Why proposed government health insurance scheme faces resistance

The recent Cabinet decision to introduce a National Health Insurance Scheme (NHIS) elaborated to the public by the Ministry of Health has caused both excitement and frustration in the different segments of our population. This is especially true of the Kampala-based formal sector public on the one hand and private sector on the other. Other segments whose views have not been brought on board are the better-off self-employed, the poor self-employed, and the unemployed and poor.

Going forward, it will be helpful to get feedback from them because they too, have concerns with the scheme in its current form. Judging from media stories, the formal and private sectors, in principle, accept that this country needs a health insurance system, which should be acknowledged and applauded.
From media stories again, there are three main concerns: First is with the proposed monthly 5 per cent of salary deduction, which some people say is too high. Second is with the choice of collection method, the monthly salary deduction which they perceive as a new income tax. And lastly, the contribution share of 1 per cent and 4 per cent between the employer and the employee respectively, which the latter see as unfair. But even without media stories, the following will be some of the concerns the poor self-employed, and the unemployed and poor (the informal sector) will raise:
The first will be a question of “what are you talking about?” because they have never seen the draft Bill and even those few who might have seen it did not understand it because it is not translated into any local languages.

Second will be why they are seen as homogenous and, therefore, billed regressively a flat Shs100,000 per year per family? They know and they can tell who is wealthier than the other in their communities. Besides, they will wish that those differences are taken into account while deciding the amount to pay into the scheme.

Thirdly, will be the issue of availability and quality of healthcare services, especially in the rural or remote areas. Fourth will be how to deal with their belief that paying for healthcare when illness has not come is synonymous with inviting ill-health. Lastly, is how actively they will participate in managing and governing the scheme because they have suffered with “fake” schemes in the past, which have stolen from them money while others promised benefits but never delivered them to their satisfaction.

Feedback from all segments of our population is, therefore, necessary because we are talking about a National Health Insurance Scheme in which all citizens are obliged to join (especially the wealthy and the healthy), where all citizens can benefit from the insured services; and where solidarity encompassing all members of the Uganda society is critical because in this scheme, there have to be subsidies from the rich to the poor, from the young to the old, from small to larger families, from workers to the unemployed, from the healthy to the sick and vulnerable. Moreover, we all have to appreciate that the core objective of a National Health Insurance Scheme is to guarantee healthcare provision to all citizens, serve all citizens (including the poor and needy) according to their healthcare needs and not according to what they pay for insurance, and help families cope with catastrophic health costs which are one of the leading reasons why some families fall into poverty.

Let me end with two messages and some recommendations:
Introducing a National Health Insurance Scheme in Uganda will be a reform. It means we shall shift (immediately or in a phased manner) from the government healthcare provision using the government health facilities (currently free for all) financed through taxes, direct out-of-pocket payments and donor revenues to a health insurance healthcare provision to those with insurance identification cards using contracted health facilities both private and government, financed through pre-paid contributions/ premiums, and government/donor grants.

Illness is destiny and every one of us will someday come to terms with it. An individual catching a disease is unpredictable so is what type of disease it will be, what kind of treatment will be needed to treat that disease, and how much it will cost. A health insurance system tries to address some, especially the finance-related uncertainties and enables a population to cope better with illness.

The government, through the Ministry of Health, has taken an important step in the right direction even if it is coming after a very long wait. It is now urgent that the next steps be expedited to get the NHIS Bill 2019 ready and tabled before Parliament for consideration. At the same time, the population should be educated about the complicated concept of insurance and about the NHIS. This role of educating the public should not be solely for the Ministry of Health, but in partnership with other institutions like the Community-based Health Insurance Schemes, the micro finance institutions most of which cover borrowers for medical expenses, and others.

The continued branding of the health insurance premium/contribution as a tax needs to be corrected to allow the public debate the scheme in a more realistic way. It is also important that the scheme is implemented “the Uganda way” because having waited for all this long, we should avoid taking the paths other countries took and reformed because they didn’t work. We should rather implement our scheme in a unique way, for example, premiums from salary workers could be deducted once every quarter as opposed to monthly deductions.

The scheme implementation phasing could follow a more representative approach like regional phasing as opposed to the common social-economic classifications where you start by enrolling those with predictable income and not so much in need as some of them already have some private insurance cover, and end with those who do not have predictable income.

Mr Makaire is the executive director, Save for Health Uganda (SHU).

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