Uganda UHC and National Health Insurance Scheme

No, I am not possessed by Universal Health Coverage, I am just trying to wrap my mind around what it really means, the opportunities and challenges it presents and what implementation would look like within the context of Uganda.

Uganda is a developing country with a national GDP of about 19.88 billion and a population of 36.35 million (World Bank,2012). It has been estimated that 5% of Ugandan households experience catastrophic medical expenses with about 2.9% becoming impoverished as a result. This is regardless of the absence of user fees which were abolished in 2001. Households are a major source of financing for health accounting for  49.7% which is about 9% of their income. Donors account for 34.9%, the Government at 14.9%(which is about 9.6% of the national budget) and international NGOs at 0.4%.(HSSP 2010)

A study by Jita et al(HSSP 2010-2015 on client satisfaction with health services in Uganda showed discontentment with unofficial user fees imposed, long lines and behavioural issues related to health workers. There was satisfaction with community initiatives which were free and offered participatory opportunities. Will the suggested implementation of the National Health Insurance scheme(NHIS) be the solution to these and other coverage and inequality issues? The NHIS has been 'in the pipeline' for over 5 years now with no actual enaction of the plan.This has been mainly due to resistance from a variety of forums such as parliament,unions, private companies and citizens who doubt the capacity of the government to effectively and efficiently manage the scheme.

In this article by Jeffrey Sachs, he emphasizes that despite the demerits of publicly provided services for Universal Health coverage, provision by private entities is not the solution unless community service provision on a large scale(including immunisation, maternity services etc) can be guaranteed which seems rather idealistic. This posses a huge challenge for countries with questionable government structures and functions. There is need thus for strengthening of these which requires not just health system but also political reforms.

How then can the challenge of inequality in Health in Uganda(decreased access by the poor in both rural and urban areas) be addressed? How can out of pocket expenditures in health which further cripple the poor be minimised and ultimately halted? Is NHIS the solution? In its initial phases, finances are to be generated from employed person accounting for 8%- 4% from each income and the remaining 4% from the employers. Already 2% of the population have private health insurance, majority of which is employer financed. It is important to consider how much it is costing these employers to provide private insurance or their staff and whether the option provided by the government would be appealing financially given the challenges already stipulated with public service delivery.

Can the NHIS work? I think so. Such methods have been effective in Rwanda, Mexico and Italy. The challenges of governance and stewardship in Uganda will need to be addressed. Also, the need to approach UHC with 'Health Systems thinking' appreciating the vicissitudes arising from changes in one of the 6 building blocks(financing). Effects on the other blocks should be anticipated to assist in re-evaluation of the strategy.

Universal Health Coverage

I wrote about about this is in previous blog about Millennium development goals. It tugged at my heart quite a bit because of the contrast between service provision at Kisoro and Mbale hospital. The Mbale experience really bothered me. Patients showing up bare expecting 'free' services only to be told that right from simple things like a cannula, they had to go to nearby shop to purchase. (Sometimes, these purchases could be made from the staff). I remember the severely anaemic children who showed up in shock and we had to send parents off in a hurry to buy cannulas.

As I sat here, I remembered a middle aged woman who I saw when she was rushed into the casualty department. I had never made so many diagnoses in one patient! HIV positive with severe anaemia, hypertension.. the list continued! The reason I remember her is because I run around, trying my best to correct as much as we could in the shortest time possible because in so many ways, she really was a ticking bomb!

She survived! Was transferred to the ward where she was monitored as she stabilised. What amazed me everytime I came to do the ward round is how she had not taken medication. She had no money to buy it! The pain! Lord! What was I to do? Tried to get her drugs but they were not available at the hospital plus she wasn't really feeding well or being taken care of.

In spite my scepticisms, I do see the difference that UHC if done properly can make to help the poorest:

• Those anaemic children who really do not have to die of malaria
• Those pregnant women who show up in the middle of the night
• The patients with chronic illness who I have always felt are too poor to have such diseases!
• The patients who needed emergency surgery
• Those who begged me to discharge them in spite the fact that they were not well because they had run out of money to be in the hospital. Some asked to return home so as to 'look for more money' before returning. 

Poverty is so real back home. But for this system to be effective, the issues underlying need to be addressed. The health system blocks need strengthening and In Uganda, staff motivation is key and salaries could really use a bump. Also, there is increasing need for appropriate oversight.

I am working on a proper paper with references and everything. I just wanted to voice my thoughts. I hope that lady is ok :-( However, that would be nothing short of a miracle. By the time I had moved to a different rotation, she had already been re-admitted about 3 times in 3 months.

Universal health is basically about health for all with Financial Risk Protection(FRP). Individual countries in adopting strategies and moving towards UHC need to ensure that whatever the 'scheme' used, patients are covered for the things especially that tend to incapacitate them health wise and financially. Clearly a physician consult did not do much for this woman, she really needed drugs.

