Uganda: Can Gen Muntu’s medical plan heal Uganda’s ailing healthcare?

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Mothers congest the postnatal care ward at Kawempe Referral Hospital in Kampala in 2016. PHOTO/FILE.

By Irene Abalo Otto

To access quality healthcare in Uganda, the most common way is out-of-pocket expenses, which to the indigent, means selling off property like livestock, land or taking a loan to foot hospital bills. 

For those in formal employment with private health insurance, they still find themselves contributing to medical bills of relatives and friends.

As presidential candidates traverse the country to sell their manifestos to voters, one of the key issues arising is access to quality healthcare. 

During his campaign launch in Makindye Division in Kampala on November 9, Gen Mugisha Muntu, the Alliance for National Transformation (ANT) presidential candidate, spoke passionately about access to healthcare.

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ANT presidential candidate Gen Mugisha Muntu. PHOTO/NMG

“These days, if a woman from a slum goes to give birth by cesarean section, the hospital asks her to pay between Shs500,000 and Shs1.5m.

Most of these women do not have the money yet they cannot postpone the condition requiring a cesarean section until money is available. The mother may not have even Shs100,000 at that time. Many times the women do not get the much needed support from their husbands. They die,” Gen Muntu said.

Gen Muntu affirmed his vision to fix the country’s ailing healthcare following his nomination to run for the country’s top office on November 3. 

While details of his healthcare plan remain scanty because the party has not formally launched the comprehensive manifesto, the retired military general plans to improve healthcare financing through a national health insurance scheme. A similar scheme has been on the cards for legislation and consideration since the 1990s.

“Health sector should promote primary care alongside curative measures. Equip hospitals and health centres and ensure medicines are stocked.

Reduce brain drain of health professionals and reduce medical tourism by government officials and use the funds to equip hospitals and remunerate the workers well,” Gen Muntu said after his nomination.

He said the cost of healthcare in Uganda can only be made affordable if there is a functioning national health insurance scheme.

“That is what we want to do as ANT (when he becomes president); to have a national health insurance scheme, so even someone who does not have cash can be treated when they go to the hospital,” Gen Muntu told his supporters in Makindye, Kampala, without giving details of how he plans to implement the plan.

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A section of maternity ward at Kayunga Hospital in 2010. Many government hospitals are in a sorry state.PHOTO/NMG

Tenable plan?
But without a clear strategy, Gen Muntu might offer lip-service to Ugandans considering that the understanding of a national health insurance scheme remains limited across sectors and regions in the country. 

“To be honest with you, I do not trust any government scheme. I will not lie to you because I think this is something for someone to get money. If the government health facilities are not working for us, then how do we embrace this new plan? ” Catherine Okello, a resident of Kisaasi, a Kampala Suburb, says.

Okello is a businesswoman who falls under the informal sector. Whereas she spends on medical care for her extended family, she wants the government to improve the existing health system by financing and paying the workers well to deliver quality service.

“It does not make sense to have insurance in a health facility that does not even have drugs. They should also let people be free to continue with their other insurances because it will be double taxation or deductions from my earnings,” Rose Namukwaya, a resident of Namuwongo, a Kampala suburb, says. She earns a small salary as a clinician.

According to health consumer experts, contributors to a health scheme must trust the system for it to work well since they are the source of funding.

“The context of health insurance is to pull resources together, so the numbers are critical.  How many people do you have and how many are very healthy? You need many people and being healthy is equivalent to [being young now]. Because [many of those] who are beyond 60 years have pre-existing conditions and need more frequent visits to health facilities than the young,” Robinah Kitungi, the executive director of Uganda National Health Users’/Consumers’ Organisation, explains.

She adds: “You need to have more healthy contributors so that you care for the indigent ones. This is pulling resources from those who have the money.”

Kitungi says for a national health insurance scheme to be effective, the management costs have to be low and contributors involved in governance.

“Are you managing efficiently by reducing corruption, taking care of fraud and forgery, especially from the private sector and the companies? Those are critical [issues] if you want to target those who cannot afford. It is important to have definite research to include even people in the taxation ring. Like the government can find out who is in Kikuube District? Insurance is also some form of taxation for those in formal employment.

The employed are not a big number, you cannot have only the employed to cater for those who cannot pay,” Kitungi says.

