Tropical Cyclone Emnati made landfall in Madagascar on Feb. 23, the second cyclone in a month to hit the island nation. These successive cyclones, along with a pair of tropical storms that hit the northeastern coast, have resulted in tens of thousands being displaced to temporary shelters, entire communities being cut off from transport links, and the destruction of homes, schools, and health care facilities.
Emnati and its predecessor Batsirai crashed into vulnerable communities that had already been suffering from the worst drought in 40 years, which has left more than 1.1 million people affected by severe acute food insecurity. The World Food Programme’s deputy country director in Madagascar, Arduino Mangoni, has claimed this to potentially be “the first climate change famine on earth.”
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Madagascar’s experience may serve as a harbinger of the devastation climate change could reap on health care systems in sub-Saharan Africa and beyond. Cyclones, droughts, and other natural disasters hamper health care delivery, exacerbating crises where the population is most at risk of disease and malnutrition.
They also exacerbate existing financial barriers to health care as many patients in Africa are forced to pay out of pocket for health services, despite more than 1 in 3 Africans experiencing extreme poverty. Families that lack the financial resources needed to access essential, sometimes lifesaving, care are vulnerable to medical impoverishment and some avoid seeking health care altogether.
Health care in an emergency
Multiple initiatives have responded to humanitarian crises across Africa with programs that deliver emergency funds for health. Many use “mobile money,” a mobile phone-based payment technology ubiquitous across sub-Saharan Africa, which enables digital savings, transfers, and payments as an alternative to formal banking.
These are critical in places such as Madagascar, where only 10% of the population has a formal bank account at a financial institution. In southern Madagascar, a partnership of public and private health system stakeholders mitigated the effects of COVID-19 and drought by digitally distributing restricted, unconditional cash transfers, subsidizing patients’ treatment and increasing access to health care services.
Yet while cash transfers are well placed to respond to immediate health needs during an emergency, they do not eliminate out-of-pocket expenses, meaning there remains a serious barrier to widespread access to health care. Additionally, they are often reliant on funding from external partners, which cannot be guaranteed in the long term.
As sub-Saharan Africa is forecast to experience more severe climate change-related disasters, which will hit health systems and income security, a more sustainable health financing solution is urgently necessary.
Equitable and sustainable health financing
Achieving universal health coverage, an integral part of the United Nations’ Sustainable Development Goals, is critical to ensuring that communities have equitable access to quality health care without risking financial hardship. Comprehensive health coverage schemes reduce the burden of health expenses on those experiencing the highest levels of poverty in society.
Digital health financing tools, adapted to local contexts, help the drive toward universal health coverage by facilitating a move away from inefficient paper-based processes and contributing to a more transparent and sustainably financed health system.
M-TIBA, predominantly used in Kenya, allows users to save funds via a mobile health wallet and pay for their health care using mobile money. It has been used to enroll over 2.5 million Kenyans in a pilot of a universal health coverage scheme.
Similarly, mTOMADY provides users in Madagascar with a mobile wallet to digitally enroll in insurance schemes, pay premiums, and save for health care costs. The platform allows insurance claims to be filed offline, before they are automatically scanned for fraud and reimbursed, speeding up the process and reducing the administrative burden for health care providers.
Scaling and access
We need to get these digital health tools into the hands of people who need them.
Such technologies often suffer from “pilotitis” and data from 2014 shows that fewer than 1% of digital health pilots have gone on to scale or achieve institutionalization. To be successful, they must directly respond to the needs of the national health system and be integrated into existing national platforms.
Government support and adoption of these tools is key, and the COVID-19 pandemic has increased the political will to accelerate digital health technologies, with some countries now aiming to fully digitalize their social protection programs.
Technologies can move toward institutionalization and scale up with the partnership of governments and international organizations. For example, mTOMADY is working with the Malagasy Ministry of Health, which has secured funding from the World Bank to distribute digital health care vouchers to pregnant people and children under 5.
The push toward universal health coverage is essential if the world is to achieve equitable health systems that do not put people at risk of poverty — and digital health financing tools may help achieve this.
Madagascar’s recent experience with devastating natural disasters demonstrates the precarity of health systems, which, all over sub-Saharan Africa, will be ever more frequently affected by the effects of climate change. To respond, it is imperative to draw on the potential of digital technologies to create a more sustainable and resilient social security net, now.
About the author
Dan Bui
Dan Bui is a Berlin-based digital healthcare policy researcher. He is currently studying for his bachelor’s degree in Modern Languages at the University of Cambridge, with research interests in digital health financing and public participation in sub-Saharan Africa.
