The Move towards Universal Health Coverage (UHC) in Uganda
Universal Health Coverage has become the culmination of efforts from around the world to realize the highest standard of the right to health. In Uganda, the state has developed and implemented policies to fulfill its constitutional obligation to provide medical services to the population. The implementation of these policies has had mixed results on the access to health care in Uganda, which is characterized by poor indicators including a high maternal mortality rate, high infant mortality rate, low anti-retro viral therapy (ART) coverage and low financial commitment from the state. Uganda has developed the Uganda National Minimum Health Care Package (UNMHCP) to ensure access to a basic level of health services for all Ugandans. Coupled with the proposed national health insurance scheme, the move towards universal health coverage (UHC) in Uganda shows positive signs of progress. This paper assesses the conceptualization of UHC in the context of Uganda and explores efforts that are being undertaken to move towards the realization of UHC in Uganda.
Health care delivery over the past years in Uganda has shown steady signs of improvement yet it remains concerning that the majority of targets under the Millennium Development Goals (MDG) relating to health were missed by a large margin. A large proportion of the public are still unable to access health care in the most basic forms and yet those who are able to access some form of health care do so by incurring catastrophic expenditures, which adversely impact their socio-economic well-being.
During the MDG period, there was a reduction in the mortality rate for those under 5 –from 152 deaths for every 1000 live births to 56 deaths for every 1000 live births. In addition, the infant mortality rate was reduced from 88 deaths for every 1000 live births to 31 deaths for every 1000 live births (Ministry of Finance, Planning and Economic Development, 2015). The core indicators reported in the Annual Health Sector Performance Report of 2015 similarly reflect poorly on the state of access to health care in Uganda.
By the end of the Financial year 2014/2015, it was reported that only 36.6% of women were attending at least 4 antenatal care (ANC) sessions, only 52.7% of women were attending deliveries in health care facilities, only 48% of people who need ART coverage receive it and only 53.4% of women can access intermittent preventive treatment, among others. The indicators for children are more promising with 90% of children immunised with a third dose of the prevalent vaccine and vaccine against measles.
The per capital government expenditure on essential medicines and health supplies was estimated around USD 2.4, which was way below the target of USD 12. Only 51% of Health Center 4s are functional with the ability to do cesarean sections while only 38% of the facilities can provide blood transfusion and only 64% of health facilities were reported to have had no stock outs of any of the six tracer medicines for a period of more than 3 months.
These indicators represent successes and failures with regard to the Ugandan health sector. Today, Ugandans still have difficulty in accessing health care services. Most women cannot access the required level of ANC and this coupled with the fact that over 45% of women cannot access health facilities for deliveries, arguably accounts for the unacceptably high maternal mortality rate of 343 deaths for every 100, 000 live births in Uganda (WHO Global Health Statistics, 2015). Health Center 4s serve as referral hospitals for the health units below them and yet only 64% of them are fully functional and only 38% of the fully functional centers are able to provide blood transfusions. This implies that the majority of patients around the country who need to access treatment that involves any form of surgery or blood transfusion will have to travel longer distances and often at their own cost.
The government’s actual expenditure on the health sector has over the past five years fluctuated between 7.8% and 8.9% of the National budget with an expenditure of 8.5% in the financial year 2014/2015 (Ministry of Health, 2015). This expenditure accounts for only 15% contribution to the financing of the health sector in Uganda with donors contributing 45% and household out of pocket expenditure contributing up to 37% which exceeds the 20% expenditure by households recommended by the World Health Organization (WHO) if the households are not to be pushed into impoverishment (The Ministry of Health, September 2015). Private insurance schemes exist to relieve the health financing burden on households but these have been mainly maintained within the formal sector leaving the informal sector –that has the highest need for health insurance– out. Efforts have been initiated to develop a national health insurance scheme to ensure that health care can be accessed across Uganda without subjecting households to catastrophic expenditure. In its current form, the Health Insurance Scheme Bill still has some shortcomings that do not answer the majority of questions required for the realization of universal health coverage in Uganda.
It is important –in light of the state of the health sector in Uganda as discussed above– to examine the conceptualization of UHC, how it has manifested internationally and how it applies to Uganda’s health system.
Cognitive Understanding Of Universal Health Coverage In Uganda’s Perspective
It is impossible to divorce UHC from the right to the highest attainable standard of health. Indeed UHC can be traced as far back as from the WHO constitution, which noted that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. The WHO Constitution set its objective as the attainment by all peoples of the highest possible level of health (WHO, 1946).
