Is the proposed National Health
Insurance Scheme (NHIS) for Uganda being rejected?
The recent Cabinet decision to introduce a National
Health Insurance Scheme (NHIS) elaborated to the public by the Ministry of
Health caused both frustration and excitement in the different segments of our
population especially from the Kampala-based formal public and private sector.
The other segments whose views have not been brought to light are the
better-off self-employed, the poor self-employed, and the unemployed and poor. Going
forward, it will be helpful to get feedback from them because they too, have
concerns with the scheme in its current form. Judging from the media stories, the
formal public and private sector in principle accept that this country needs a
health insurance system, which should be acknowledged and applauded. From the
media stories again, they have three main concerns: First is with the proposed
monthly 5% of salary, the amount which some say is too high; second is with the
choice of collection method, the monthly salary deduction which they perceive
as a new income tax; and lastly is with the contribution share of 1% and 4%
between the employer and the employee respectively seen as not fair by the
employees. Even if no media stories (sorry if I am wrong) have run to show how
the other population segments reacted to the proposed scheme, I believe that
them too welcome the scheme in principle, however, the following will be some
of the concerns the poor self-employed, and the unemployed and poor (the
informal sector) will raise: The first will be a question of “what are you
talking about?” because they have never seen the draft bill and even those few
who could have seen it did not understand it because it is not translated into any
local languages; second will be an issue of why they are seen as homogenous and
therefore billed regressively a flat Ugx 100,000 per year per family? they know
and they can tell who is wealthier than the others in their communities and
they will definitely wish that those differences are taken into account while
deciding the amount to pay into the scheme; thirdly will be the issue of availability and quality of health
care services especially in the rural/ remote areas; fourth will be how to deal
with their belief that paying for health care when illness has not come is
synonymous with inviting ill-health; and lastly is how actively they will
participate in managing and governing the scheme because they have suffered
with “fake” schemes in the past which have stolen from them money while others
promised benefits but never delivered them to their satisfaction.
Feedback from all segments of our population is
therefore necessary because we
are talking about a National Health Insurance Scheme in which all citizens are
obliged to join (especially the wealthy and the healthy), where
all citizens can benefit from the insured services; and where solidarity encompassing
all members of the Uganda society is critical because in this scheme there have
to be subsidies from the rich to the poor, from the young to the old, from
small to larger families, from workers to the unemployed, from the healthy to
the sick and vulnerable. moreover, we all have to appreciate that the core objective
of a National Health Insurance Scheme is to guarantee health care provision to
all citizens, serve all citizens (including the poor and needy) according to
their health care needs and not according to what they pay for insurance, and
help families cope with catastrophic health costs which are one of the leading reasons
why some families fall into poverty.
Let me end with two messages and some recommendations:
1)
Introducing a national health insurance
scheme in Uganda will be a reform. It means we shall shift (immediately or in a
phased manner) from the Government healthcare provision using the Government
health facilities (currently free for all) financed through taxes, direct
out-of-pocket payments and donor revenues to a health insurance healthcare
provision to those with insurance identification cards using contracted health
facilities both private and government, financed through pre-paid
contributions/ premiums, and Government/ donor grants for especially subsidies.
2)
Illness is destiny and every one of us
will someday come to terms with it. An individual catching a disease is
unpredictable so is what type of disease it will be, what kind of treatment
will be needed to treat that disease, and how much it will cost. A health insurance system tries to address
some especially the finance related uncertainties and enables a population to
cope better with illness.
The Government through its Ministry of Health has taken
an important step in the right direction even if it is coming after a very long
wait. It is now urgent that the next steps be expedited to get the NHIS bill
2019 ready and tabled before parliament for consideration. At the same time,
the population should be educated about the complicated concept of insurance
and about the NHIS. This role of educating the public should not be solely for
the Ministry of Health, but in partnership with other institutions like the
Community Based Health Insurance Schemes, the Micro finance institutions most
of which cover borrowers for medical expenses, and others. The continued
branding of the health insurance premium/ contribution as a tax needs to be
corrected to allow the public debate the scheme in a more realistic way. It is
also important that the scheme is implemented “the Uganda way” because having
waited for all this long, we should avoid taking the paths other countries
already took and reformed because they didn’t work, we rather should implement
our scheme in a unique way for example, premiums from salary workers could be
deducted once every quarter for example as opposed to monthly deductions, the
scheme implementation phasing could follow a more representative approach like
regional phasing as opposed to the common social-economic classifications where
you start by enrolling those with predictable income (formally employed) and
not so much in need because some of them already have some private insurance
cover, and end with those who do not have predictable income and are much more in
need of the scheme.
Makaire
Fredrick
Executive
Director
Save
for Health Uganda (SHU)
SHU is promoting Community Health Insurance Schemes in
9 Districts of Central and Western Uganda
makairef@yahoo.com
