancy between taxes paid and the treatment cost of tobacco related health disease and death. The WHO 'MPOWER' package was emphasized as a tool to assist countries with tobacco reduction measures. In addition, patients should be motivated by clinicians and family members to quit smoking with both counseling and the early use of pharmacotherapy. In the same vein, the formulation of legislations to control cardiovascular risk factors including the control intervention for the effective implementation of physical exercise and encouraging a low-calorie dense foods to prevent CVDs mortality related to obesity and diabetes mellitus are strongly recommended. This will however, require an involvement from policy makers for the formulation of public health interventions geared at curbing the burden of CVDs in Africa. Moreover, there is a shortage in drugs and equipment for monitoring CVDs between African countries which needs to be addressed for CVDs prevention. This is due to preference in healthcare expenditures for infectious diseases at the detriment of CVDs in Africa. Various partnerships including the WHF, the United Nations the Non-communicable disease alliance (NCD Alliance), Pan African Society of Cardiologists (PASCAR), American Heart Association (AHA), Medtronic Foundation, Heart and Stroke Foundation of South Africa, World Heart Day events, The Kenyan-Heart Talking Walls project are key continental and inter-continental foundations trying to achieve and prevent

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some countries in SSA [35] .A comparative study of five African countries (Ghana, Tanzania, Kenya, Rwanda and Ethiopia) sought to help fill this gap by looking at how a national health system insurance schemes can cover the poor or not, as the case may be. Selected countries had were national insurance schemes with the intent of providing health insurance for all their inhabitants. Ghana, Kenya and Tanzania had similar health insurance programmes [36–40]. Ghana's National Health Insurance Scheme (NHIS), covers every citizen by law. Tanzania and Kenya had separate insurance schemes for the public and private sectors. Rwanda and Ethiopia operated a Community-Based Health Insurance (CBHI), but Rwanda's CBHI was the only one with wide coverage of the poor. Hence, setting down insurance policies or programmes does not guarantee reaching the poor. Many have questioned whether African countries have been too eager to adopt Western-style policies that are not necessarily appropriate to their context-specific fiscal laws. The selected countries are characterized by large informal sectors, making it difficult for the rolling out of health insurance scheme models that depend on this group. After almost 12 years of introducing national health insurance in Ghana, less than 40% of the population were covered by the health system insurance scheme. In spite of provisions made to cover the poor, health system insurance programmes have faced challenges in enrolling this group. Defining who the poor are is a task that policymakers have grappled with. Many terms have been used to identify the poor—ultrapoor, very poor, indigent and vulnerable. Coining these terms and explaining what they mean and who qualifies to be categorized as such has become not only burdensome but costly—and political [41].

The way forward to establishing a sustainable cost-effective and context specific health system insurance scheme in SSA should take into consideration the following. Firstly, the fact that the educational and socioeconomic status of a family play key roles in the decision of whether to enroll in health insurance should take into consideration that community-based health insurance provides some financial protection by reducing out-of-pocket spending [42]. Secondly, data analysis from micro-level household indicates that community financing improves access by rural and private sector workers to needed heath care and provides them with some financial protection against the cost of illness. Thirdly, analysis from macro-level cross-country gives empirical support to the hypothesis that risk-sharing in health financing matters in terms of its impact on both the level and distribution of health, financial fairness and responsiveness indicators [43].
