Provision of Actuarial Consultancy Services to Select March 2017 Private Health Insurers in Uganda

LITERATURE REVIEW

Prepared for:

Finance Management Specialist, USAID/Uganda Private Health Support Program, Plot 28, Prince Charles Drive Kololo, P. O. Box 29628,

Kampala, Uganda

The information contained within this document is confidential to Kenbright Actuarial & Financial Services (KAFS) & USAID/Uganda Private Health Support Program and has been produced solely for the purpose of consideration by USAID/Uganda Private Health Support Program.

Literature Review USAID/Uganda Private Health Support Program

TABLE OF CONTENTS

List of Figures ...... 3 List of Abbreviations ...... 4 1. TRANSFORMING OUR WORLD: THE 2030 AGENDA FOR SUSTAINABLE DEVELOPMENT ...... 5 Facts & Figures ...... 7 Child Health ...... 7 Maternal Health ...... 7 HIV/AIDS, malaria and other diseases ...... 7 2. THE CONSTITUTION OF UGANDA...... 9 Social and economic objectives ...... 9 Health Service Commission ...... 9 General ...... 9 3. UGANDA DEVELOPMENT VISON 2040 ...... 10 Population and environment ...... 10 2040 vision ...... 11 4. UGANDA HEALTH FINANCING STRATEGY (2015/16 – 2024/25) ...... 13 Background ...... 13 Country Context ...... 14 Organization of the health system in Uganda ...... 17 Health Sector in Brief ...... 19 Towards an integrated health financing system ...... 20 Situation Analysis of Current Health Financing System ...... Error! Bookmark not defined. Sources of Health Financing ...... 21 5. NATIONAL HEALTH INSURANCE SCHEME ...... 25 Scheme Membership ...... 25 Objective of the Scheme ...... 25 Functions of the Scheme ...... 25 Health Care Benefits ...... 27 6. HEALTH SECTOR DEVELOPMENT PLAN 2015/16-2019/20 ...... 29 7. PRIVATE HEALTH INSURANCE IN UGANDA ...... 31

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List of Figures

Figure 1: Proportion of the total budget allocated by sector (Includes on budget ODA) ...... 15 Figure 2: Growth in Total GOU Budget and Health Budget ...... 16 Figure 3: Percentage contribution of ODA to total budget and to the health budget (2010/11-2014/15)...... 17 Figure 4: Health Financing Functional Chart for Uganda (2014) ...... 22 Figure 5: Health Care Benefits under proposed NHIS ...... 27 Figure 6: Uganda Insurance Industry Statistics ...... 34

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List of Abbreviations

NAME DEFINITION FUE Federation of Uganda Employers GDP Gross Domestic Product GoU Government of Uganda HIO Health Insurance Organisations HMO Health Membership Organizations HSDP Health Sector Development Plan HSSIP Health Sector Strategic and Investment Plan MOFPED Ministry of Finance Planning and Economic Development NDP National Development Plan NGO Non-Governmental Organization NHIS National Health Insurance Scheme NHP National Health Policy ODA Official Development Assistance OPD Out-patient Department PPPH Public Private Partnerships for Health PSFU Private Sector Foundation Uganda SDG Sustainable Development Goals UHC Universal Health Coverage UHF Uganda Healthcare Federation UIA Uganda Insurers Association UN United Nations UNMHCP Uganda National Minimum Health Care Package USAID United States Agency for International Development

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1. TRANSFORMING OUR WORLD: THE 2030 AGENDA FOR SUSTAINABLE DEVELOPMENT

1.1. The 17 Sustainable Development Goals (SDGs) of the 2030 Agenda for Sustainable Development officially came into force on 1 January 2016 (United Nations, 2016).

1.2. With these new goals countries, will mobilize efforts to end all forms of poverty, fight inequalities and tackle climate change, while ensuring that no one is left behind.

1.3. The SDGs, build on the success of the Millennium Development Goals (MDGs) and aim to go further to end all forms of poverty and the universal need for development that works for all people. The new goals are unique in that they call for action by all countries, poor, rich and middle-income to promote prosperity while protecting the planet.

1.4. They recognize that ending poverty must go together with strategies that build economic growth and addresses a range of social needs including education, health, social protection, and job opportunities, while tackling climate change and environmental protection.

1.5. The UN highlights the need to ensure healthy lives and promote well-being for all, at all ages as Goal 3.

1.6. Under this goal, the UN has set out the following targets to enable them to achieve the goal:

• Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

The goal of UHC is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.

• Ensure universal access to sexual and reproductive healthcare services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

• Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing states

• Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

• Reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030

• End preventable deaths of new-borns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births, by 2030

• By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases Kenbright Actuarial & Financial Services Page5 of 37

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• Reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

• Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

• Halve the number of global deaths and injuries from road traffic accidents by 2020

• By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

• Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

• Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all.

1.7. Other SDGs related to health are:

Goal 1: End poverty in all its forms everywhere.

Goal 2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture.

Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.

Goal 5. Achieve gender equality and empower all women and girls.

Goal 6. Ensure availability and sustainable management of water and sanitation for all.

1.8. Since 1990, there has been an over 50 percent decline in preventable child deaths globally. Maternal mortality also fell by 45 percent worldwide while new HIV/AIDS infections fell by 30 percent between 2000 and 2013, and over 6.2 million lives were saved from malaria.

1.9. Despite this incredible progress, more than 6 million children still die before their fifth birthday every year. 16,000 children die each day from preventable diseases such as measles and tuberculosis. Every day hundreds of women die during pregnancy or from child-birth related complications. In many rural areas, only 56 percent of births are attended by skilled professionals. AIDS is now the leading cause of death among teenagers in sub-Saharan Africa, a region still severely devastated by the HIV epidemic.

1.10. These deaths can be avoided through prevention and treatment, education, immunization campaigns, and sexual and reproductive healthcare. The Sustainable Development Goals make a bold commitment to end the epidemics of AIDS, tuberculosis, malaria and other communicable diseases by 2030. The aim is to achieve universal health coverage, and provide access to safe and affordable medicines and vaccines for all. Supporting research and development for vaccines is an essential part of this process as well.

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Facts & Figures

Child Health

• 17,000 fewer children die each day than in 1990, but more than six million children still die before their fifth birthday each year

• Since 2000, measles vaccines have averted nearly 15.6 million deaths

• Despite determined global progress, an increasing proportion of child deaths are in sub-Saharan Africa and Southern Asia. Four out of every five deaths of children under age five occur in these regions.

• Children born into poverty are almost twice as likely to die before the age of five as those from wealthier families

• Children of educated mothers—even mothers with only primary schooling—are more likely to survive than children of mothers with no education

Maternal Health

• Maternal mortality has fallen by almost 50 per cent since 1990

• In Eastern Asia, Northern Africa and Southern Asia, maternal mortality has declined by around two-thirds

• But maternal mortality ratio – the proportion of mothers that do not survive childbirth compared to those who do – in developing regions is still 14 times higher than in the developed regions

• More women are receiving antenatal care. In developing regions, antenatal care increased from 65 per cent in 1990 to 83 per cent in 2012

• Only half of women in developing regions receive the recommended amount of health care they need

• Fewer teens are having children in most developing regions, but progress has slowed. The large increase in contraceptive use in the 1990s was not matched in the 2000s

• The need for family planning is slowly being met for more women, but demand is increasing at a rapid pace

HIV/AIDS, malaria and other diseases

• At the end of 2014, there were 13.6 million people accessing antiretroviral therapy

• New HIV infections in 2013 were estimated at 2.1 million, which was 38 per cent lower than in 2001

• At the end of 2013, there were an estimated 35 million people living with HIV

• At the end of 2013, 240 000 children were newly infected with HIV

• New HIV infections among children have declined by 58 per cent since 2001

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• Globally, adolescent girls and young women face gender-based inequalities, exclusion, discrimination and violence, which put them at increased risk of acquiring HIV

• HIV is the leading cause of death for women of reproductive age worldwide

• TB-related deaths in people living with HIV have fallen by 36% since 2004

• There were 250 000 new HIV infections among adolescents in 2013, two thirds of which were among adolescent girls

• AIDS is now the leading cause of death among adolescents (aged 10–19) in Africa and the second most common cause of death among adolescents globally

• In many settings, adolescent girls’ right to privacy and bodily autonomy is not respected, as many report that their first sexual experience was forced

• As of 2013, 2.1 million adolescents were living with HIV

• Over 6.2 million malaria deaths have been averted between 2000 and 2015, primarily of children under five years of age in sub-Saharan Africa. The global malaria incidence rate has fallen by an estimated 37 per cent and the mortality rates by 58 per cent

• Between 2000 and 2013, tuberculosis prevention, diagnosis and treatment interventions saved an estimated 37 million lives. The tuberculosis mortality rate fell by 45 per cent and the prevalence rate by 41 per cent between 1990 and 2013.

1.11. While the SDGs are not legally binding, governments are expected to take ownership and establish national frameworks for the achievement of the 17 Goals. Countries have the primary responsibility for follow-up and review of the progress made in implementing the Goals, which will require quality, accessible and timely data collection.

1.12. With its universal applicability and its importance in shaping development priorities, the 2030 Agenda will open new avenues to integrate human rights into global and national policies. It encompasses and seeks to address issues to do with social, economic and cultural rights; this is inclusive of the right to development. Development can be hindered through lack of awareness, reduced ease of access to health services, substance abuse, high medical expenses and more.

1.13. USAID works with the public and private sector to increase the access and availability of quality health services, improve health systems, encourage healthy behaviour and develop sustainable programs that result in improved health and nutrition in focus districts and targeted populations. This is in line with the 2030 Agenda.

