Is the National Health Insurance Scheme the final piece to achieving Universal Health Care in Uganda?

 

As a citizen one has rights, termed fundamental or otherwise. However, the most fundamental of them is the right to life. And the basic tenets of a quality life, are simply being alive and healthy.

A unique aspect about the Constitution of the Republic of Uganda is that before setting out the constitutional commands it enumerates the national objectives and directive principles of state policy which form the basis of the constitution. One of these is that, the state shall take all practical measures to ensure the provision of basic medical services to the population. The guiding principles for Uganda’s health system are anchored in the Health Sector Development Plan 2015/6 – 2020/21, and the National Development Plan II (2015/16-2019/2020) and the Ten (10) year EAC Health Sector Investment Priorities Framework (2018-2028) which clearly define the health sector priorities alongside numerous opportunities for the private and public sector to synergize and collaborate.

 

The Government of Uganda has taken a number of legislative and policy steps to ensure that medical services are available, accessible to and affordable by the people of Uganda. Bernie Sanders an American politician, on accessibility to health care said, “health care must be recognized as a right, not a privilege. Every man, woman and child in our country should be able to access the health care they need regardless of their income”. This is a conceivable definition of Universal Health Coverage(UHC).

 

To achieve UHC, three aspects need to be addressed. Firstly, enhancement of the Uganda education system to support interventions that ensure access to knowledge that will reinforce health education messages to impact positively on lifestyle decisions and health indicators across socio-economic groups. Secondly, a new approach to community planning and environmental management that addresses sanitation gaps. Finally, and most importantly introduction of an all-encompassing sustainable health financing strategy that delivers health care services to residents of Uganda.

 

Adequately and sustainably financing Uganda’s health sector remains one of the nation’s most challenging conundrums. While several health financing strategies are currently available in Uganda with limited scope and impact, the game-changer it is expected, will be the undertaking of the planned National Health Insurance Scheme(NHIS).

 

It is against this background that the Government of Uganda seeks to introduce a National Health Insurance law which seeks to establish a National Health Insurance Scheme to provide for compulsory registration for health insurance for every person resident in Uganda. This mechanism would settle the incurred medical bills of patients when they receive health care services at health facilities be they public or private, facilitate the provision of efficient, equitable, accessible, affordable and quality health care to all, including the indigent. The planned scheme will collect funds and hold, deposit, invest, administer and disburse the funds received; accredit, supervise, monitor and regulate the health care providers to provide health care services; as well as negotiate and enter into contracts with accredited health care providers.

 

However, there are concerns from non-state stakeholders that NHIS, lays the financial burden of supporting the scheme’s operation squarely at the feet of those in formal employment and particularly their employers. The total number of people formally employed, if measured through the statutory National Social Security Fund contributions, amounts to less than one million out of a population of over 40m, the majority of whom are under the age of 18 and make no economic contribution. The indigent and those informally employed have proven a challenge to identify, engage and absorb into the NHIS dialogue although efforts are still ongoing.

 

Several questions remain unanswered, as the sector bounds toward NHIS, most importantly with so few contributors to the pool, how can more resource be channeled and how best can existing resources be stretched to do more? Despite all the other initiatives being considered including the amendment of the NSSF Act to provide health benefits, undoubtedly, most stakeholders’ hopes are pinned on the NHIS, therefore it is important to examine the existing health system infrastructure and identify opportunities for investment and collaboration to bring Uganda closer to realizing UHC.

 

The introduction of the National Health Insurance scheme creates great opportunities for growth and improvement of investment in the sector. As the government grapples with resourcing and availing healthcare services to every resident, the private sector has invested significantly, albeit in an uncoordinated and geographically imbalanced manner, to complement and supplement the government’s efforts, along the health sector supply chain.

 

The health facility mix in Uganda is comprised of GOU health facilities which are the majority in the country coupled with the commercial non-state actors who operate for profit and the Private Not for Profit (PNFP) facilities. The resulting symbiosis of this infrastructure mix naturally supports the introduction of public private partnerships (PPP). NHIS offers both public and private sector players, in several sub-sectors an open space to explore investment in state of the art facilities which would attract all nature of users into Uganda through medical tourism.

 

It is believed there is no health worker in Uganda that is solely employed by the public sector, and thus in pursuit of economic gratification, public sector health workers openly moonlight in private facilities they own or for which they are in employment. Meaning the 47% health workers in the table below employed by the private sector is understated. The overall meagre human resources in the health sector available in the country are thus thinly spread geographically and between both the public and the private sector with a persistent human resource gap in public facilities.

