Can the national health insurance scheme be revived?

Over the years, Uganda has had twists and turns in its health financing reforms. In 1993, the government introduced user fees for all public health services as part of broader health reforms. However, eight years later, President Yoweri Museveni overturned this policy, announcing the abolishment of the fees during the 2001 general election campaign season. There is evidence to show that this policy improved access to health services. However, recent studies conducted by Ugandan researchers and WHO indicate that the action did not solve the problem of OOP health expenditure.

 In a 2023 report that examines health financing reforms in Uganda, published in the Internal Journal of Health Policy and Management, Prof Robert Basaza, a health policy specialist at Uganda Christian University’s Department of Public Health, notes that, “Political commentators considered user fees removal as a political pledge fulfillment by the current President during the 2000 election campaigns. During these campaigns, the electorate had decried the high costs of healthcare services which left many of them without any option but to forego the needed services.

Notably, it (the abolition of user fees) improved access to health services among the poorest households. Over the years, this policy has drifted as evidenced by the increasing OOP health expenditures.”

 The researchers also note that despite this, the current government has not introduced any new reforms to reduce the financial hardship faced by Ugandans, leading to the conclusion that it (the government) is not interested in major policy reforms that contradict the current free healthcare policy.

A wake-up call?

Twenty years after the abolition of user fees, the Minister of Health, Dr Jane Ruth Aceng, now says the notion that healthcare should be free of charge is hindering the progress of the health system.

 "Healthcare is expensive. I have travelled around the world and I have never found a country that offers free health services as Uganda does. We are burying our heads in the sand when we pretend that services can be free, yet we do not have the money to support this. The NHIS Bill has been on the agenda since last year and it needs to be fast-tracked because it is the only way we are going to mobilise additional resources for health. We cannot keep talking about free health services. Somebody must pay for it," she says.

 Currently, the health sector is struggling to address gaps such as poor or limited infrastructure in some health facilities, low drug supply, and a small number of doctors and specialists in the public service.

 “In the revised NHIS Bill, each Ugandan will be required to pay Shs15,000 per month, so that a grandmother in the village can afford health care. There will be no employer contribution. However, dependents below 18 years have to be paid for, so the more children you have, the more you will pay. So, this will also be a family planning tool,” the minister says.

 Dr Aceng adds that recently at the United Nations, Uganda and many other countries, made commitments to ensure universal health coverage. Some of the commitments were to address financial risk protection through the introduction of the NHIS to protect households from catastrophic health expenditure and improve community-led health interventions with a focus on disease prevention and working with community health extension workers.

Involving the private sector

Dr Peter Kibuuka, the chief executive officer of Kampala Hospital, says the private sector should be brought on board if the NHIS is to register success.

 “Health facilities have to be accredited based on competence and no favouritism should be given to public facilities. When it [NHIS] comes, every Ugandan will have access to quality care because they will go to the best clinic next to them if it is accredited or to a government facility. Many private facilities have already invested heavily in equipment and have the human resources needed to handle complex medical conditions, and in some instances, are more efficient in offering services than public facilities,” he says.

 Fredrick Makaire, the executive director of Save for Health Uganda, an organisation that offers community-based health insurance, says when the NHIS becomes functional, there is a need to work with private insurance service providers since they already have structures within the community.

 “Working with community-based health insurance schemes would ease the collection of premiums from people in the informal sector because we have been working with them. Community-based health insurance schemes have structures from the villages to sub-county and district level, so they can use those structures to mobilise and sensitise families,” he says.

 Lubega adds that the introduction of the NHIS would not negate the necessity of private health insurance service providers.

 “NHIS is only providing a basic cover, which means, specialised medical services will still be done outside it. Therefore, NHIS is designed for the ordinary/poor Ugandan. We, therefore, recommend that either the government or donor agencies make contributions to the poor. The IRA is ready to ensure effective sensitisation to drive acceptance and ensure rollout, implementation and supervision of the scheme to achieve the intended purpose,” he says.

How are other countries making it work?

Through the National Health Insurance Fund (NHIF), where members contribute a premium, the Kenyan government has been providing health insurance to its nationals since the 1960s. Contributions are mandatory for those in the formal sector and voluntary for those in the informal sector. The country also finances its healthcare through revenues collected, donor funding, private health insurance, and OOP spending by citizens at points of care.

 According to a 2023 University of Nairobi research report, national health insurance coverage in Kenya stands at around 20 percent, much higher than Uganda’s current two percent. It is common for individuals to have more than one insurance scheme. As such, there is no mutual exclusivity in enrollment into any scheme.

The NHIF operates three main schemes namely; the civil service scheme (CSS), the national scheme (SupaCover), and health insurance subsidy for the poor (HISP). Each scheme offers different benefit packages with considerable variation between inpatient and outpatient care. NHIF also implements free maternity, older persons and persons living with severe disabilities, and secondary school students’ insurance programs to enhance social protection and inclusivity.”

 According to the report, informal sector workers enroll in NHIF by paying a fixed annual premium of $59.9 (Shs228,698) for SupaCover. Coverage rates are low and attrition is high among this group, posing universal coverage challenges. Formal sector employees pay a graduated monthly rate based on salary scale, ranging from $1.5 (Shs5,727) to $17 (Shs64,906).

 In Rwanda, the government runs a Community-Based Health Insurance (CBHI) scheme with people categorised into four groups. Category I pays Rwf3,000 ($4.65 or Shs17,753) per person and this category is supported by the government and donors.

Individuals in Category II and III pay Rwf3,000 per person and those in Category IV pay Rwf7,000 ($10.85 or Shs41,425) per person. Information from the United Nations suggests that membership in Rwanda’s CBHI scheme grew from 27 percent in 2003 to 91 percent in 2010.

Key figures to note

Proposed membership contribution  in Uganda

Shs180,000 annually

Shs15,000 per year for vulnerable people such as the elderly

What is paid in Kenya?

Shs228,700 annually for individuals in the informal sector

Between Shs68,700 and Shs778,800 annually for those employed in the formal sector

 What is paid in Rwanda?

Between Shs17,753 and Shs41,425 annually, depending on socio-economic status.