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2. THE CONSTITUTION OF UGANDA

2.1. Uganda’s constitution came into effect in October 1995. The constitution sets out political objectives, the protection and promotion of human rights, social and economic objectives, cultural objectives, accountability, the environment, foreign policy objectives and duties of a citizen. This review briefly considers the areas of the constitution related to healthcare and access to medical treatment.

Social and economic objectives 2.2. As part of the general social and economic objectives the constitution states that the State shall endeavour to ensure that all Ugandans enjoy rights, opportunities and access to health services.

2.3. The constitution also highlights;

The State shall take all practical measures to ensure the provision of basic medical services to the population.

Health Service Commission 2.4. A Health Service Commission shall be set up, with members of the Commission appointed by the President, with the approval of Parliament. The Commission shall advise the President in relation to health services.

2.5. The Commission has the power to: • appoint, remove and exercise disciplinary control over persons in any office in the health service,

• review the training and qualifications of members of health service,

• advise the President in acting and/or making decisions in relation to the health service,

2.6. The Commission is not under any authority or supervision but is expected to make a report to Parliament in respect of each year on the performance of its functions and to consider government policy relating to health.

General 2.7. The Constitution states that Health Policy is a function and service for which the Government is responsible. Furthermore, health is one of the eight areas where cooperation is required among districts.

2.8. The key point is the provision of basic medical services to all Ugandans. Where organizations can play a role in ensuring access to healthcare, even for only a subset of the population, this reduces some of the burden on the State, and assists in meeting the Constitutional rights of Ugandans.

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3. UGANDA DEVELOPMENT VISON 2040

3.1. The Uganda Vision 2040 provides the structure for meeting Uganda’s vision statement, which is “a transformed Ugandan society from a peasant to a modern and prosperous country within 30 years”. The aim is to change from a predominantly low income country to a competitive upper middle income country in 30 years.

3.2. This literature review focuses on the aspects of Vision 2040 which are important to understand the healthcare market in Uganda, as well as areas which we consider to be of importance or interest to healthcare organisations.

3.3. Vision 2040 is a 30-year plan, which was implemented in 2010 and is to be headed by the President, but the responsibility also rests with those in government, the private sector, civil society, political organisations and other institutions. It is recognised that the private sector will remain the engine of growth and development.

Population and environment 3.4. The Ugandan population was estimated to be 32 million people in 2010, of which 60% were below the age of 18 years. Roughly 51% of the population was female. The population has limited access to and use of modern technology. Furthermore, in 2009 only 28% of the population had access to formal financial services.

3.5. Vision 2040 notes high levels of fertility rates, where the fertility rates are 6.7 children per women. It is estimated that this will decline to 4.0 children per women in 2040, due to programs implemented as part of Vision 2040, which are particularly focused on education.

3.6. In 2010, it was estimated that 80% of the total workforce was employed by micro and small enterprises, which make up nearly 90% of the private sector. These enterprises produce largely for the domestic market. Employment in agriculture accounts for 65.6% of the labour forces and contributes 21% to the GDP.

3.7. Vision 2040 sets out several attributes which are desired in Ugandan citizens. These include patriotism, concern for other citizens particularly vulnerable citizens, and a sense of gender equality. There is also a desire to foster a sense of optimism, unyielding spirit and for citizens to fulfil their responsibilities as citizens.

3.8. Aspirations for Uganda’s future development were determined through nationwide consultations with various stakeholders. These consultations identified that Ugandans desired to have access to affordable quality healthcare services and to have strong safety nets.

3.9. The population characteristics outlined in Vision 2040 should be kept in mind, when developing products which can meet the needs of the population. Vision 2040 outlines several challenges which organisations offering health insurance must overcome, to produce market relevant products.

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2040 vision 3.10. Vision 2040 has identified the establishment of international and national referral hospitals in each regional city as one of the thirteen core projects. To achieve the core projects Vision 2040 identifies several strategies and policy reforms which must take place. These include a review of the government service delivery system, pursuing a planned urbanisation policy and to develop a universal health insurance system through public private partnership.

3.11. It is noted that the health service delivery system as at 2010 is expensive, inefficient and not sufficiently responsive to the health needs of the population. To address this, a shift from public centred healthcare to a public private partnership arrangement is proposed. A key strategy is to adopt a universal health insurance system.

3.12. During the Vision period, there will be a shift from facility based systems to household based systems. The aim is to empower households to take greater control of their health by promoting healthy practices and lifestyles. A preventative health system is preferred to a curative health system, due to being cheaper to run.

3.13. Primary healthcare services should be provided at the community level and non-communicable diseases will be managed at a health sub-district level. Government will focus on building highly specialized health care services and establishing international and national hospitals in each regional city in partnership with the private sector and other countries. This should reduce the number of Ugandans requiring healthcare treatment outside of Uganda.

3.14. Another health strategy is to improve the nutrition status of the population, especially for children and women of reproductive age. School feeding policies will be developed and implemented.

3.15. Access to basic needs such as education, health services, food, housing and equitable distribution of income among all citizens will be promoted. In line with this, the target Gini coefficient for 2040 is 0.32.

