Who Pays When Africans Fall Sick?

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April/May 2025Tanzania
Health Insurance

Photo Illustration by Ezinne Osueke / THE REPUBLIC. Source Ref: PEXELS.

THE MINISTRY OF health

Who Pays When Africans Fall Sick?

Across Africa, millions in the informal sector remain uninsured—not from apathy, but due to the exclusionary nature of health systems. In Tanzania and beyond, digital innovations offer promising models for more inclusive health insurance.
Health Insurance

Photo Illustration by Ezinne Osueke / THE REPUBLIC. Source Ref: PEXELS.

THE MINISTRY OF health

Who Pays When Africans Fall Sick?

Across Africa, millions in the informal sector remain uninsured—not from apathy, but due to the exclusionary nature of health systems. In Tanzania and beyond, digital innovations offer promising models for more inclusive health insurance.

It was a Tuesday afternoon when I first heard the words that would haunt me for years: Siwezi kulipia bima ambayo ni utapeli, which means, ‘I can’t pay for insurance—that is a scam.’ The voice belonged to a woman who introduced herself as Mama Asha, probably in her mid-30s, standing beside her frail, dehydrated child suffering from acute diarrhoea. I was a frontline intern nurse at one of the regional hospitals in Tanzania. My simple question about health insurance to Mama Asha triggered a flood of frustration and pain. Her story was not unique; it was the echo of millions. 

Mama Asha sold food at a local market in Moshi-Kilimanjaro, rising before dawn to prepare chapati and beans. Her daily earnings barely sustained her family. She once invested her hard-earned money into a health insurance scheme, hoping it would be her safety net. When illness struck, reality shattered that hope. Essential drugs were ‘out of stock’ and she had to pay out-of-pocket to save her life. That day, insurance became a cruel joke to her. 

I remember her eyes: defiant, tired, and deeply sceptical. Her rejection of insurance was not ignorance; it was survival. And she was not alone. 

THE REAL COST OF FALLING SICK

Mama Asha’s reality is mirrored across the continent. The numbers paint a grim picture. In Tanzania, only 15 per cent of the population is covered by health insurance. According to the World Bank, 60 per cent of health financing in Africa is out-of-pocket, the highest globally. Yet, every year, nearly 344 million people globally are pushed into extreme poverty because of out-of-pocket health expenses. The critical question is: Are people unwilling to enrol in health insurance, or are insurers failing their customers? Or perhaps we are attempting to transplant foreign models into African soil, hoping they will bloom? 

Universal Health Coverage is the global aspiration, but in Africa, it remains largely a distant dream. The Abuja Declaration of 2001 urged African governments to allocate at least 15 per cent of their budgets to health. Over two decades later, few countries have honoured that promise. The result? Thousands of Africans continue to suffer and die from preventable illnesses like malaria, not because we lack knowledge or treatment, but because we haven’t prioritized access to affordable, trusted healthcare. For too long, health systems have expanded unevenly, leaving informal workers and low-income families outside the safety net. Without meaningful reforms that provide financial, geographical, and informational access, the cycle of preventable deaths will persist. Had this promise been fully honoured, Africa would be telling a different health story. Diseases like malaria, which claimed 608,000 lives in 2022—mostly children—could have been drastically reduced through universal access to preventive care, diagnostics and treatment. We might not be leaning so heavily on now-dismantled United States foreign aid programmes, such as the United States Agency for International Development (USAID). Notably, American programmes like PEPFAR and the President’s Malaria Initiative (PMI) have strengthened African health systems. PEPFAR has provided treatment to over 20 million people, while PMI has helped cut malaria deaths by more than 60 per cent, saving nearly 7 million lives. With solid domestic investment in health insurance coverage and primary care systems, we can reduce our dependence on external donors and build resilient, African-owned health systems. 

Countries like Cabo Verde, Rwanda, and a few others that have taken the Abuja commitment seriously and invested in robust community-based health insurance schemes show significantly better health outcomes. From lower maternal mortality rates to increased immunization coverage, the results are compelling. 

So why have most countries fallen short? The barriers are complex. Political instability, shifting government priorities, debt burdens, and lack of accountability all play a part. But perhaps most crucially, many governments lack the data systems and inclusive governance structures to effectively plan, allocate and monitor health spending. Without these, even the best-intentioned policies remain aspirations on paper. 