Universal Health Coverage is geared towards ensuring access to required health services and to ensuring that populations maintain and improve their health (WHO Website, 2016). The WHO defines UHC as ensuring that all people have access to the required promotive, preventative, curative and rehabilitative health services, of sufficient quality to ensure that people do not suffer financial hardship when paying for available services.
Access to health care for all is the cornerstone for UHC. To fulfill UHC’s objectives, all people ought to have access, without discrimination, to nationally determined sets of quality and affordable basic health services. (UN General Assembly, 12 December 2012 ). States have been urged to ensure equitable distribution of quality health care infrastructure and to ensure that health financing systems include a method of prepayment of contributions for health care to share risk and minimize catastrophic health care expenditure (WHO World Health Assembly, 2005).
The WHO highlights three dimensions regarding UHC. This includes: a) the extent of services covered (what is covered?); b) the proportion of population covered (Who is covered?); c) the degree of financial protection (who covers the cost and or what is the cost?).
The coverage of services includes a set of services that have been clearly defined as part of a country’s move towards UHC. This may include a description of which maternal and child health services are offered such as emergency obstetric care, pre-natal care etc.
Coverage of the population will include who is able to access the services. For example, services should be available to vulnerable populations such as elderly, mothers, children, or people living in remote areas. It is important to note that although the term universal means that everyone is covered, it may not be entirely possible. The 2010 World Health Report also notes that, “none of the high-income countries that are commonly said to have achieved universal coverage actually cover 100% of the population for 100% of the services available.”
Coverage of the cost of health care considers financial contributions, which are made by the government or a government-supported scheme and may include pooled funds, pre-prepayment schemes or increased government spending. Within this dimension, the ideal situation is that the patients’ direct payments are avoided and in case they are not completely dealt away with, then the costs required should not create financial hardship.
It is important to note that while the definition and purpose of UHC is the same, there isn’t a “one size fits all” approach to UHC. Different countries such as Rwanda, Ghana, Brazil and Thailand have taken on different approaches that take into consideration their unique context, challenges and available resources. Therefore Uganda requires a unique approach, which also implies that advocacy must consider the Uganda’s unique circumstances regarding UHC.
Figure 1: Source WHO Website
The move towards UHC should be implemented along the proposed three dimensions. For example, health financing reforms can reduce the level of cost-sharing and user fees, increase the services covered under the available pool of funds and make the services available to more people (WHO Website, 2016). The dimensions reflect the set of policy choices relating to benefits and their rationing involved in reform towards UHC. Considering the limited pool of funds available within any health setting, choices need to be made regarding proceeding along any of the policy dimensions.
Movement towards increasing coverage of needed health services should include provision for quality, promotion, prevention, treatment, rehabilitation and palliative health care. They should be responsive to the needs of the people and should be available across the different levels of the health system. To increase financial risk protection, consideration ought to be made to minimizing the incidence of catastrophic health expenditure, which could lead to impoverishment as a result of out of pocket payments. An increase the number of people covered by health services should, on the other hand, consider equity in order to ensure that all people get what they need at an affordable price in light of all social economic disparities including age, income, sex, etc. (Dr Marie-Paule Kieny, 2016).
The global community has Sustainable Development Goals (SDGs) set sights on achieving universal health coverage for all under Goal 3, which seeks to promote health and well-being for all. In addition to aiming for UHC, the SDGs aspire to reduce global maternal mortality to less than 70 deaths per 100,000 live births, end preventable deaths of new-borns and children under five. Countries aim to reduce neonatal mortality to at least 12 per 1000 live births, end the epidemics of AIDS, Tuberculosis, Malaria among other communicable diseases and to ensure universal access to sexual and reproductive health care among others.
Manifestations of UHC in Uganda’s Health Policy Framework
The support in moving towards UHC at the global level is unanimous. As indicated above, support has become mainstreamed among other targets in the global development agenda. UHC similarly has been featured heavily in Uganda’s health policy framework, which indicates a strong commitment by the government to work towards its realisation.
Uganda Vision 2040
The Vision 2040 (the Vision) is Uganda’s development agenda leading up to the year 2040 and provides the overall policy foundation that will guide Uganda’s policies as it aims to move from a low income country to an upper middle income country (The Republic of Uganda, April 2013).
It is apparent that the movement towards UHC will be an essential feature to the realisation of the Vision’s objectives. The Vision aims to reduce the percentage of the population living below the poverty line to less than 5%, increasing life expectancy to 85 years, reducing infant mortality per 1000 live births to 4, reducing maternal mortality rate per 100,000 live births to 15 and reducing the infant mortality rate per 1000 live births to 8. These targets hinge on the realization of UHC and one of the strategies proposed to overcome the high cost of accessing health care is a policy shift towards a public-private partnership. This joint approach to health financing could lead to the creation of a universal health insurance scheme, which could help Uganda reach its targets.