3.16. The Gini index is a measurement of the income distribution of a country's residents. The number ranges between 0 and 1 and is based on residents' net income. It helps define the gap between the rich and the poor, where a coefficient of 0.00 reflects completely equal distribution of wealth, and a coefficient of 1.00 reflects the greatest skewness of wealth.

3.17. Several targets for 2040, which reflect the health of the population, have also been set. These include;

• increasing the life expectancy at birth from 51.5 years in 2010 to 85 years in 2040,

• reducing infant mortality from 63 deaths per 1,000 live births to 4 deaths,

• reducing maternal mortality from 438 deaths per 100,000 live births to 15 deaths,

• under 5 mortality rate per 1,000 should be reduced from 96 to 8 deaths and

• child stunting as a percentage of under 5 years should reduce to 0% from 33%.

3.18. A strategy has been set out in Vision 2040 describing the envisioned role for the private sector to play in promoting access to healthcare for all. Organisations should be cognisant of the proposed roles, to structure themselves to fit with Vision 2040.

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3.19. A system for universal pensions for all citizens over the age of 65 years will be also implemented over the Vision period. Pensioners have a strong need for healthcare insurance, to meet their increasing healthcare requirements. If quality insurance can be offered, at a price which is reasonable given the pension, and in a financially sustainable method, this will fill a key need.

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4. UGANDA HEALTH FINANCING STRATEGY (2015/16 – 2024/25)

Background 4.1. The health of the Ugandan population is central to the socio-economic transformation of the country. Along with increased literacy rates and vibrant economic growth, health outcomes are improving which translates to reduced mortality rates over the last 10 years. However, some of the millennium development goals are not on track due to numerous challenges in the health system.

4.2. The main objective of this Health Financing Strategy is to facilitate attainment of Universal Health Coverage through making available the required resources for delivery of the essential package of services for Uganda in an efficient and equitable manner.

4.3. The rationale for developing Uganda’s HFS is to provide a framework through which Uganda will finance its health sector to achieve its stated goals. It will guide the country in equitably and sustainably mobilizing resources and efficiently utilizing them to implement sector plans.

4.4. The development of the HFS was guided by evidence generated through an extensive review of relevant documents, including: The National Health Accounts (NHA) studies and the Mid-Term Review of the Health Sector Strategic and Investment Plan (HSSIP) 2010/11 - 2014/15, as well as a review of international evidence on best practices in health financing.

4.5. The instruments to achieve universal health coverage are sound health financing mechanisms. The strategic interventions herein are revenue collection, risk pooling and strategic purchasing. Thus, in the medium term, no person should face risk of impoverishment when accessing health care nor should anybody forego medical services because of financial reasons.

4.6. Uganda has achieved remarkable success in health care service delivery though it has the lowest per capita health expenditure in the East African Community. However, it is now facing the challenge of increasing health care allocation due to the increasing population and health care costs.

4.7. The country has unacceptably high out of pocket expenditure at the level of 50% of total health expenditure, government spending is around only 16%, and there are no mentionable social health insurance programs.

4.8. These challenges call for focusing on deepening and broadening the resource base for health in Uganda. The country will require more than just increased financial resources for health; it will require improved ways of organizing resource mobilization, allocation and expenditure to obtain the maximum value for money to ensure equitable and sustainable financing and financial protection against health expenditures of the entire population.

4.9. The Health Financing Strategy has been developed over a period of a year since the adoption of the Health Sector Strategic Plan (HSSIP 2010/11-2014/15).

4.10. It is the second Health Financing Strategy for Uganda, and it came at a time of global commitment towards Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC).

4.11. This strategy will serve as a critical element in Uganda’s pathway to achieving the health-related SDGs and attaining UHC. Uganda is transitioning from the Millennium Development Goals (MDGs) to the SDGs, in which UHC is the all-encompassing health goal. Kenbright Actuarial & Financial Services Page13 of 37

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4.12. The development of the HFS is underpinned by the Constitution, Vision 2040 and the National Development Plan (NDP II). Constitutionally, the GoU has an obligation to provide basic health services to its people and to promote proper nutrition and healthy lifestyles. The Constitution further entitles all people in Uganda to enjoy rights and opportunities and to have access to education, health services and clean and safe water.

4.13. Uganda’s Vision 2040 envisions “a transformed Ugandan society from a peasant to a modern and prosperous country within 30 years” and has been developed to shape Uganda’s long-term development strategy. It also acknowledges that good health is essential in ensuring socio-economic transformation and is critical if Uganda is to attain its long-term vision.

4.14. The NDP II also places great emphasis on investing in the promotion of people’s health and nutrition, and the need to improve health and promote well-being. The MOH recognizes that strengthening human capital development is fundamental to accelerating the country’s transformation.

4.15. The HFS has been developed in line with sectoral policies and development plans, including the National Health Policy (NHP II) and the Health Sector Development Plan (HSDP) 2015/16 - 2019/20.

