Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme :  Comment on &quot;Health Coverage and Financial Protection in Uganda: A Political Economy Perspective&quot;

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Abstract

Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a National Health Insurance Scheme (NHIS). This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda’s experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up NHISs.

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Abolition of user fees: the Uganda paradox.

Bart Criel, Jean Macq, Juliet Nabyonga-Orem … (2011)

Inadequate health financing is one of the major challenges health systems in low-income countries currently face. Health financing reforms are being implemented with an increasing interest in policies that abolish user fees. Data from three nationally representative surveys conducted in Uganda in 1999/2000, 2002/03 and 2005/06 were used to investigate the impact of user fee abolition on the attainment of universal coverage objectives. An increase in illness reporting was noted over the three surveys, especially among the poorer quintiles. An increase in utilization was registered in the period immediately following the abolition of user fees and was most pronounced in the poorest quintile. Overall, there was an increase in utilization in both public and private health care delivery sectors, but only at clinic and health centre level, not at hospitals. Our study shows important changes in health-care-seeking behaviour. In 2002/03, the poorest population quintile started using government health centres more often than private clinics whereas in 1999/2000 private clinics were the main source of health care. The richest quintile has increasingly used private clinics. Overall, it appears that the private sector remains a significant source of health care. Following abolition of user fees, we note an increase in the use of lower levels of care with subsequent reductions in use of hospitals. Total annual average expenditures on health per household remained fairly stable between the 1999/2000 and 2002/03 surveys. There was, however, an increase of US$21 in expenditure between the 2002/03 and 2005/06 surveys. Abolition of user fees improved access to health services and efficiency in utilization. On the negative side is the fact that financial protection is yet to be achieved. Out-of-pocket expenditure remains high and mainly affects the poorer population quintiles. A dual system seems to have emerged where wealthier population groups are switching to the private sector.

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Discontinuation of cost sharing in Uganda.

G Burnham, George Pariyo, Fred Wabwire-Mangen … (2004)

To assess the effects of ending cost sharing on use of outpatient services and how this was perceived by health workers and members of a health unit management committee. From 10 districts across Uganda, 78 health facilities were selected. Attendance at these facilities was assessed for eight months before and 12 months after cost sharing ended. The data represented 1 966 522 outpatient visits. Perceptions about the impact of ending cost sharing were obtained from the 73 health workers and 78 members of the health unit management committee who were available. With the end of cost sharing, the mean monthly number of new visits increased by 17 928 (53.3%), but among children aged <5 years the increase was 3611 (27.3%). Mean monthly reattendances increased by 2838 (81.3%) among children aged <5 years and 1889 (24.3%) among all people. Attendances for immunizations, antenatal clinics, and family planning all increased, despite these services having always been free. Health workers reported a decline in morale, and many health unit management committees no longer met regularly. Use of all services increased - even those that had never before been subject to fees. The loss of some autonomy by the health facility and diminished community governance of health facilities may have long term negative effects.

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Global health actors no longer in favor of user fees: a documentary study

Émilie Robert, Valéry Ridde (2013)

Background Since the advent of health user fees in low- and middle-income countries in the 1980s, the discourse of global health actors (GHAs) has changed to the disadvantage of this type of healthcare financing mechanism. The aim of the study was to identify and analyze the stance of GHAs in the debate on user fees. Methods We conducted documentary research using public documents published by and officially attributed to GHAs from 2005 to 2011. We categorized GHAs into four groups: intergovernmental organizations, international non-governmental organizations, government agencies, and working groups and networks. We then classified the GHAs according to their stance relative to the abolition of user fees, and conducted a thematic analysis of their discourse to understand the arguments used by each GHA to justify its stance. Results We identified 56 GHAs, for which we analyzed 140 documents. Among them, 55% were in favor of the abolition of user fees or in favor of free care at the point of delivery. None of the GHAs stated that they were in favor of user fees; however, 30% did not take a stand. Only the World Bank declares that it is both in favor of user fees and in favor of free care at point of service. GHAs generally circumscribe their stance to specific populations (pregnant women, children under 5 years, etc.) or to specific health services (primary, basic, essential). Three types of arguments are used by GHAs to justify their stance: economic, moral and ethical, and pragmatic. Conclusions The principle of “user pays” seems to have fizzled. Production and dissemination of evidence, as well as certain advocacy networks, may have contributed to this change in discourse. However, GHAs should go a step further and translate their words into action, so that free healthcare at the point of delivery becomes a reality in low- and middle-income countries. They should provide technical and financial support to those countries that have chosen to implement user fee exemption policies, sometimes influenced by a GHA.

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Journal

Journal ID (nlm-ta): Int J Health Policy Manag

Journal ID (publisher-id): Int J Health Policy Manag

Journal ID (publisher-id): Kerman University of Medical Sciences

Title: International Journal of Health Policy and Management

Publisher: Kerman University of Medical Sciences

ISSN (Electronic): 2322-5939

Publication date Collection: 2023

Publication date (Electronic): 03 July 2022

Volume: 12

Electronic Location Identifier: 7348

Affiliations

¹School of Medicine, Uganda Christian University, Mukono, Uganda.

²School of Public Health, Gudie University Project, Kampala, Uganda.

³Institution of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

⁴Faculty of Social Sciences, Ndejje University, Kampala, Uganda.

⁵College of Health Sciences, Makerere University, Kampala, Uganda.

Author notes

[* ] Correspondence to: Robert K. Basaza Email: rbasaza@ 123456gmail.com

[¶ ]Contributed equally and both are first authors.

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Robert K. Basaza https://orcid.org/0000-0003-3220-5548

Article

DOI: 10.34172/ijhpm.2022.7348

PMC ID: 10125197

PubMed ID: 35942967

SO-VID: db341e31-cfca-4bc8-a785-45d890c79e2b

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This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme : Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

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Most cited references 8

Abolition of user fees: the Uganda paradox.

Discontinuation of cost sharing in Uganda.

Global health actors no longer in favor of user fees: a documentary study

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