Government has said it is targeting to achieve 49 percent of coverage with projected revenue of Shs 3 trillion in the first year of rolling out the National Health Insurance Scheme (NHIS).
The provisions of the National Health Insurance Bill which was initiated in 2002 following an assessment of the feasibility of developing a social health insurance in Uganda, were recently approved by Cabinet.
The insurance scheme seeks to reduce on the out-of-pocket expenditure that Ugandans spend to access health care. Government also believes that once it is rolled out, health insurance will spur competition among service providers which will in turn promote quality of services thus reducing costs due to economies of scale.
The Commissioner for Planning, Financing and Policy in the Ministry of Health, Dr Sarah Byakika told reporters on Thursday that international practices have demonstrated that health insurance has the ability to avert financial risks that arise from high out-of-pocket expenditure on sickness, disability, and that it guarantees the population social health protection.
According to the provisions of the draft Bill, every Ugandan aged 18 and above, who is either employed or has a source of income will be obliged to make a monthly or annual contribution to the Fund.
In the case of persons whose income is derived from salaried employment, government will deduct from the wage or salary from the employee and the employer will equally contribute. Employees in the formal sector (public and private) will contribute 4% of their monthly salary while employers will contribute 1% of the employee’s monthly salary.
For those that are self employed, said Byakika, modalities will be formulated to ensure they make an annual contribution, determined by the total amount they earn.
“If employer fails, they are liable to a penalty equal to twice the amount they should have contributed. In the case of the Self employed persons, deadlines will also be determined, so they are not inconvenienced. But they will also suffer penalty,” she said during a media breakfast meeting.
Pensioners will contribute 1% of their monthly pension payment.
Those in the informal sector will contribute an average Shs 100,000 per annum. But Byakika said that given that this particular sector is “very broad and varied”, consisting of the very rich and very poor, government will determine contributions based on the individual’s total income.
As a prerequisite, anybody seeking health services will be required to present an identification card proving they subscribed to the scheme, short of which they will have to pay for the service.
At the moment, only 2 percent of Ugandans are covered by the private and community based health insurance schemes. This is in comparison with Kenya whose coverage stands at 35%, Tanzania at 25%, Rwanda at 28% and Burundi at 24%, according to 2014 statistics by World Health Organization (WHO).
The subscribers’ contribution will also cater for their spouse and a maximum of four children. The Bill defines a child as one who is below 18 years or has no income and is still living with the contributor’s house or a person who is wholly dependent on the contributor or student that isn’t on any scholarship.
However, the Commissioner said the insurance package will not cover treatment or supply of medicine where the health care provider has not diagnosed the illness or injury or prescribed the medicine. This will be an out-of-pocket bill.
“It also doesn’t include claims for compensation or treatment for injuries arising from occupational hazards or accidents, which are covered under the Motor Vehicle Insurance (Third Part Risks) Act and the Workers Compensation Act,” Byakika said.
Similar to the existing private health schemes, the benefits under the national scheme shall not exceed a certain amount of money (to be prescribed by the regulations made under the law).
Categories of people who will receive health care at no cost include indigents (orphans, vulnerable children, poor older persons, persons with disability, the destitute and refugees).
“The indigents will be enrolled at a rate of 10% annually or otherwise based on the reserves generated or subsidies from other sources”.
“In the first year, we project 49% coverage of the health insurance scheme. If that is achieved, that will be great and we will be better than those countries that began earlier than us. We want to start next year,” Byakika said.
The 49 percent is premised on projections which indicate that people in the public formal sector with 4 of their dependents make up 5% of the population. Those in the private formal sector with 4 of their dependents make up 25% of the population.
Pensioners form 1% while indigents and the informal sector (with 2 of their dependents) would total to 2% and 16% of the total population respectively in the first year of implementation.
The current budget for the health sector (2019/20) from government of Uganda is Shs 2.86 trillion. Byakika said that the health insurance scheme is projected to raise Shs 3 trillion annually.
The scheme will cover most common disease conditions such as Caesarean Section for mothers giving birth, emergency services, immunization, among others. However super specialized health services such as surgeries will not be part of the package.
The likely impediment however could turn out to be the fact that the majority of Ugandans are still employed in the informal sector, which makes it difficult for government to assess their income.
Byakika said it is important that the informal sector is quickly organized into groups that can contribute to the scheme.
“We need to think so hard,” she said.
Nevertheless, she said the already existing community health insurance schemes and other associations or groups such as market traders, boda boda associations, church based and cultural organizations, are low-hanging fruits that can be leveraged.
The Permanent Secretary in the Ministry of Health, Dr Diana Atwine said; “National Health Insurance is the way to go worldwide. We believe it will significantly reduce our out-of-pocket expenditure”.
“It will cut out the informal payments we have in our health facilities. Under table payments will be gone,” she said.
“It will cause competition. If a facility doesn’t put up good infrastructure for people to come, then it will not get paid. Quality of care will significantly improve, partly because we shall have additional funds”.
Dr Atwine as well said the fact that the population will part with some money for health services will cultivate some level of responsibility and sense of ownership as opposed to the current status quo where everything is expected from government.