The question we must now confront is not just why we haven’t kept our promises—but whether we are willing to build the systems and trust required to deliver on them. Because if we did, Africa’s biggest health problem would no longer be malaria, or tuberculosis, or maternal deaths. It would be something else entirely, because we would have already overcome the preventable. 

The informal sector, where millions of boda boda (motorcycle) riders, mama lishe vendors (a Swahili phrase for mothers who sell food on the streets), and small-scale farmers toil, is systematically excluded. Health insurance models, imported and imposed, often fail to resonate with their realities. 

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WHY IS AFRICA STILL HERE?: THE LEGACY OF IMPORTED SOLUTIONS

Why, after decades of development aid and health financing pledges, are we still here? Post-independence Africa inherited more than borders, it inherited systems designed for others. Health insurance, as we know it, is an import built around formal employment structures. Premiums are deducted from salaries, and claims are processed through organized systems. But what happens when 80 per cent of your workforce earns daily wages from informal jobs? 

Are we importing the wrong solutions? The western model of employer-based insurance or hefty monthly premiums is alien to a boda boda rider who earns in cash daily. Risk pooling and annual coverage sound sophisticated, but what about someone whose income is unpredictable and seasonal? Boda boda riders, vegetable vendors and small farmers do not receive payslips. Asking them to commit to a fixed monthly premium is asking them to choose between food and insurance. Unsurprisingly, they often choose food. 

Trust remains broken. Insurance, to many Africans, feels like a distant institution designed to profit off their pain. Stories of denied claims, stock-outs, and hidden costs fuel distrust. Last year, while riding in a boda boda in Dar es Salaam, I probed the rider about owning health insurance. He shared how he pooled his resources to pay for an insurance scheme, only to be turned away at a certain private hospital because ‘the system was down’ and was asked to pay cash. These repeated failures make insurance feel like a gamble, not a safety net. Is it the people who are unwilling, or are insurers failing them?   

There is a deeper question we must confront: have we attempted to build a health insurance model rooted in Africa’s realities, or have we merely imported systems that work elsewhere and hoped they would fit? 

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WHERE ARE AFRICAN SOLUTIONS?

There are glimmers of hope—pockets of innovation proving that an African approach is possible. 

In Kenya, the M-TIBA platform allows people to use mobile money to save, manage, and pay for healthcare services, through their phones. It allows low-income families to set aside small amounts via mobile phones, accessing funds when illness strikes, and connecting them to insurers. This taps into Africa’s mobile revolution, where over 600 million people use mobile money. 

Similarly, in Tanzania, several startups are pushing boundaries to provide health insurance coverage for informal sector workers, an often-overlooked group in traditional insurance models. My colleagues and I at Afya Lead launched Pamoja Bima, a digital insurance enrolment system with a pay-as-you-use option. Our goal is to simplify insurance access, making it just as easy as buying a SIM card. We engaged informal sector workers directly, listening to their fears—long queues, unclear benefits, rigid payments—and their needs. Those conversations shaped everything. As these workers feared committing large sums up front, we introduced micro-payment options through digital cards, and other simple QR coded cards—which fits well with their ‘mobile’ nature and that of their livelihoods. And because literacy levels varied, we made these options accessible via voice-assisted USSD codes, not just apps. This bottom-up approach was a philosophy; insurance must fit the lives of people, not the other way around. For governments seeking to expand insurance to the informal sector, this is key. Engage users early. Build systems around their realities. Flexibility, simplicity and trust are the foundations of true universality. 

Despite the promising progress these models show, implementing them at scale always comes with challenges. One major obstacle is the absence of reliable, nationwide databases to track informal workers and link them to tailored health insurance schemes. In countries like Kenya, platforms such as M-TIBA have benefited from existing mobile money networks and data infrastructure, but in many other African countries, fragmented data systems and limited digital ID penetration make it difficult to accurately map, enrol, and follow up with informal sector populations. Without this foundational data, insurers struggle to assess risk or offer flexible, personalized packages. Additionally, integrating these digital systems into existing health service delivery remains a challenge. To overcome these challenges, a multi-pronged approach is needed. Governments, fintech startups and insurers must collaborate to develop inclusive digital ecosystems that are built on robust data infrastructure, potentially leveraging blockchain for transparency and security. Governments should lead the charge by subsidizing premiums for the most vulnerable, supporting public awareness campaigns, and ensuring that digital insurance services are seamlessly integrated into public health facilities, while engaging the private sector to enrol and innovate technologies on win-win conditions. If anchored in community trust, backed by political leadership, and built with digital inclusion at its centre, these innovations can truly deliver health security to Africa’s informal sector. 