4.16. The NHP II puts emphasis on ensuring that financial barriers do not prevent people from using the health services they need and ensuring that people do not suffer severe financial catastrophe because of using the services.

4.17. The HSDP provides the strategic direction for the implementation of the NHP and aims "to accelerate movement towards Universal Health Coverage with essential health and related services needed for promotion of a healthy and productive life". It also underscores the need to provide a quality package of essential health services, accessed by all, without suffering financial hardship.

Country Context 4.18. Uganda is a low-income country with estimated Gross National Income (GNI) per capita of US$ 660 (2014). Uganda’s economic growth rate has averaged about 5.5% per annum over the years of implementation of the NDP 1 (2010/11-2014/15). This represents a deceleration from growth rate of 8% that was observed in the period 2006-2010.

4.19. Uganda’s economic growth rate, although commendable, is currently the least when compared to the other countries in the East African region. This state of affairs is attributed to domestic spending pressures and volatile external environment.

4.20. Uganda’s weak external position is due to low regional trade and weaker global demand resulting from the relapses in the global economy, following the global financial crisis and civil unrest within the regional markets especially in Southern Sudan.

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4.21. While the proportion of the budget allocated to the health sector has stagnated at around 8% of the total budget (figure 1 below), the proportion of the budget allocated to roads and works and energy and minerals increased from 18.7% to 23% of total budget within the same period.

Figure 1: Proportion of the total budget allocated by sector (Includes on budget ODA)

Source: MOFPED; Background to the Budget

4.22. Although general government budget has been increasing over the years, allocations to the health sector have not matched with this increase. For instance, while the health budget has increased by 93 per cent over the 5 years (FY 2010/11-2015/16) from UGX 660 billion (FY 2010/11) to UGX1, 271 billion (2015/16), total government budget increased by 148 per cent from UGX 7,377 billion (FY 2010/11) to UGX 18,311 billion (FY 2015/16).

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4.23. The health sector budget as a percentage of total government budget has been declining in the last five years (Table 1 and Figure 2).

Table 1: Total GOU Budget and Health Sector Budget (FY 2010/11-2015/16) Billions (UGX) Year Health as % of total budget Health Budget growth Total Government Budget growth 2010/11 660 7,377 8.9 2011/12 799 21% 9,630 31% 8.3 2012/13 829 4% 10,711 11% 7.7 2013/14 1,128 36% 13,065 22% 8.6 2014/15 1,281 14% 14,986 15% 8.5 2015/16 1,271 -1% 18,311 22% 6.9 Source: MOFPED; Background to the Budget

Figure 2: Growth in Total GOU Budget and Health Budget

Source: MOFPED; Background to the Budget

4.24. In the short to medium term, external resources are expected to remain important for some sectors such as health (Figure 3). These external resources include both grants and loans.

4.25. An interesting factor to note is the fact that while ODA as a proportion of the total Government budget has been decreasing, the reverse has been observed in terms of donor resources as a proportion of total health expenditure. Specifically, while the contribution of ODA to total government budget has declined from 25% in FY 2010/11 to 18% in FY 2014/15, the proportion donor resources contributing to total health budget increased from 14% to 42% within the same period (Figure 3).

4.26. The increase in this period is attributed to increased contribution of Global Health Initiatives specifically, Global Fund for HIV/AIDS, Tuberculosis and Malaria (GFATM) and Global Alliance for Vaccines Initiative (GAVI). The most recent National Health Accounts estimates show that external resources were the dominant source of health expenditure contributing 47% of total health expenditure (FY 2011/12).

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Figure 3: Percentage contribution of ODA to total budget and to the health budget (2010/11-2014/15)

Source: MOFPED; Background to the Budget

4.27. The elasticity of growth of health funding in Uganda is mostly dependent on growth in external funding and not increased domestic resources. While the elasticity of growth of health expenditure was estimated at 1.44 (implying that a 1% increase in GDP would lead to a 1.44% increase in health spending), this elasticity decreases to 0.95 when one excludes external resources. This implies that an increase in domestic resources alone does not guarantee significantly increased resource availability for Uganda’s health sector.

4.28. Per the fiscal space analysis in 2010, the health budget quadruples every ten years, but because of the high population growth rate per capita spending on health only about doubles.

Organization of the health system in Uganda 4.29. The health care system of Uganda is organized under a decentralized arrangement. At the top is the Ministry of Health, which is responsible for policy and standards formulation, quality assurance, and resource mobilization. The districts and local governments are responsible for managing all health care providers under their jurisdiction. The districts are further divided into health sub districts (HSDs), which are administered at the health centre IV level. The districts and HSDs are responsible for leadership in the planning and management of health services, supervision and quality assurance, procurement and supply of drugs, and provision of technical, logistic and capacity development support.

4.30. One of the core aims of decentralization was to ensure that districts can direct resources to funding health services in line with local priorities.