It is therefore envisaged that by 2040, the public sector would have relieved itself of its financial obligation to provide for health care with the public contributing through social health insurance schemes. One of the major concerns of the development of the national social insurance scheme is the risk of the state ignoring its obligation to provide health services to the public at no cost. This would culminate in the state relying on the insurance pool to offset public expenditure on the health sector.
The National Development Plan 2015
Under Vision 2040 is a series of six development plans meant to guide the country’s development over a period of five years, each leading up to the realization of the Vision. The Vision’s second development plan was launched in 2015 and similarly reflects the commitment of the state to improve the state of the health sector in Uganda (The Republic of Uganda, June 2015).
While there was progress in the first phase of the national development plan –characterized by increase in physical access to health facilities and increase in the pentavalent vaccine coverage rates– the state of the health sector remains worrying because of the high maternal mortality rate and regular stock outs of essential drugs across health facilities in the country.
The Plan recognizes the major contribution that households incur in financing their health care. This has affected access to health care and the targets put in place to strengthen the health systems by establishing a national health insurance scheme to work towards UHC. Core health targets for 2020 include the increase in health facility conducted deliveries to 64% with hopes of reducing maternal deaths to 119 per 100,000 live births, reducing deaths under five in health facilities per 1000 live births to 16 and increasing the percentage of people accessing health insurance to 6% from 1%.
It appears then that the focus of the current phase of the National Development Plan’s (NDP) national financial coverage is the establishment and immediate operationalization of the scheme. Achieving such a goal would lead to more people accessing health insurance in Uganda. In light of the plan’s highly ambitious indicators, it is pertinent that efforts to establish the scheme be increased, as its need is urgent.
The National Health Policy 2010
The National Health Policy gives the Government of Uganda the policy framework for health care services. The National Health Policy is informed by various policy aspirations such as: Vision 2040, the National Development Plan, the obligations of the state under the Constitution and its international and regional commitments.
The Policy is focused on the delivery of the National Minimum Health Care Package to Ugandans and details the composition of the health system in Uganda explaining that it consists of the district health system (communities, Village Health Teams VHTs or health centres: HCs I, II, III and IV and general hospitals, Regional Referral Hospitals (RRH) and National Referral Hospitals (NRH)).
The policy explains the financing mechanism for the health sector, which includes government revenues and development assistance under the Sector-Wide Approach (SWAp) with private not-for-profit providers, private wings of public hospitals, and private health providers being financed through user fees. There is thus a high dependency on user fees, which has created equity gaps resulting in the poor unlikely to afford services.
To finance public health services, the National Health Policy undertakes to provide adequate resources to the health sector with the guidance of UHC and social health protection. The policy identifies the development of a national health financing strategy that is cognisant of international and regional commitments. This strategy aims to redress the gaps in health financing in Uganda by prioritising the UNMHCP and the establishment of health financing mechanisms based on pre-payment and financial risk pooling.
The Health Sector Strategic Development Plan 2015/2020
The Health Sector Strategic Development Plan (the Plan) provides the overall health sector-planning framework and provides the strategic focus of the health sector. The Plan highlights how it will contribute to the Second National Development Plan, the Second National Health Policy and the Vision 2040.
The Plan reiterates the nature of health financing in Uganda and mentions the 37% contribution that households make (out of pocket) for financing their health care needs. This household contribution exceeds the 20% expenditure recommended by the WHO and the 45% contribution that development partners make to health financing in Uganda.
For the development-planning phase 2015-2020, the Plan undertakes to increase the protection of financial risk within households in order to minimize impoverishment as a result of high health care expenditures. The protection of financial risk may result in establishing systems for revenue generation, establishing systems for risk pooling, establishing systems for strategic purchasing of services and improving financial and procurement management systems. It is envisaged that the implementation of the Plan will reduce out of pocket expenditure as a percentage of total health expenditure to 30% and will increase government allocation to the health sector as a percentage of the total government budget to 15% in accordance with the commitments of the Abuja declaration.
From the policy planning frameworks, it is clear that there is a strong policy commitment in support of the move towards the realization of UHC. The effort towards UHC in Uganda appears to be centred on the provision of the UNMHCP and the establishment of risk protection against catastrophic out of pocket expenditures on health care. Efforts to implement these two initiatives are already underway however, their impact on universal access to health care still raise questions relating to the proposed health and financial risk protection coverage.