I was about to voice my concerns as to whether UHC can actually attain universal health but the more I think about it, the more I am convinced that yes, health coverage can help free the poor from the crippling power of illness. However,again, this can not stand alone. Other health promotion activities are still necessary to curb preventable illnesses and prevent 'over-usage' of the services. It must also be noted that many of the out pocket expenses in relation to poor health are not always addressed within the existing framework of health systems such as transport to the health centres and food for the attendants and patients as shown in rural Tanzania. 

Health systems: What do we need? More money?

There is  saying: Money answereth all things. Even in health, many times the belief is that things will be better even in developing contexts "if only we had more money". Is that really true? Is all we need money? If that were the case, with the influx of donor aid following the formation of the millennium development goals, the health status and development of struggling countries like mine would have been resolved but that is not the case. The graph below is a comparison of spending and life expectancy(2000).

Countries that invest more in health generally have better health than those that don't however the good health could be due a cascade of other things such s good roads,fewer wars etc. Interestingly, there seem to be diminishing returns in health status regardless of increases expenditure beyond a certain point(above). Comparison between countries with similar economies (OECD) illustrates this further.

Capitalism: A cause and Linchpin of poor health.

According to Dictionary.com, Capitalism is:
An economic system in which investment in and ownership of the means of production, distribution, and exchange of wealth is made and maintained chiefly by private individuals or corporations, especially as contrasted to cooperatively or state-owned means of wealth.

Dr. Owain Williams(Centre for Health and International Relations, UK), presented a lecture on Governance: Globalisation, Institutions and Capitalism. He discussed the challenges in Global health governance such as boarder-less disease, the crisis of non-communicable diseases, resource scarcity, failure of co-ordination, supply and demand challenges(causing low R&D for neglected diseases) and market failure. With increasing Public-Private-Partnerships, privatisation, emergence of numerous NGOs with better wage structures than government institutions, globalisation of health services, pharmaceutical companies' TRIPS agreements.. Health has become a commodity that can be bought by the highest bidder. This is disadvantages poorer communities.The main health impact of capitalism is increased inequality. He argues that this is not normal, accidental or necessary.

I think the presentation was interesting, broadening my understanding on the ways in which disposition for economic gain tips the balance for health in favour of the rich. Governments need to ensure that their health systems protect and meet the needs of their poor.


"As a species we are increasingly eating, drinking and smoking ourselves to death." Owain Williams

Foreign Aid: Gift?

According to Derrida 1992: " For there to be a gift, there must be no reciprocity, return, exchange, countergift, or debt. If the other gives me back or owes me or has to give me back what I give him or her, there will not have been a gift, whether this restitution is immediate or whether it is programmed by a complex calculation of a long-term deferral or difference.

For there to be a gift, it is necessary ... that the donee not give back, amortize, reimburse, acquit himself, enter into a contract, and that he never have contracted a debt ... It is thus necessary, at the limit, that he not recognize the gift as gift. If he recognizes it as gift, if the gift appears to him as such, if the present is present to him as present, this simple recognition suffices to annul the gift. Why? Because it gives back, in the place, let us say, of the thing itself, a symbolic equivalent"

All I can say is "Selah!"(Think on that)!!!!

Review: Uganda

Uganda is actually in stage one of the demographic transition. This is because on critical analysis of the data in the tables previously posted, there is no significant decline in mortality rates. The population is high and the growth rate fluctuates. The fertility rate is still very high- according to the 2002 census it was 6.9 children per woman.

A country is unable to maximise benefits of a high population until it has undergone the transition characterised by massive decline in death rates followed by a decline in birth rates. The value of this is that it produces decreased dependency ratios with a large work force population.

Unfortunately, this model predicts that it will be a while before Uganda attains this transition and unless efforts are concerted to decline the mortality and fertility rates, it will take many years before Uganda is able to attain its desired economic output. A large population(currently 34 million) can have massive negative impacts on the economy as it reduces the capital available for investment in human capital.

References
KLASEN, S. & LAWSON, D. The impact of population growth on economic growth and poverty reduction in Uganda. 2007. Diskussionsbeiträge aus dem Volkswirtschaftlichen Seminar der Universität Göttingen.

POPULATION SECRETARIAT. Ministry of Finance, Planning and Economic Development. Uganda. http://www.popsec.org/key_facts.php

UBOS. 2001. The 2000/01 Ugandan Demographic and Health Survey.  Kampala: UBOS.

Topic one: Demographic Transition

This refers to changes in birth and death rates as society transitions from a 'traditional' to a more 'modern ' society. I put those words in quotes because their direct meaning is not exactly representative of what is implied in this definition. As countries and societies develop, changes are usually seen in the population numbers.

Stage 1: High death rates and high birth rates- the population is thus fairly stable
Stage 2: The death rate begins to drop(possibly owing to accessibility and availability of better health services,people living longer due to better lifestyles). This leads to an increase in the population growth.
Stage 3: The birth rates begin to drop usually due to increased accessibility to family planning services, education, woman emancipation. The total population however continue to rise because the death rates are still continuing to drop.
Stage 4: The birth rates and death rates become constant leading to stabilization of the total population.
Stage 5: This is a projection where the death rate exceeds the birth rate i.e there is below replacement rate fertility. This would lead to a decline in the total population.

www.census.gov/international/data/idb/informationGateway.php

I think Uganda is in stage two. The death rate is decreasing significantly with a marked decline in the under 5 mortality(refer to able below) however the birth rates are still high hence population growth. As evidenced by the pyramid, there are still very high birth rates(large number 0-4yrs) with only a small fraction in the middle aged and elderly categories.