 

HRH Category MOH PFP PNFP Private Sector % of Total Total
Doctors 1,047 3,733 361 80% 5,141
Nurses 16,490 8,250 4,145 43% 28,885
Midwives 8,815  — 987 1% 9,802
Clinical Officers 2,702 3,425 558 60% 6,685
Laboratory staff 2,447 5,733 746 73% 8,926
Anaesthetic Cadre 238 -26 147 34% 359
Pharmacists 45 588 24 93% 657
Dispensers 169 210 172 69% 551
Other allied staff 3,295 2,528 382 47% 6,205
Total Available 35,248 24,441 7,522 48% 67,211
Sources:  Compiled from multiple sources for the USAID Uganda Private Health Support Program Private Sector Assessment

The private sector has invested in the development of Human Resources in Health (HRH) owning 70% of Uganda medical training institutions. While regulation and oversight of curricula and performance of medical training schools remains under the Ministry of Education, the existing model clearly illustrates the potential for investment to provide human resources to fill the existing HRH gaps.

Medical Training Institutions by Ownership (2015)
Type Status MOH PNFP PFP Total
Nurse/Midwifery Registered 14 7 6 27
Licensed 0 19 30 49
Not registered, not licensed 0 0 3 3
Subtotal 14 26 39 79
Allied Health Professions Registered 22 2 6 30
Licensed 0 7 19 26
Not registered, not licensed 0 0 3 3
Subtotal 22 9 28 59
University Medical Schools Registered / Licensed 4 0 1 5
TOTAL 40 35 68 143
Sources: Capacity Program inventory of health training institutions, 2015

Weaknesses and gaps in infrastructure expose several investment opportunities in both the public and the private sector in Uganda’s health economy. The NHIS proposal compels us to consider projects in the health sector including but not limited to investment in training of all nature, opportunities in the initiating where necessary and expanding where possible the provision of specialized medical care in areas like neurology, urology, orthopedics, plastic surgery, setting up new hospitals and pharmacies, setting up diagnostic centers and diagnostic facilities.

The call for investments in health and PPPs to transfer risk and address the health sector funding gaps stems from the national budget projected resource envelope for FY 2018/19 of UGX 29.274 Trillion. The Health sector is projected to experience reductions in their budgets which will represent a drop from 1,824 billion Uganda shillings to 1,636 billion Uganda shillings. Therefore, while the intention and policy position of the Government of Uganda is to have these services provided at no cost to the population, the national purse and the miniscule tax base mean there is a glaring funding gap between how much is budgeted and what is received to provide the required minimum health care package to the population.

To support efficiency of resource management the government embraced a preventative care intervention policy. Uganda has one of the continent’s most successful immunization programs against some of the most prevalent life threatening diseases such as diphtheria, polio, tetanus, tuberculosis, measles, whooping cough, hepatitis B and H. Influenza with the program recently expanding to include cervical cancer for girls under twelve years at no cost to the beneficiaries.

 

The health sectors poor access to financial resources coupled with Uganda’s mixed health system, is an optimum environment to explore investment opportunities. The health system and infrastructure in place is conducive through government policies that brought health services nearer to the people, by having a hospital or a level IV primary care facility per 100,000 people. This has been largely achieved, despite the persistent challenges of inadequate facilities owing to low financing as well as misuse of the available resources.

Generally, primary health care services are available in Uganda, both through public and non-state health facilities. However, equipment in public facilities, and in some private facilities, where it is outdated or non-functional due to poor maintenance, may not be used due to lack of consumables, or expertise for it to be operational and in service. The specialty services, if available, come at a very high cost to low income groups, and at service points where accessible the facilities are congested, and mainly in urban areas with most located in Kampala.

Poorly distributed expertise and insufficient equipment is a further strain on Uganda’s fledgling health system, which is ill-prepared to deal with the more complex health needs that would benefit from new technology and techniques. Even the provision of national health insurance cannot provide the solution, where expertise, experience and equipment are unavailable. There are billions of shillings lost through hidden and quantified expenditure by the state and individuals on medical tourism emanating from Uganda, in search of expertise and equipment not available in Uganda. The historical view of this was that in the past people traveled mainly from the less-developed countries to major medical centers in highly developed countries for treatment unavailable at home. This is not entirely true as the cost of the treatment is becoming a factor for consideration. The cost of accessing these services in Uganda is driven up by several factors but most notorious of these is that there are too few patients accessing the services domestically.

Investors in Uganda’s health system are proficiently protected by the Uganda Public Private Partnership (PPP) legal and institutional framework, which was birthed from the PPP Policy 2010 and the PPP Act 2015, the Public Procurement and Disposal of Assets Act 2003, supplemented by the Public Finance Management Act 2015, and the National Audit Act 2008. These together with several other laws and policies form the basis for the PPP process which apply to all public private partnerships in respect to design, construction, maintenance and operation of infrastructure or services for projects including health care facilities.

The GOU has taken some timely crucial tentative steps to setting the foundation for a viable NHIS through interventions such as the introduction of National ID as a unique identifier. Also notably Government is clearly aware of systematic shortcomings and is gravitating towards working closely with the private sector and international investors through partnerships in order to build the necessary infrastructure and build the crucially needed capacity, to create a much needed enabling environment, without which, the planned National Health Insurance Scheme is a non-starter