Key Initiatives in Uganda’s Move towards UHC
The Uganda National Minimum Health Care Package
The development of a National Minimum Health Care Package is based on the presumption that no single state has the infinite amount of financial resources that are required to provide health care for its all of its populace. Indeed there is a need to identify priorities to which the resources available can be committed to obtain the most optimal value in terms of access to health care for all.
It has been argued that the purpose of the minimum health care package is to assist in resource allocation within the health sector as it faces a growing burden resulting from a disproportionately small health care budget. By identifying package of services that the state would mandatorily provide to all members of the public at no cost, the rest of the services being accessed would be incurred out of pocket or through health insurance (Sengooba, 2004). This approach provides a minimum value to the states’ commitment in providing health care to those in need and to ensure the best possible value of the available resources by allocating them to the interventions that have the most benefit in improving people’s health (Sengooba, 2004). This argument is validated by the Constitutional obligation to provide basic medical services to the population under the National Objectives and State Principles of State Policy and is further validated by the obligation of the state to ensure the realization of the highest standard of the right to health under its international commitments.
The value of the minimum health care package however exceeds merely setting a minimum core of health care services that should be accessible by the public. The national package should be considered as a starting point to ensure that the highest priority services are not ignored or omitted and form a basis upon which further priorities can be determined by the state as the resource pool available for health grows and as the health challenges continually rise (Bobadilla, Cowley, Musgrove, & Saxenian, 1994).
In Uganda, the Health Sector Strategic Plan first defined the national minimum health care package. It was to include a package containing 12 ‘technical care programmes’ including control of Communicable Diseases, integrated Management of Childhood illness, sexual and Reproductive Health and Rights, immunization, environmental health, health education and promotion among others. At that time, these health intervention areas were set as priorities for the people of Uganda to access within the resources available (Ministry of Health , 2000).
The package has since evolved and the thrust of the National Health Policy has thus been defined to deliver the Minimum Health Care Package consisting of the most cost-effective priority health care interventions (The Ministry of Health, July 2010). In tandem with the move towards UHC, the policy attempts to ensure universal access to quality UNMHCP consisting of promotive, preventive, curative and rehabilitative and palliative services for all prioritized diseases and conditions, to all people in Uganda, with emphasis on vulnerable populations.
The package includes a wide range of clusters including: Health promotion, environmental health, disease prevention and community health initiatives, including epidemic and disaster preparedness and response, maternal and child Health, prevention, management and control of communicable diseases, and prevention, management and control of non-communicable diseases.
It can be argued that within the conceptualization of UHC, the UNMHCP should be considered as the core composition of health services. With the pool of resources available to the public sector, UHC should be availed to all the members of the public. Efforts must be taken to ensure the expansion of the contents of the package along three dimensions of UHC by increasing progressively the content of the package, increasing the number of people able to access the services in the package and reducing the financial risk of catastrophic out of pocket expenditure by the people able to access the package.
The National Health Insurance Bill, 2012
To address the inequities as a result of the high cost health care, the government abolished user fees in 2001 in all public health facilities and departed from the norm in which user fees were charged to make up for the deficit in financial resources for health care expenditure (Xu, et al., 2006). The removal of user fees was not followed by an adequate allocation of resources to the health sector. In turn, the removal of user fees affected the quality and accessibility of health care services, which led to the consideration of insurance as a viable option for health financing (Xu, et al., 2006). Insurance involves the sharing of risk by pooling resources and transforming a low-probability, but immense expected loss into certain, but very small loss. It is frequently used for financing and allocating health care (Wiesmann & Johannes Jütting, 2000).
The first attempt to address the health financing problem through health insurance was made through a community based health insurance initiative with the first scheme set up in 1996 at a rural hospital in Kisiizi (Basaza, Bart Criel , & Patrick Van der Stuyft, 2007). Community based insurance schemes are typically run by the health facility which took premiums from communities in exchange for guaranteed free treatment when needed (Ibid). Today the scheme has significantly evolved to include health insurance voluntarily acquired by individuals with private health providers, insurance provided by employers to their employees and, most importantly for this study, the development of a national health insurance scheme in Uganda (Zikusooka & Kyomuhangi R, 2007).
The health insurance scheme that has been proposed under the National Health Insurance Scheme Bill is managed by a statutory body, the National Health Insurance Scheme (Clause 2 and 4). The purpose of the scheme is to facilitate the provision of accessibility, affordable, acceptable and quality healthcare services to all residents irrespective of their age or economic, health or social status and to develop health insurance as a complementary mechanism of health care financing in Uganda
The National Health Insurance Scheme is limited to public servants and members of the private sector under the National Social Security Fund, which excludes the members of the informal sector (Clause 5). It also provides for a community health insurance scheme for the individuals who do not fall within the formal private sector or do not work for the public service. The greatest challenge for the community health insurance scheme is that the informal sector in Uganda is not well-structured and strategic consultation and consideration will have to be undertaken so that community health insurance schemes comprehensively ensure financial risk coverage for individuals within the informal sector who constitute the majority of Ugandans.
