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How will the poor be identified to benefit from National Health Insurance? Reflections from a stakeholder workshop in Kampala | Health Policy Planning and Management (HPPM) Department - For healthy Policy studies

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How will the poor be identified to benefit from National Health Insurance? Reflections from a stakeholder workshop in Kampala

Thursday, August 8th, 2019

BY MAYORA CHRISPUS| In June 2019, the Executive (Cabinet) announced that it had approved a proposal for establishment of a National Health Insurance Scheme (NHIS) in Uganda. This proposal has been under debate for the last almost 15 years, and this pronouncement was sweet melodies to stakeholders, especially the Ministry of Health, who have been behind this discussion for a long time. The pronouncement was however received with mixed reactions especially from the public, and the public servants whose salaries and earnings are the major target for this NHIS. But the negative reactions are partly borne out of inadequate or a complete lack of information about the proposed scheme and its operational structure. The next step for the NHIS is a discussion in Parliament before it is fully passed into law. Within this period therefore, critical input aimed at streamlining and clarifying the proposed scheme is apparent.

The need to identify the poor and indigents for exemption under the NHIS

The NHIS proposes different categories of membership and relevant premium payments or contributions required. Within the Bill, however, is a proposal to exempt certain classes of society, on account of their inability to pay required premiums, or their vulnerabilities. However, the challenge is always about how to appropriately identify these groups of people in order to benefit. Experiences show that in the presence of programs that have potential to benefit certain sections of society, there are tendencies for literary everyone to come forward to claim being part of the targeted community, unless there are clearly verifiable and indisputable criteria. Otherwise, if feasible strategies are not identified and implemented across the board, a program risks leaving out the target group and instead taking on beneficiaries that ordinarily would not fall within the classification.

Participants listening to an ISER presentation at the workshop

The NHIS process recognizes this challenge and already discussions and debates have started. As part of this discussion, the Initiative for Social and Economic Rights (ISER), a civil society organization, convened various stakeholders in July 2019, in Bugolobi, Kampala. Among the stakeholders were academia, researchers, Ministry of Health, Ministry of Gender, Labor and Social Development (MGLSD), Equal Opportunities Commission (EOC), Uganda Bureau of Statistics, National Union of Disabled Persons (NUDIPU), Community-based insurance organizations and schemes, among others. The aim of the stakeholder discussion was to reflect on already existing “means tests” or approaches for identifying the poor and vulnerable and which of these approaches would be most appropriate for adoption for the NHIS Scheme. This was a select team based on their various expertise, and more than 30 participants were in attendance.

Participants in one of the group discussions

Existing approaches to identify the poor and indigents: How comprehensive are they?

At the stakeholder workshop, approaches used by three major institutions, to identify the poor, were discussed.

  • The Uganda Bureau of Statistics (UBOS), which is the governments statistics and data house, approaches vulnerability from a poverty perspective. An individual is vulnerable if they are poor – that is, they cannot afford the minimum expenditure required by an individual to fulfil his or her basic food and non-food needs. The poor are those whose expenditure (or income) falls below the poverty line, currently estimated at 30, 611 (per month) in 2009/10 prices.
  • The Ministry of Gender, Labor and Social Development (MGLSD), uses various approaches to identify the poor and vulnerable. Majorly however, it applies
  1. Geographical Targeting – a region is selected based on predetermined criteria or vulnerability indicators. For example, often affected by weather vagaries, or is at risk of some problem, or hard-to reach
  2. Self-targeting – everyone in community is encouraged to participate, but the benefit package made unattractive for those who don’t need it to voluntarily opt out
  3. Community-based targeting – community members have capacity to identify the most deserving of society as long as criteria is pre-defined. There are however conflicts that could emerge, which need to be addressed
  4. Proxy-means testing – use of observable characteristics like household or individual characteristics and then socioeconomic status can be inferred based on those observable characteristics
  5. Categorical targeting – targeting based on categorical indicators like age, sex, marital status, as measures of vulnerability.
  6. Vulnerability targeting – emphasizes risk and vulnerability faced by a particular category of people within a community or region.
  • The Equal Opportunities Commission (EOC), similarly uses a vulnerability concept to identify target beneficiaries. Weights are allocated to each indicator of vulnerability and totaled across to arrive at an aggregate weight. There are majorly five categories of vulnerable populations: children, Youth, women, men, and older persons. Within each of these categories are micro indicators used for measurement.


How feasible, comprehensive, and all-inclusive are these approaches?

It was noted from the discussions that there is no clear method that could be used, except that there was need to compare the advantages of using one method over the other, against their disadvantages. Even across government, there is not yet harmonization. Different MDAs adopt different approaches depending on specific programs. Yet, it would be prudent that a standard formula and approach be adopted for use across government. There is a global discussion about the applicability of the poverty-line as a measure of poverty and vulnerability. This is because it is narrow, not easy to ascertain for economies with large informal and subsistence sectors, and the time it takes for it to be updated. Relying on this measure would prove futile. We need to learn from experiences from other countries that have walked this road before, rather than re-inventing the wheel. For example, in Ghana, vulnerable groups were identified as: children below 18 years, pensioners, persons older than 70 years, and street and homeless persons. 

Summary message from the workshop:

  • It is not easy to identify the vulnerable and more so when the objective is to exempt them from paying some cost – everyone will always want to benefit
  • A concrete criterion should be multi-dimensional, and must recognize that some categories face extreme vulnerabilities that others even when they all belong to the vulnerable group, and so these should be the priority targets
  • The UBOS approach may not be feasible, rather the NHIS team should work towards an approach that harmonizes MOGLSD and EOC to generate a robust criterion, moving forward
  • Finally, whatever approach is taken, the process must be transparent and inclusive, involving all stakeholders and the community, so as to reduce unnecessary resistance and friction

Overall, I think the NHIS process is just at the start. The longest journey lays ahead. As the Bill heads to Parliament for closer scrutiny and debate, all energies must be devoted to developing clear tools and frameworks to operationalize a number of proposals made within the Bill. This stakeholder workshop was a great opportunity and platform to contribute to the NHIS, in the spirit of improving health care financing to ensure that no one is left behind on the road towards Universal Health Coverage (UHC) in Uganda.

*The author works as a Health Economist with SPEED Project and the Health Policy and Systems Unit of Makerere University School of Public Health.

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