Background
Socio-economic and political context underlying NHIS development
Financing health services in Uganda
Policy | Provisions relevant to NHIS |
---|---|
Constitution of Uganda 1995 [26] | • Objective XIV (b) is to ensure that Ugandans have access to health services |
• Objective XX is a commitment to take all measures to provide basic medical services to the population | |
Health Sector Strategic Plan (HSSP) 2000/01–2004/05 [27] | • SHI as one of the key objectives of its healthcare financing component |
• Government would continue to develop and support alternative healthcare financing schemes | |
Poverty Eradication Action Plan (PEAP) 2004/2005–2007/2008 [28] | • Objectives are pro-poor focused and are consistent with the MDGs |
• Human development and improving health outcomes among the key priorities | |
Cabinet Minute No. 63 (CT 2006) | • Directed the Minister of Health to issue drafting instructions for the bill establishing the National Social Health Insurance Scheme to the First Parliamentary Council; Directorate in the Ministry for Justice responsible for legislative drafting |
National Development Plan (NDP) 2010/11 – 2014/15 [29] | • Provides for the establishment of health-financing mechanisms (NHI and other community health-financing mechanisms) based on prepayment and financial risk pooling with the goal of achieving universal coverage and social health protection |
NRM Presidential Manifesto 2011–2016 | • Provides for establishing a national health insurance scheme as one of the work programs in the health sector in 2011–16 |
Health Sector Strategic and Investment Plan (HSSIP) 2010/11–14/15 [30] | • Calls for health insurance, with the goal to increase financial access to healthcare and reduce the catastrophic expenses that impoverish households, to be introduced gradually, leading eventually to universal health coverage |
• Commitment to fully harmonise health policies, standards, and guidelines for the East African Community by 2014–15 | |
• Guided by the principles of: (i) access for all to a minimum package of services; (ii) equitable distribution of services; and (iii) effective and efficient use of health resources | |
National Health Policy [14] | • Upholds the obligation of the government regarding citizens’ access to healthcare |
• Guided by the same principles as HSSIP 2010/11–14/15 | |
Cabinet Minute No. 84 (CT 2011) | • Directed the Minister of Health to issue additional principles of the bill to the First Parliamentary Council taking into consideration stakeholder concerns |
Process of NHIS development
Phase I, 1995–99: ‘people’s power’
Phase II, 2001–05: ‘hopeful start’
Phase III, 2006–11: ‘stakeholder concerns’
Financing the proposed NHIS
NHIS | CHIS* | PCHIS* | |
---|---|---|---|
Common arrangements
| |||
Role of proposed Board of Directors of NHIS | For oversight of health insurance schemes and in-house operations of public sector workers and their dependants scheme, the social health insurance scheme | Represented on the Board. The NHIS Board will provide regulations | Represented on the Board. The NHIS Board will provide regulations |
Regulation by Insurance Regulatory Authority of Uganda. | Yes | Yes | Yes |
Participation in solidarity funds | Provides funds to CHI for indigents | Membership for indigents shall be paid by the NHIS | Contributes part of the premium to the solidarity fund for paying premiums to indigents. |
Specific issues
| |||
Ownership | Government | Private | Private |
Current coverage | - | 5–10% of the population where the schemes exist | 1% of the national population |
Target membership | Public formal-sector workers and their dependents | Informal-sector workers and their dependents. | Employees and dependents from the private formal sector |
Proposed/current source of funding | Mandatory payroll deductions and contributions from both employees and the government | Contributions from personal earning for those above the poverty line. | Mandatory payroll deductions and contributions from employees and private-sector employers |
Payment from the solidarity fund for those below the poverty line | |||
Benefit package | Stipulated in the bill | Negotiated with the private healthcare providers | Negotiated with employers, trade unions, and individual members and insurance companies. |
Methods
Stakeholder analysis and design of the NHIS
Stakeholders and their policy positions
National government actors/ politicians | Public sector | Private sector | Civil society | Donors |
---|---|---|---|---|
i) Parliament (ruling party and opposition) | i) National Social Security Fund (NSSF) | i) Private for profit and non-profit providers | i) NGOs | i) Providing for Health (P4H). |
ii) President (executive president) | ii) Insurance Regulatory Authority of Uganda (IRAU) | ii) Private insurance companies | ii) Trade unions and employee groups | ii) Swedish Development Agency |