The Improved Community Health Fund (iCHF) represents another innovation in Tanzania’s health insurance, particularly for rural and informal sector populations. The government-oriented iCHF model decentralized healthcare financing, allowing families to enrol in affordable insurance schemes tailored to their local healthcare needs. It simplified registration, provided family coverage, and strengthened primary healthcare infrastructure. Though challenges like service quality inconsistencies persisted, iCHF’s participatory and community-centred approach proved instrumental in boosting enrolment and fostering trust in health insurance. Going forward, the lessons from iCHF should guide the implementation of Tanzania’s new universal health insurance bill. Incorporating flexible payment options, decentralizing enrolment, and ensuring community participation will be key to achieving widespread coverage and long-term success.  

The lesson? When insurance is visible, affordable and flexible, people respond.

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WHAT IF WE DARED TO DREAM BIGGER?

What if Africa built its own health insurance ecosystem—not as an adaptation of western models, but from the ground up, woven into our social and economic fabric? 

Imagine a system where health insurance is woven seamlessly into the daily lives of Africa’s informal workforce, a system built with their realities, values, and aspirations at its core. Picture a boda boda rider in Dar es Salaam, who, after earning fares for the day, effortlessly sends a small insurance premium through mobile money daily or weekly, matching the unpredictable cash flow that defines his work. A mama lishe joins a cooperative of fellow market vendors, pooling their resources into a shared health fund, much like the trusted Ujamaa spirit of communal support from the days of Julius Nyerere, where solidarity and collective welfare were the backbone of survival. Technology becomes their ally, blockchain secures every transaction, creating an unbreakable chain of trust every contribution, every payout, visible and verifiable, erasing the shadows of corruption and fraud that have long eroded confidence. When illness strikes, this mama lishe does not face humiliation at the dispensary counter; she taps into her cooperative’s fund, processed in real-time through her mobile phone, ensuring she receives treatment without begging for help or selling her stock.  

Beyond borders, this vision extends further, a Tanzanian trader crossing into Uganda to buy goods no longer worries about falling sick far from home; her coverage travels with her, granting access to care across East Africa, powered by regional integration and digital portability. It is trust rebuilt. It is the future Africa deserves—designed by Africans, for Africans. 

This is not utopia. It is possible. It requires merging fintech innovation with community solidarity, backed by political will and African ingenuity. To succeed, platforms must be designed for low-literacy users, with USSD options in local languages. Control of such a bold health integration could lie with the well-funded and strong Africa Centres for Disease Control and Prevention (Africa CDC). This body will act as a unifying platform for data standards, interoperability, and equitable financing models, much like what the Africa CDC’s Digital Transformation Strategy envisions. Fintech firms, local cooperatives and governments would collaborate to register informal workers into a common database and tailor flexible payment models to suit their health needs and specific contexts. 

COURAGE, TRUST AND LOCAL SOLUTIONS

The road ahead is not easy. Entrenched systems resist change. Yet the status quo is not an option. Mama Asha’s child deserves more. Every boda boda rider deserves security beyond their daily hustle.  

To policymakers: Move beyond Abuja declarations on paper. Design policies with the informal sector at the centre. To insurers: Rebuild trust. Engage, listen, and innovate. Meet people where they are. To innovators and startups: Dream bolder. Fintech and mobile penetration offer unprecedented tools. Co-create solutions with the people, not for them. To development partners: Shift from charity to capacity-building. Support African-led insurance ecosystems, not imported band-aids. To every African: Demand better. Health is dignity. Insurance should not be a privilege; it is a right.  

The question remains: Who pays when we fall sick? The answer must no longer be ‘no one.’ It must be ‘all of us.’ Mama Asha’s voice still echoes in my heart. But now, I hear something else alongside it: Hope⎈

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