Social health insurance is not practical

Dr Coutinho in his office at Infectious Disease Institute at Mulago hospital. The doctor has received a prize of 100 million yen (Shs2.8b). Photo by Faiswal Kasirye.

By Walter D Odoch,

The Daily Monitor of July 20 reported that the shelved health insurance plan gets a new lease of life. It stated that two American institutions, Brigham and Women’s Hospital (BWH), in Boston and Care Right have signed a pack to be the first health insurance providers once the National Health Insurance Scheme (NHIS) /Social Health Insurance (SHI) starts.

I am convinced the two institutions are not best suited to offer such expertise to Uganda’s health system financing arrangement, especially given the health financing practice in the US health care system. But also, BWH is a teaching hospital of Harvard University, the same institution that conducted the feasibility study on Social Health Insurance in Uganda in 2001. The institution may just want to justify their findings that it is feasible to introduce the SHI in Uganda! Uganda’s health care system arrangement, it is far from suitable to implement a SHI, currently.

Before this SHI/NHIS is introduced, there is need for serious reforms in the health system financing arrangement.

Currently, in Uganda’s public health system, the three health financing functions of collection of money, purchasing of healthcare and provision of healthcare are performed by the same entity, the government. This is bound to be associated with serious efficiency, quality, equity, effectiveness and accountability challenges. And we need not have a SHI to streamline this.

We need to separate these functions and ensure that the entities that are to perform these functions have capacity and are well regulated.

The question to ask is why you should force me to pay my money (NHIS/SHI is compulsory once passed by Parliament) yet you do not have the capacity to provide (or ensure the contracted provider offers) the right healthcare. Introducing NHIS/SHI at this point in Uganda would be defeating the very aim why we need such an arrangement, i.e. to ensure that people are protected form impoverishment resulting from accessing healthcare.

This is because, having forcibly gotten my money to provide care through health insurance, but because of the poor care that you will provide, I will still be forced to seek care from elsewhere (usually from private practice-traditional or formal) and pay for it. Therefore, I would have paid twice for my health care. Is this protecting me form financial catastrophe associated with ill health as a citizen?

In addition, in the NHIS Bill, there is supposed to be a board and other technical persons that will manage this scheme. This structure will need to be oiled to function. According MOH estimate, they think through NHIS they will raise about Shs250 billion from the formal sector (public and private). You can only be sure that a large portion of this money will go to the administration (NHIS board and technical staff’s take home, office running and fuel guzzler vehicles); hence NHI contribution to financing actual healthcare will at most be negligible.

I do not think we are significantly going to get additional amount into care provision through NHIS/SHI.
MOH should advocate for an earmarked health tax (and essentially this is what the Bill is about). But when they call it NHIS/SHI, issues of having an entity to manage it will come in as well as explicitly defining the benefits. But when we leave it as an ear marked tax, we will not need any additional complex and expensive management entity.