Abstract
BackgroundUganda is proposing introduction of the National Health Insurance scheme (NHIS) in a phased manner with the view to obtaining additional funding for the health sector and promoting financial risk protection. In this paper, we have assessed the proposed NHIS from an equity perspective, exploring the extent to which NHIS would improve existing disparities in the health sector.MethodsWe reviewed the proposed design and other relevant documents that enhanced our understanding of contextual issues. We used the Kutzin and fair financing frameworks to critically assess the impact of NHIS on overall equity in financing in Uganda.ResultsThe introduction of NHIS is being proposed against the backdrop of inequalities in the distribution of health system inputs between rural and urban areas, different levels of care and geographic areas. In this assessment, we find that gradual implementation of NHIS will result in low coverage initially, which might pose a challenge for effective management of the scheme. The process for accreditation of service providers during the first phase is not explicit on how it will ensure that a two-tier service provision arrangement does not emerge to cater for different types of patients. If the proposed fee-for-service mechanism of reimbursing providers is pursued, utilisation patterns will determine how resources are allocated. This implies that equity in resource allocation will be determined by the distribution of accredited providers, and checks put in place to prohibit frivolous use. The current design does not explicitly mention how these two issues will be tackled. Lastly, there is no clarity on how the NHIS will fit into, and integrate within existing financing mechanisms.ConclusionUnder the current NHIS design, the initial low coverage in the first years will inhibit optimal achievement of the important equity characteristics of pooling, cross-subsidisation and financial protection. Depending on the distribution of accredited providers and utilisation patterns, the NHIS could worsen existing disparities in access to services, given the fee-for-service reimbursement mechanisms currently proposed. Lastly, if equity in financing and resource allocation are not explicit objectives of the NHIS, it might inadvertently worsen the existing disparities in service provision.
Highlights
Equity in health has been defined as the absence of systematic disparities in health between social groups who have different levels of underlying social advantage/disadvantage [1]
Overview of the National Health Insurance Scheme (NHIS) The development of the National Health Insurance scheme (NHIS) is hinged on the WHO resolution [7], Uganda’s Constitution [23], the National Health Policy [24] and the Health Sector Strategic Plan I & II [25]
A feasibility study undertaken in 2001 recommended that Uganda pursues a strategy of starting up Social health insurance (SHI) gradually, by initially covering only civil servants and their families located in large cities plus workers and their families employed by large companies such as those employing 250 workers or more
Summary
Equity in health has been defined as the absence of systematic disparities in health between social groups who have different levels of underlying social advantage/disadvantage [1]. Regional referral hospitals provide general curative and preventive services, specialist services, in-service training and research. A general hospital provides general curative and preventive services, in-service training, consultation and research to community based health care programmes. HC III and II, which are categorized lower level health units/facilities, provide mainly ambulatory services as included in the Uganda Minimum Health Care Package of services. The HC IIs only provide out patient care and community outreach services; they provide the first level of interaction between the community and formal health services. Functionality of these health facilities has been noted to be sub optimal with lower levels of care affected more than higher levels. Percentage of HCIIs, offering child immunization with all equipment available, is only 55% compared to hospitals at 90% [9]
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