4.31. The health care system is made up of public, private-not-for-profit, and private-for-profit providers as well as traditional and complementary practitioners. For the public facilities, the national and regional referral hospitals report to the central government; while general hospitals and health centres (types II—IV) report to the local governments.

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4.32. The private-not-for-profit providers are predominantly faith-based and are administratively coordinated nationally by the respective bureaus and locally by the diocesan boards.

4.33. The private-for-profit providers predominantly comprise clinics, but also include drug shops and vendors operating informally.

4.34. In terms of overall numbers of health facilities, excluding clinics, the public sector dominates: 55 percent of all hospitals, health centres II, III, and IV are government-managed, and the rest of the health facilities which are private and NGO-managed.

4.35. Private-for-profit health facilities receive a subsidy from government using an input-based payment approach with no incentive for efficiency and equity.

4.36. A summary of health facilities in Uganda by ownership and by level is shown in Table 2.

Table 1: Facility Ownership in Uganda (By Level of Care) Level Ownership Percentage (Level) Public PNFP/ NGO PFP Total Hospital 63 64 20 147 3% Health Centre IV 170 15 8 193 4% Health Centre III 916 264 70 1,250 24% Health Centre II 1,695 520 1,395 3,610 69% Total 2,844 863 1,493 5,200 100% Percentage (Ownership) 55% 17% 29% 100% Source: Health Facility Inventory 2012

4.37. It is worth noting that although the health infrastructure has expanded, a vast majority of health facilities are not fully functional, lack equipment, staff, and are poorly maintained. There is also inequity in the distribution of the functional health service providers with these located mainly in urban and peri-urban areas.

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Health Sector in Brief 4.38. Uganda has made small but consistent improvements in overall human development and health in the past. Key health impact indicators have improved too. Hospital services are provided by public, private not-for- profit and private health institutions with majority being provided by the public sector.

4.39. A major challenge to the health sector is the shortage of essential medicine. The shortage gets translated into lower use of outpatient care services; districts that spent all their essential medicine budgets had higher use of OPD services probably due to lower stock-out of medicines.

4.40. Health work force in the country is inadequate and is attracted towards greener opportunities provided by the private for-profit sector in and outside the country.

4.41. The GoU recognizes the importance of a healthy population for economic development and its efforts are reflected in strategies including: • the Uganda National Action Plan 2011–2016, which was to scale-up multisector efforts to establish a strong nutrition foundation for Uganda’s development;

• the formulation of the Uganda Food and Nutrition Policy;

• the establishment of the Uganda National Health Research Organization.

4.42. As per the 2010 Uganda Health Financing Review, 72% of the Ugandan households live within 5 km from public health care facilities. An additional 10.5% have access to other health facilities indicating that 82.5% of the Ugandan households have access to any health care facility within 5 km radius. Many existing government facilities, however, lacked basic infrastructure and other essential inputs.

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Towards an integrated health financing system 4.43. The main objective of the Uganda Health Financing Review (Ministry of Health, 2010) is to assist in the process of developing the national health financing strategy in Uganda. The emphasis is on a comprehensive (quantitative and qualitative) analysis covering all potential sources of financing, including the health financing systems at and below the district level and community-based mechanisms.

FINANCING FINANCING RESOURCE INSTITUTIONAL KEY INSTRUMENT CHANNEL MECHANISM

NGOs Government budget(subsidies) Direct purchasing Hospitals

External resources

Household resources

(user free)

Philanthropic resources

NGO resources

GOVERNMENT Government budget Direct purchasing MoH Budget

Hospitals

External resources Districts

Household resources Demand side financing (cash transfers) (payment ward)

COMMUNITY Government budget (indirect through Banking Community based credit BASED subsidies to NGOs) Household resources Community based

NGO resources(subsidy) Insurance Provider based

PRIVATE Employer resources Insurance Micro insurance

Formal insurance

Provider based insurance

Household resources Insurance Microinsurance

Micro-credit

Employer run facilities

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4.44. Given the existing health financing dynamics and the likely future potential of various options in the country, an approach that integrates various health financing sources, pooling mechanisms and purchasing types may be ideal for Uganda to create a win-win situation for all stakeholders. The approach to be adopted should take into account the following points:

• Government is a dominant player with strong potential for provision and financing of health care, pooling of risks and resources, regulation, and leadership.

• Government health care provision and financing are decentralized to some extent

• Decentralized planning process has its roots firmly set up, but is still evolving

• Households are a major player in health financing, particularly in resource

• Private sector (both for-profit and not-for-profit) has significant presence in health care provision, pooling (insurance) and financing (employer based)

4.45. The government is in a better position to lead the proposed integrated system with adequate private participation in health care provision, pooling and resource mobilization; communities could bring in social and financial capital.

Sources of Health Financing

4.46. The sources of health financing are public, private funds (mainly household out-of-pocket expenditure), development partners (ODA) and voluntary health insurance.