iii) Prime minister | iii) National Planning Authority (NPA) | iii) Private-sector foundation | iii) Health professional associations | iii) UK Department of International Development |
iv) Cabinet | iv) Uganda Manufacturers Association | iv) Belgian Technical Cooperation | ||
v) Ministry of Health | v) Community health insurance schemes | |||
vi) Ministry of Finance, Planning and Economic Development | vi) Federation of Uganda Employers | |||
vii) Ministry of Public Service | ||||
viii) Ministry of Gender, Labour and Social Development | ||||
ix) Local governments (district and urban authorities) |
High support | Medium-level support/low opposition | High opposition | |
---|---|---|---|
High influence
| i. Parliament | i. Trade unions | i. National Social Security Fund (NSSF) |
ii. Prime minister | ii. Federation of Uganda Employers | ||
iii. Cabinet | iii. Uganda Manufacturers Association | ||
iv. Ministries (MOH, MOFPED, MOPS, MOGLSD) | iv. Private sector foundation | ||
v. Providing for Health (P4H) | |||
Medium-level influence
| i. Insurance Regulatory Authority of Uganda | i. Local governments (district and urban authorities) | - |
ii. IRAU | |||
iii. National Planning Authority | |||
Low influence
| i. Private for-profit providers | i. NGOs & religious medical bureaus | - |
ii. Community Health Insurance Schemes | ii. Donors (bilaterals) | ||
iii. Health professional associations | |||
iv. Private insurance companies |
Stakeholders offering a high degree of support and having high-level influence
Stakeholders offering a high degree of support and having medium-level influence
Stakeholders offering a high degree of support and having low-level influence
Stakeholders offering medium-level support and having a high degree of influence
Stakeholders offering medium-level support and having medium-level influence
Stakeholders offering medium-level support and having low-level influence
Stakeholders offering a high degree of opposition
Results and discussion
Health financing
Stakeholder engagement
Additional considerations
Conclusions
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It is vital to undertake a comprehensive stakeholder analysis as part of any substantive health-sector reform to identify, address, and overcome concerns before they harden into inflexible opposition. An intensive, detailed stakeholder analysis during the design process could pinpoint rising issues or threats, minimise obstacles to passage, build coalitions, and channel information and resources to promote and sustain reform implementation [49, 51].
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The positions of stakeholders can be influenced to shape the direction in which they develop over time. Thus, policy makers and implementers need to consider periodic re-categorisation of stakeholders to capture emerging positions and shifting power dynamics as well as sustain their continued engagement. If stakeholder analysis is not re-evaluated at regular intervals, it can slow down or halt the policy design and development process—even when there is strong support from senior executive and legislative representatives.
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The private sector represents an important stakeholder in health-financing reforms, and its role needs to be carefully considered. Comprehensive feasibility and actuarial studies of the health insurance scheme need to be complemented by broader political economy analyses and social impact assessments that specifically examine the potential effects of SHI on employment and investment in the private sector.
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A situational analysis of health-sector policies and recent health reforms may need to be conducted to identify potential conflicts with the proposed NHI plan. Launched after major political change and against the backdrop of abolition of user fees, the NHIS faces additional challenges that overlap with technical issues, stakeholder management, and the common apprehension that often surrounds major health reforms. It is necessary to address these challenges. This will entail reconciling the views of two different sets of stakeholders on how to overcome the financial barriers to access: those advocating user fee abolition to achieve universal healthcare; and those advocating the imposition of some level of contribution for insurance coverage as the vehicle for universal healthcare. For example, Kenya and Tanzania had to reintroduce user fees before implementing their NHI schemes [4, 64, 68]. The government of Uganda may need to re-evaluate the impact on changes in the level of community financing of services in the current environment of abolishing user fees before pressing on with stakeholder discussions and NHIS implementation [6, 64].