For those who were involved in the planning process of the current national health insurance scheme under consideration, the amount to be contributed or deductions are likely to impede implementation if all stakeholders do not agree on what premium is affordable to each category in the Bill.

“We have done some thinking around the policy and said it should be four per cent premium contribution or less, for public service but that depends on your investment so that people are not restricted to a particular package. But the government needs to think about a big subsidy for those in civil service because their [salary] is too small. Government should figure out how to pay for them.” Kitungi explains.

She adds that because the people who can already afford to pay for healthcare are the ones walking into government hospitals and getting better care even without paying for it, the poor have had to use their own money outside crowded government facilities to access medical care.

Building trust
To build trust in the health financing system, health experts say there is also need to see the same quality of service in all areas where the scheme will operate.

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An attendant stands by her patient at Nebbi Hospital in 2015. PHOTO/ PATRICK OKABA.

There is no universal national insurance scheme to cover all citizens yet private healthcare is too expensive for majority Ugandans.
Gen Muntu’s proposed healthcare plan could require people to contribute money to the scheme in form of premiums. 

However, given that Uganda’s national poverty estimates have wide variations across regions, this could become a challenge. 
According to the 2016/2017 Uganda National Household Survey, 21.4 per cent of the population is below the national poverty line.

However, compared with the 2012/2013 poverty map, poverty in most sub-counties increased significantly in 2016/2017. This puts many people at risk of dying when they fall sick due to lack of access to proper healthcare.
 

Health insurance: Uganda’s case
In Uganda, health insurance organisations are involved in collecting insurance premiums from either individuals or companies in return for a specified health benefit package for those who are covered by insurance.

The insurers are not involved in actual health service provision.
In contrast, health maintenance organisations have a dual role that involves the collection of insurance premiums from individuals and/or companies on one hand, and the actual provision of health services to those who are medically insured on the other. It is still not clear how many of these providers are offering such pre-payment schemes.

Background: Other alternatives
Community Health Insurance Scheme (CHIS)
There are, however, other community health insurance schemes that have been operational since 1995 when the Ministry of Health introduced the Community Health Insurance Scheme (CHIS). But a few people, mostly in central and western Uganda, have embraced and benefited from the system. 

Uganda’s health sector takes CHIS as a better option for the informal sector since it gives room for community participation and has relatively affordable premiums compared to commercial health insurance schemes.

In a CHIS, communities choose the model they want and how it will be operated as contributors to the scheme. There are always specific amounts for particular packages just like any other insurance but at a relatively lower cost.

Other countries
Kenya, Rwanda and Ghana are among countries that have tried to some degree of success to implement a national health insurance scheme for their populations. 

A common factor identified by all countries is the need to ensure that poor and marginalised people are included in the scheme.

But before Gen Muntu’s presidential promises, the Ugandan government is making some efforts at legislating about the scheme. The discussion started in Parliament in 2012, with a Bill to operationalise the national health insurance scheme.

Uganda’s efforts
In June last year, Cabinet approved the draft National Health Insurance Scheme (NHIS) Bill 2019 to be presented to Parliament for debate and enactment. The scheme is a contributory, prepared system that requires mandatory prepayment of premiums as established by law.

Whereas Gen Muntu promises to have a national health insurance scheme take care of high costs of quality healthcare for, especially the poor, this could be a good idea wrapped in a repeated rhetoric for the well-to-do, who can afford to pay the premiums.

According to advocates of the Bill, prepayment can help people plan for their expenditures on health and government can equally contribute for the low income earners so that people contribute and demand quality care.

“We are asking that the Bill should be passed into law. The free healthcare services being provided by the government right now does not guarantee quality care. But out-of-pocket expenditure for healthcare is too high. That money can be channeled into prepayments for quality healthcare.

That situation is undesirable and prepayment is better because it is planned for,” Proscovia Namulondo, the community and advocacy officer at Save for Health Uganda, says.

For those who have an insurance scheme with their employer, Namulonde believes the same group of people can be catered for within the NHIS.
“If your employer is already paying, they can continue to pay for it through the NHIS. There are people who are failing to go to health facilities because they fear the high costs. Some people walk back home with the prescriptions without buying the medicine,” Namulondo says.

Source Daily Monitor.

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