4.47. Public managers of health care resources include the MOH, other line ministries, districts health services and parastatals, while private managers include private health insurance agencies, households, facility-based NGOs and private firms.

4.48. According to the NHA report, public institutions managed about 30%, while about 70% was managed by private institutions/households. In the absence of more recent NHA data, it is difficult to tell whether this picture has changed in the last seven years.

4.49. Within the public sector, MOH headquarters manages the biggest percentage, followed by district health officers and health facilities. Within the private sector, households and NGOs manage the biggest proportion. A small percentage (less than 0.2%) is managed by insurance agencies (and health maintenance organisations).

4.50. Prepayments form a small proportion of funding for Uganda’s health sector. There is limited cross- subsidisation and high fragmentation within and between health financing mechanisms, mainly due to high reliance on out-of-pocket payments and limited prepayment mechanisms.

4.51. Without compulsory health insurance and low coverage of private health insurance, Uganda has limited pooling of resources, and hence minimal cross-subsidisation. Although tax revenue is equitable, the remaining financing mechanisms for Uganda are inequitable due to their regressive nature, their lack of financial protection and limited cross-subsidisation.

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Figure 4: Health Financing Functional Chart for Uganda (2014)

Source: Data from Uganda’s National Health Accounts

4.52. Some of the critical issues currently facing Uganda’s health financing system are: (a) Revenue Collection

i. Overall gross under-funding for the health sector, in the face of growing needs driven by increased population and new technologies, resulting into a failure to achieve sector objectives

ii. Low contribution of domestic revenue particularly general tax revenue. Capacity to generate additional domestic resources for the sector will remain weak in the short term

iii. Heavy dependence on external funds, in addition to being unpredictable

iv. Challenges in effective coordination and harmonization of external resources

v. Very high OOP payments which are associated with high catastrophic payments and impoverishment

vi. Very low levels of prepayment with voluntary prepayment schemes

vii. In the short to medium term prospects for increased resource mobilization from both domestic and external sources remains limited

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(b) Resource Pooling

i. High level of fragmentation between and within resource pools. The concept of purchasing is new to the sector and needs to be developed.

ii. Lack of mechanisms for income and risk cross subsidization and risk equalization between the different sources of revenue

iii. Lack of alignment of donor funding to health sector priorities often leading to inefficiency and inequity

iv. weaknesses of donor funding predictability and managing projects by government

(c) Purchasing

i. Input based purchasing which does not have any incentives for high performance and quality

ii. In the public sector, government is the provider and at the same time the purchaser which is a disincentive for both efficiency and quality

iii. Payment for services based on a fee-for-service basis, in the absence of appropriate regulation of private sector, contributing to increased cost escalation in the private sector

iv. Challenges monitoring, regulation and in putting in place incentives for private sector providers to ensure both efficiency and quality

v. Traditional input financing reinforces the inequities between the rural and urban areas and is not fully reflective of the population’s health needs.

4.53. The insurance sector in Uganda is still under-developed and it contributes very little as a source of health financing. There is a generally very low insurance market penetration with insurance contributing less than 1% of Gross Domestic Product. The health insurance market is faced with challenges of sustainability due to the very low membership numbers and high dropout rates.

4.54. This scenario is unlikely to change in the short term. While there are current efforts to establish a National Health Insurance Fund(NHIF), in the short term the focus will be on institutional capacity building before NHIF is implemented. While there are suggestions for earmarking taxes as an option to raise resources for the health sector, this option maybe challenging because it may be seen to interfere with the power and roles of other key stakeholders such as MOFPED and Parliament.

4.55. In the face of low funding, Uganda is also under considerable pressure to increase spending for health. This is driven primarily by the rapidly growing population and the need to adopt for more effective—and expensive— health technologies and service standards to combat the high disease burden.

4.56. Besides, continuing resource mobilization and reducing waste, Uganda needs to take proactive steps to mitigate growing pressure to increase health spending.

4.57. Except for government funds, there are no clearly defined resource pools in Uganda. The desired long term position is to have one health fund, but in the short to medium term pooling may not necessarily refer to having all sector resources in one bank account. Virtual pooling of resources is applicable to the Ugandan context.

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4.58. Virtual pooling refers to ensuring that funds from different sources are directed and planned for in a coordinated purchasing approach to ensure that they fund sector priorities identified within the sector development plans.

4.59. The government, with support from development partners, shall provide adequate resources to the health sector. Efforts for improving health financing in Uganda shall be guided by the concepts of Universal Coverage and Social Health Protection.

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5. NATIONAL HEALTH INSURANCE SCHEME

5.1. The Ministry of Health had announced plans to introduce a National Health Insurance Scheme where all Ugandan residents would be required to a have a health insurance policy. The scheme was expected to start in the 2012 financial year.

5.2. The scheme, proposed in 2007, is premised on helping all Ugandans access basic health care services through compulsory contributions of 4 per cent of an employee’s salary and the employer contributing another 4 per cent to make it 8 per cent per worker.

