National health insurance: A forgotten health policy issue at the presidential debate

By Chrispus  Mayora

It was an interesting moment watching the ‘historic' presidential debate with a lot of expectations. The debate focused on domestic issues that will shape Uganda's future. Generally, being the first of its kind, it did not disappoint

Most candidates seemed to appreciate that the health sector needs some improvements, albeit a lot being done. Indeed in general, candidates argued for the need to increase financial allocation to the health sector.

To the candidates, increasing funding will ultimately improve infrastructure, health worker remuneration, improve stocks of supplies and medicines and better health service delivery. Whether insufficient funding for health is the problem is a debate for another day.

While this could be in candidates' manifestos, during the debate, I did not hear details on where these additional finances would be generated from. Most of funding for government programmes is often generated from tax and non-tax revenues.

However, Uganda's tax base is narrow and may not generally raise sufficient resources to service the country's competing needs. A narrow tax base is even constrained by lack of an ‘earmarked taxation' policy, where revenue from taxes, say on cigarettes, or beers could be directed to improving the health services. In addition, further increases in taxation to raise more finances could serve to reduce people's disposable incomes, dis-incentivise production, and may be politically untenable. 

The Uganda National Health Accounts (NHA) 2013, reveals that although government financing for health had been increasing overtime, it had not even reached 10%, which is way below the 15% Abuja declaration (target).

The same review found that Ugandan households contribute more than 50% of financial resources for health, through direct purchasing of services, informal payments for "free" care, and other hospital expenses. About 40% of households in Uganda lack resources necessary for their health care needs, and in some cases, they sell off property including land to access health care, and this contributes to poverty, impoverishment, and deaths.

With the path to increasing taxes being a tricky one, we must identify new approaches to raise sustainable resources for health care in Uganda, while ensuring that the poor are protected from financial catastrophe due to ill-health.

One such approach to resource mobilisation is health insurance. Indeed most countries have successfully used this strategy to raise funds for health. Currently in Rwanda, more than 90% of the population is covered by health insurance. In Uganda, the National Health insurance scheme (NHIS) has been under debate for close to a decade now without much policy progress. With health insurance, individuals with ability to pay contribute premiums to a single pool, and those without ability to pay (indigents) are covered by additional funds from the government or development partners.

The single pool allows members to share health risk and all subscribers can access health services anywhere, anytime without having to pay direct cash. Upon provision of the service, the health service provider then receives funds for the service from the fund holder (insurance company or any such institution holding funds on behalf of its members).

In this way, members are assured of services anytime, health providers are also assured of payments anytime they provide the services, which payments will help them improve service delivery, quality, incentivize their workers, and everyone is happy! For health insurance to successfully function, however, mechanisms to strengthen the health system to ensure a minimum level of functionality must be in place and this could probably require some seed funding from government and implementing partners.

It is time that as a country - and especially our presidential candidates - we move away from prescribing theoretical solutions to improving our health system. As voters, it is our duty to interrogate - beyond increasing financing for health - where resources for implementing the promises will come from.

of a national health insurance scheme (NHIS), a big ticket health policy, which has long been on the shelves. The NHIS may not be a panacea to the health system challenges in Uganda, but will go a long way in addressing the financing gaps as a starting point.

The writer is a health economist with the SPEED Programme - Makerere University School of Public Health & CARTA PhD Fellow, W its School of Public Health, South Africa