Dr Ezra MunyamboneraFor the last four years, I have closely followed the debate on having a Uganda National Health Insurance Scheme (NHIS) and kept wondering why the process has taken that long.

While Uganda has originated good policies that have been copied by other countries, one wonders why it takes so long to formulate and implement a policy. Could it be a human resource issue? Could it be lack of commitment by politicians?  Is it the failure of the public to demand for services? All these are puzzles to policy formulation and implementation in Uganda.

Puzzles aside, the proposed equal cost sharing arrangement between employees and government to the NHIS may not be sustainable if not carefully thought through. It may cause further misery to the already tax-burdened public servants who pay NSSF contributions of five per cent, PAYE of 30 per cent, and the indirect taxes.

From the research angle, one would question the basis of the ministry of Health planners to propose the four per cent equal cost sharing to the scheme. I believe that there should be a well-researched empirical justification to provide alternative options like in other countries.

The public would like to see different options without necessarily a mere comparison with other countries and adopt the structures. There is, therefore, need to use facts and figures in this agenda and come up with workable solutions. Before government approves the proposed sharing arrangement, we suggest that the Health ministry conducts a baseline analysis of the responses to the scheme from the public and private players, to have an agreeable position.

Who knows, even the informal sector could suggest effective mechanisms through which Ugandans will contribute to the NHIS. Evidence shows that implementing a national health insurance scheme takes time and may require initial government funding, as confidence is built amongst public servants and the formal private sector.

Universal coverage is usually achieved through a mix of health financing tools. To include the poor and informal sector workers, tax-based financing as well as micro health insurances are appropriate instruments. However, the poorest of the poor can only be reached by tax-financed approaches. In various countries, experiences of initiatives to link up different funding systems are already available. Different financing approaches are not in competition with one another.

Instead, they complement each other. Ghana, for instance, took first steps to replace its out-of-pocket health financing system by introducing the NHIS in 2004. Their approach presents a unique mix of social insurance and mutual health organisation principles that is driven by strong political commitment, a pro-poor focus, and support from several development partners.

The government targeted 50 to 60 per cent of the Ghanaian population for the first 10 to 15 years. Tanzania, on the other hand, introduced a national health insurance in 1993. To primarily assure its financial sustainability, the government initiated a mix of schemes: the National Health Insurance Fund (NHIF) for public sector employees and the voluntary Community Health Fund (CHF) for informal sector workers and poor households at local level.

These are being successfully supplemented by private health insurances and micro-insurance schemes run by churches, informal sector groups, and cooperatives.Vietnam and the Philippines follow a three-tier-strategy with standard social health insurance for formal sector employees and civil servants. They also have voluntary insurance for independent and informal sector workers, and a tax-financed component for the poor.

There may be no general blueprint for successful social health protection systems. But such policies always have to be rooted in a society-specific context. This refers to factors such as the prevailing economic situation, the structure of the labour market, the degree of urbanisation, or soft factors such as cultural values or societal consensus.

The Ugandan ministry of Health should, therefore, take note of this to avoid having another forced national saving scheme in a guise of health protection. There are categories that may qualify for contributory arrangements such as public servants, others may be subjected to a compulsory contribution of user fees to be implemented at public health units. Such mix of health insurance mechanisms is working elsewhere.

Recommendation: policy advice on social health protection has to offer tailor-made approaches adapted to the specific needs and characteristics of the country instead of general blueprint solutions borrowed from elsewhere.

The government should consider initially creating a health fund or financing the national health insurance scheme as the citizens adapt to gradual payment terms. The proposed equal cost sharing of four per cent is contestable and has to be revisited. A wider citizen consultation should be implemented to get feedback information on the various options that can be applied to the scheme.

A successful extension of social health protection also requires a coherent sectoral and multisectoral approach.

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