Kenya has a pluralistic health system, with the government, private actors and donors involved in the financing and provision of health care. Since the late 1980s, the government has encouraged private investment in health care and there is now a large and diverse private health care delivery sector comprising for-profit and non-profit facilities. The growth of private provision has in turn created demand for private health insurance. Private health insurance cover is mainly purchased by higher-income employees in urban areas and only covered under 2% of the population in 2013 (Ministry of Health, 2014). It is beyond the financial reach of most of the population in a country plagued by poverty and income inequality, where access to affordable health care depends not just on the availability of funds but also on the availability of health workers and facilities. Until 2006, health insurers operated in an unregulated environment and there have been issues with fraud. The chapter begins with an overview of health financing policy in Kenya, then outlines the nature of the private health insurance market, the regulatory framework and barriers to market expansion.

Australia’s Medicare is a universal, publicly funded comprehensive insurance scheme that provides all its citizens with free treatment in public hospitals, and subsidizes out-of-hospital medical services and pharmaceuticals. Yet alongside this public insurance there exists a strong private health insurance sector that covers private in-hospital treatment or general (largely dental and other) ancillary services. Policy initiatives implemented since 1997 have provided both incentives and penalties to encourage the uptake of private insurance. The proportion of the population with insurance for hospital treatment grew from around 33% in December 1996 to a high of 45% in 2000; it then declined slightly until 2007 and has increased since then to 47% in December 2015 (APRA, 2016). Consequently, significant public funds have been directed to support the private health insurance industry and, by extension, the private health care sector. Current policies reflect the ambiguities of the electoral popularity of Medicare alongside the push to restrain public spending.

When compared with the other case studies analysed in this book, the role played by private health insurance in Switzerland may seem peculiar and perhaps corresponds only with the Netherlands post-2006 (see ). The crux of the Swiss health sector is a system of federally established universal health insurance coverage with atypical characteristics lying somewhere between private and social insurance (OECD 2006; Leu et al., 2007).

Life can be a tale of woe so people contrive arrangements that insulate them from the consequences of some familiar feared mishaps. Insurance – a small present payment in promise of larger compensation in the event of future losses – is one such arrangement. Insurance contracts recompense policy-holders for, for instance, loss of or damage to their home in a fire or their car in an accident, or the death of a benefactor who took out life insurance. People may also buy insurance that will cover some (maybe most) of their medical costs if they or members of their family fall ill and need care.

South Africa’s apartheid history of legislated discrimination on the basis of race has left a legacy of massive income inequalities–with, at 0.63 in 2011, one of the highest Gini coefficients in the world (World Bank, 2017)–and inequalities in access to social services. It has also left an indelible imprint on the health sector, where private health insurance was developed to serve white workers, whereas the public health sector served the majority black population and lower-income whites.‹ The use of the terms African, Coloured, Indian (and the combined group black) and white indicates a statutory stratification of the South African population in terms of the former Population Registration Act. The use of these terms does not imply the legitimacy of this racist terminology, but is necessary for highlighting the impact of former apartheid policies on the health system.› Since the first democratic elections in 1994, there has been considerable commitment to addressing these inequalities. However, progress has been limited: income inequalities have in fact been growing and inequalities within the health sector are increasingly related to class rather than race.

Japan, the Republic of Korea and Taiwan, China are neighbouring high-income countries with some similarities in health systems policy. All three have historically organized publicly financed health coverage around the labour market, with the government paying for some or all of the costs of self-employed, retired or poorer people, but Japan has a much higher share of public spending on health and a much lower share of out-of-pocket payments than the other two. All three rely heavily on the private sector to deliver health services. And in all three, private health insurance plays a supplementary role, offering subscribers daily cash benefits in case of hospitalization or lump sum payments in case of severe illness such as cancer. Although private health insurance markets in these countries are marginal in terms of spending on health, they cover relatively large shares of the population.