The Scheme has a wide range of functions including collection and management of funds, formulation and implementation of guidelines on contributions and benefits, determining the criterion for accrediting health care providers, registering and regulating accredited health care providers, negotiating and entering into contracts regarding health care services, negotiating and determining capitation and other payments due to accredited health care providers and licensing and monitoring community insurance schemes.
Three forms of health insurance are proposed under the Bill. The health insurance scheme under the National Health Insurance Scheme for public servants and members of the National Social Security Fund (Clause 5), the community health insurance schemes is for groups of individuals who are neither beneficiaries nor members of the national health insurance scheme (clause 8) and the indigent people who are neither part of the national health insurance scheme nor qualify for community health insurance. Every person in Uganda must be a member of either the National Health Insurance Scheme or a Community health insurance scheme except for those who have been declared to be indigents in which case they will be entitled to benefit from the National Health Insurance Scheme (Clause 11).
As for the contributions to the scheme, public servants are required to make a contribution of 4% of their net salary to which the government adds an equivalent contribution. The National Social Security Fund is also required to make contributions to the fund for its members (Clause 11). It is anticipated that the government will make contributions to the National Health Insurance Scheme on behalf of all indigent persons.
The scheme entitles the beneficiaries to a package of benefits containing a wide range of services including outpatient services, laboratory investigations, dental services, reproductive health services, inpatient services, minor and major surgeries and rehabilitative services (Schedule 1). The scheme specifically excludes, among others, health care services and medicines not prescribed by an accredited health worker, illnesses resulting from occupational injuries and cosmetic surgery within a defined amount with a proposal of co-payment where the amount required for treatment exceeds the amount of the benefit prescribed (Clause 33). The Bill also proposes regulations to deter over and underutilization of health care, which includes unnecessary diagnostic and therapeutic procedures and interventions, irrational prescriptions, long or over stay on admission, inappropriate referral practices (Clause 44). Caution must to be taken to avoid interfering with access to health services in the name averting over utilization or underutilization of health care.
According to the recommendations by regional offices, accredited health care providers are paid for the services provided or payment of capitation or payment of both fees for services rendered in accordance to the health services provision under the scheme (Clause 46).
An elaborate administrative mechanism for the scheme is proposed by the Bill including the Board of Directors, the Managing Director, the Accreditation committee, the Regional Health Insurance Offices and the Appeals Tribunal. The Board of Directors of the scheme that is responsible for among others defining the policies of the scheme. The Managing Director shall be the chief executive officer of the scheme. The accreditation committee shall be responsible for accrediting health care providers. The Regional Health Insurance offices shall be responsible for supervising, monitoring and evaluating the activities of the Scheme and of the community health insurance schemes in their region. The Appeals Tribunal shall be responsible for reviewing decisions by the Board or Regional Health Insurance Offices.
The provisions of the Bill indicate progress towards establishing financial health coverage in Uganda. However, the slow progress has made towards its enactment, it is apparent that it will be a while before the Scheme is fully operational. The Act has still not yet been tabled before parliament and is still being amendments at the Ministry level. And yet within the Bill, several regulations are proposed including regulations for the community insurance scheme, regulations for payment of benefits to the health service providers, regulations for portability of benefits among others. The implication of these regulations is that even after the Act has been enacted, we shall have to wait for the regulations to be developed and approved by the Ministry of Health before the Scheme becomes fully operational. This is in addition to establishing and constituting all of the administrative structures that are proposed by the Act.
It is evident from the discussion above that there is a strong political commitment in Uganda to move towards the realization of UHC. The development of the minimum health care package was a strategic initiative however, effort needs to be made to ensure that the package is implemented across the country and it’s accessible to everyone. This is especially important having regard to the development of a comprehensive national insurance scheme. The national health insurance scheme is still a long way from becoming fully operational and yet its operationalization should meet a health system that can effectively meet its needs. Health workers need to be recruited and health services need to be brought closer to the people if the implementation of the minimum package and the operationalization of the national health insurance scheme is to improve the realisation of the highest standard of the right to health in Uganda in the move towards UHC.
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By Denis Bukenya
Coordinator – Human Rights Research Documentation Centre (HURIC)