National health insurance can build health sector

‘National health insurance not crowd funding can sustainably build the health sector in Uganda'

By Dr. Suzanne Kiwanuka

Public appeals by families or individuals for contributions to help pay for exorbitant medical bills are now commonly accepted as a health financing option in Uganda.

A few recent ones include the Fund Carol and Amani campaigns. Others are corporately organised and include run for cancer, sickle cell and so on.

The fancy term coined for this is crowd funding. I for one cannot fathom how we think this is a sustainable solution to our festering health care system problem. Crowd funding is not something a country should even consider as an option for financing health. Yet not one person can say that there are a lot more people who need to be rescued out of the gapping mouth of the lion of health related bankruptcy.

But without a doubt, this scenario point to a crisis in the Uganda's healthcare system, which will never be solved through crowd funding. What is wrong with crowd funding, one may ask?

For sure, multiple lives have been saved through crowd funding and many families have been rescued from the brink of financial catastrophe, but still there is still something fundamentally flawed with this approach?

First, I compare crowd funding to the good side of a bad apple. Although you eat the good side you eventually get to the bad side and it does not look good any more. Or perhaps I would compare it to a pyramid scheme, where the few who are lucky to get on board early are able to get their dues while the late comers are left in a fix?
But at least a pyramid scheme does not have the threat of an impending death hovering over it like crowd funding for health. Or perhaps I would compare crowd funding to a house with leaky pipes where the owner is busy patching up the leaks with plumber's putty and not bothering to replace the entire system.

While crowdfunding may temporarily plug gaps in the health care system, it only addresses the symptoms of these problems.  And even worse, crowd funding as a popular solution to averting catastrophic expenditure at household level only shifts attention away from these problems and could delay or prevent reforms that would benefit the vast majority of people.

Moreover crowd funding campaigns are largely based on personal appeal, sensationalism, social position, networks and or luck, all of which introduce unquantifiable inequity. Those with socially stigmatised illnesses such as substance addiction and mental illness are unlikely to form the basis of a successful campaign compared to cancer, accidents, children and others with inspiring life stories. Even so, there is always the underlying potential for fraud in campaigns.

About 19.7% (2013) of Uganda's population lives below the national poverty line and catastrophic health expenditures are not specially reserved for such as these because an accident, a sudden job loss, a sick parent, is all it takes to completely derail a family's life.
Uganda's move towards instituting national health insurance will go a long way towards plugging some of the health financing gaps. To bridge the prevailing disparity in access to care, the country strive among other things, to incorporate the informal sector and to conduct means testing to determine exemptions and waivers so that no one gets left behind.

Further, this health insurance reform will only succeed if the health care system is robust enough to bear the brunt of increasing insured clientele.

To avoid invariably favoring the private sector with our health insurance funds, (just as we have recently favored foreign health care systems with crowd funding), the country MUST use available funds to strengthen the capacity of specialized and general public facilities so that they can provide this much needed care.

In addition, the country needs to put in place mechanisms to boost efficiency and manage the skyrocketing cost of health care because without an efficient health system even funding will be useless. Health insurance is certainly a more sustainable and better way to ensure that health is not disproportionately access and helps us to keep our money inside our country to benefit our health system and our people more.

Although crowd funding is fantastic at addressing need and activating people's most charitable selves it will never be a substitute for broad healthcare reform.  If relied upon as a solution, crowd funding will continue diverting attention from a weak health sector and resources from a country in dire need of them to build other systems.

The energy and brilliance of crowd funding could be channeled towards advocating for the sort of health policy change that could eliminate the service barriers. We can keep donating to individual causes but lets not forget that even the best of intentions can perpetuate devastating, systemic inequalities.

With health insurance we can embark on replacing the plumbing of the system to provide services to more people more fairly and more sustainably.

The writer is a Senior Lecturer and Health Policy Expert- SPEED - Makerere University School of Public Health