The demographic translation curve however does not put into account population decreases following immigration.

www.census.gov/international/data/idb/informationGateway.php

Australia is in stage 4. The above diagram reflects a decrease in birth rates, with low infant and under 5 morality. There are also visibly low death rates throughout the population . This is a stable population.

Demographic overview- Uganda (United states census bureau www.census.gov)

Demographic Indicators	1995	2005	2013	2015	2025
Population
Midyear population (in thousands)	19,640	26,917	34,759	37,102	50,692
Growth rate (percent)	2.2	3.3	3.4	3.3	2.8
Fertility
Total fertility rate (births per woman)	7.2	6.7	6.1	5.9	5.0
Crude birth rate (per 1,000 population)	52	48	45	44	37
Births (in thousands)	1,014	1,301	1,576	1,649	1,877
Mortality
Life expectancy at birth (years)	45	50	54	55	59
Infant mortality rate (per 1,000 births)	89	77	62	59	45
Under 5 mortality rate (per 1,000 births)	156	131	102	96	70
Crude death rate (per 1,000 population)	18	14	11	11	8
Deaths (in thousands)	350	381	393	397	420
Migration
Net migration rate (per 1,000 population)	-11	-1	-0	-1	-1
Net number of migrants (in thousands)	-224	-29	-0	-27	-27

Demographic overview Australia:(United states census bureau www.census.gov)

Demographic Indicators	1995	2005	2013	2015	2025
Population
Midyear population (in thousands)	17,976	20,232	22,263	22,751	25,054
Growth rate (percent)	1.2	1.3	1.1	1.1	0.9
Fertility
Total fertility rate (births per woman)	1.8	1.8	1.8	1.8	1.8
Crude birth rate (per 1,000 population)	14	13	12	12	12
Births (in thousands)	256	260	272	276	290
Mortality
Life expectancy at birth (years)	78	81	82	82	83
Infant mortality rate (per 1,000 births)	6	5	4	4	4
Under 5 mortality rate (per 1,000 births)	7	6	5	5	4
Crude death rate (per 1,000 population)	7	6	7	7	8
Deaths (in thousands)	125	131	156	162	199
Migration
Net migration rate (per 1,000 population)	4	6	6	6	5
Net number of migrants (in thousands)	80	124	130	129	122

The differences seen between the demographic transition witnessed in Uganda and Australia can be attributed to:
1. High death rates in Uganda due to high infant and under 5 mortality rates due to communicable diseases, many underlying issues of which have been addressed in Australia.
2. High fertility rates due to cultural perspectives concerning large numbers of children, religious and cultural perspectives affecting use of family planning services which are inaccessible in some places.

The demographic transition is important because it can lead to an increase in productivity and economic growth as the 'workforce population increases with respect to the 'dependant' population.

Epidemiological transition:
Stage 1: Pestilence and famine
Stage 2: Receding pandemics
Stage 3: Degenerative and 'man-made' conditions
Stage 4: Delayed degenerative conditions and re-emerging infections.

The epidemiological transition directly underlies the demographic transition as it explains the changes in mortality and birth rates.

According to Harper et al(2010), the epidemiologic transition initially explained by Aromran was in 3 stages which were gauged from the Palaeolithic baseline. Research suggests that people lived long(low death rates) and that the population was probably kept stable then because of the low birth rates. During the post Palaeolithic period, people began to keep animals and this led to emergence of new diseases(zoonoses etc) thus higher death rates. The fertility rates were also high as people began to settle and have larger families.
 - The next stage is characterised by receding of pandemics with technology advances. The stages listed above then follow.
The model was disregarded by epidemiologists as they prefer to focus on one disease at a time- it is too unspecific. However, it has value in guiding interventions as predictions can be made for anticipated problems e.g increase in diabetics, re-emergence of infections etc





Literature Reflections:
1. Sen, A(1999) Critical Reflection: Health in development, Bulletin of World Health Organisation, 77(8) 619-623.

• "Economic growth is not an end in itself"  but rather is supposed to facilitate betterment of life. The example of the comparison between the African Americans and Chinese and Indians of Kerla was very useful in illustrating this point. The African Americans have higher per capita incomes than the Chinese and Indians above however their mortality are higher.
• Work done by Sudhir Anand & Martin Ravallion which compared different countries showed that life expectancy and GNP(Gross National Product) are directly proportional only in two instances where the GNP affects: income of the poor and investment in health care.
• The effects on development on health are thus largely dependent on how the income is used.
• He also analysed how some countries with low incomes have improved their health through "support-led" processes. These focus on social support of health and education. In "growth-mediated" processes, success is dependent on economically growth which is then appropriately invested.