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.