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.