To support or not to support the National Health Insurance Bill?

Dr Elizabeth Ekirapa Kiracho

Uganda is in the process of developing a roadmap for achieving universal health care coverage. Uganda as a country, therefore, needs to find ways of ensuring that more Ugandans receive a basic essential package of quality preventive, curative and rehabilitative services without financial hardships.

However, a review of the health care expenditure for Uganda indicates that 41% of the health care expenditure is paid at the time when people need care. What does this mean? If you don't have the money you don't get the service. But as we all know illness can't be postponed. A lot of people have died because they did not have money either to go to hospital or to pay for the services required at the hospital. While others have died because the hospitals or health facilities did not have the resources required or where so poorly managed that they could not provide the required lifesaving service required. 

The recently passed National Health Insurance (NHI) Bill provides an opportunity for people to contribute money before they are sick so that they can receive the services that they need when they are sick. Moreover, the services they receive may even cost more than what they have contributed. That per se will not improve the problem of poor service delivery but it provides an opportunity for us to get a larger pool of financial resources that can be used to improve health service delivery. 

Most people agree with this analogy and indeed say insurance is good but they say they are not willing to pay for it because they believe that the government will misuse their hard earned money.  I agree there is a high chance of that happening, but in my opinion that does not mean that the fear of the corrupt should stop us from making beneficial decisions that could save the lives of Ugandans! Besides, the status quo is not any better. 

Allow me to ask you a question? How many of you have stopped using motor vehicles because of the high risk of accidents on Uganda's roads? You still get into a vehicle, but you ensure that you drive carefully, wear a seatbelt, obey traffic rules etc so that you avoid accidents. So I believe that as citizens we should support the NHI scheme and then put in place measures to hold government accountable to put in place institutional arrangements that will safe guard our funds and ensure that the promised services are actually delivered.

I have a few suggestions of steps we can take to ensure that the NHI delivers the promises that we expect.

• Firstly, ministry of health and its partners should strengthen preventive services by revitalizing preventive care provision so that we reduce the need for curative services.
• Secondly, let them critically review the resources available and provide a small effective package of services initially. As people's income increases and they can pay more premium then the package can be increased. For example, in the initial phases insurance could cover catastrophic high cost illnesses such as severe pneumonia, severe malaria, caesarian sections, emergency operations which government is currently unable to provide to every Ugandan. Why? Because the money collected through the NHI is unlikely to be adequate to cover both basic primary care services and more specialized services as per our minimum health care package.  The scheme would most probably run bankrupt and fail to deliver what it has promised.
• Thirdly, let the government increase its share of the national budget so that it meets the cost of other basic primary health care services. Government currently covers only 17% of the health care expenditure.
• Fourthly, ensure that at least 80% of the money collected through insurance is used to purchase the required resources for service delivery and not for administrative costs. This will enable the NHI to actually provide the services that it promises to provide.  
• Fifthly put in place institutional arrangements that will ensure that the money provided is used efficiently and accounted for correctly.
• Sixthly the NHI members should hold the scheme accountable and expect them to account for the funds that they receive and the services that they promise to provide. 

As I close, I must emphasise that there are several things that we need to fix within the health system, but refusing to pass the insurance bill will not solve these problems. How we should solve those problems is a debate for another day, but one that we must hold.  For now, let us pass the NHI Bill, co-design it with key stakeholders, develop a detailed roadmap and implementation plan and start small by piloting it in a small area and then we keep on improving it.

Let us remember the common adage "Start small but start now!" 

The writer is a health economist with SPEED project and the chairperson of the Department of Health Policy Planning and Management of the Makerere University School of Public Health