5.3. The government indicated in the budget speech for financial year 2016/2017 that the National Health Insurance Bill had been gazetted and was awaiting first reading in Parliament, but Ugandans may have to wait longer for this to become a reality.

5.4. The latest hurdle in the process is the indication by the Ministry of Finance that the projected cost of implementing the National Health Insurance Scheme (NHIS) is not affordable to the government.

5.5. A key component of the Bill which is said to be unaffordable is the money required for government to pay for health insurance for indigents. An indigent is defined as a person who has no visible or adequate means of income or who has nobody to support him or her.

Scheme Membership 5.6. The following categories of employees shall be members of the Scheme: • Public servants • All employees who are employed in Uganda and are residents of Uganda, who are in the employment of employers with five or more employees.

5.7. A member of the Scheme shall register with the Scheme not more than four dependants, who shall be beneficiaries of the Scheme.

Objective of the Scheme (a) facilitate the provision of efficient, equitable, accessible, affordable and quality health care to the beneficiaries of the Scheme; (b) develop health insurance as a complementary mechanism of health care financing in Uganda; (c) ensure the quality and equity of health care, the appropriate utilisation of services and patient satisfaction in the provision of health care; (d) encourage private sector participation in the provision of health care services; and (e) provide health care services to the indigent.

Functions of the Scheme • collect funds and hold, deposit, invest, administer and disburse the funds received; • accredit, supervise, monitor and regulate the health care providers; • negotiate and enter into contracts with accredited health care providers; • determine the payment mechanism to be used to pay an accredited health care providers; • carry out research and provide statistics on matters relating to health insurance in Uganda;

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5.8. Every person resident in Uganda who is not a member or a beneficiary of the Scheme shall be registered as a member of a private commercial health insurance scheme or a community health insurance scheme.

5.9. A community health insurance scheme shall be registered in Uganda as a company without share capital.

5.10. All scheme funds shall be subjected to all rules and regulations applicable to public funds.

5.11. Accounts shall be audited by Auditor General and a report submitted to Parliament. Board shall submit audited accounts to the Minister for Health. Minister shall lay a copy of the report together with the statement of accounts before Cabinet.

5.12. The Scheme is open to voluntary registration by persons who are not required by the Act to be registered with the Scheme.

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Health Care Benefits 5.13. Every beneficiary shall be entitled to all the benefits specified in the below schedule:

Figure 5: Health Care Benefits under proposed NHIS Health Care Service Health Care Service under the Scheme Health Care Service not provided by the Scheme Outpatient Services • Consultation • Designer lenses and frames • Laboratory Tests • Complicated hearing aids • Approved X-ray • Evacuation • Prescribed drugs and medicines • Diagnosis and treatment of common ailments • Referral to medical officers and high level of care • Outpatient surgery • Preventive services like immunization and screening for breast, cervical and prostate cancers • Ophthalmologic and optical services • Ear- Nose- Throat services • Health education • Counselling • Removal of foreign bodies • Laboratory investigations • Emergency cases Laboratory Laboratory tests including pregnancy tests, Investigations haematology, chemistry, serology and hormones, tests including reproductive health, microbiology, parasitology, blood transfusion and histology Dental Services • Extractions • Dentures and braces • Fillings • Cosmetic dental surgery • Oral diseases Reproductive Health • Ante-natal care Services • Normal delivery • Emergency reproductive health services including episiotomy, forceps delivery vacuum extraction and caesarean section • Post abortal care • Adolescent reproductive health services • Post-natal care including Family Planning Services Inpatient • Admissions in private and general ward • Conditions covered by other • Investigative and diagnostic medical arrangements examinations (for example CT scan, ultra sound • Dangerous sports like motor x-ray) racing and sky diving • Inpatient treatment of different diseases • Hospitalizations related to • Nursing care obesity • Minor and major surgery • Cosmetic procedures • Orthopaedic treatment and • Alternative medicine • Referral to specialists and other units Kenbright Actuarial & Financial Services Page27 of 37

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• Emergency cases • Evacuation • Ambulances services for referral purposes • Psychiatric and neurotic conditions Minor and major • Amputation surgical operations • Appendicectomy • Archidectomy • Male circumcision • Debridement • Post abortion uterine evacuation • Excision • Herniorrhaphy • Hydrocelectomy • Incision and Drainage • Laparotomy • Plaster Of Paris (POP) • Surgical Toilet and Suture/Supra Pubic Puncture (S.T. S/S.P.P) • Removal of uterine fibroids • Hysterectomy • Cholestecystectomy • Haemorrhoidectomy • Reduction of rectal prolepses • Sigmoidectomy • Mastectomy • Cysto-oophorectomy • Disarticulation • Fistula and rectal repair • Anal dilation • Surgical methods of contraception Rehabilitation • Physiotherapy • Crutches Source: The National Health Insurance Bill, 2014

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6. HEALTH SECTOR DEVELOPMENT PLAN 2015/16-2019/20

6.1. The goal of this Plan is to accelerate movement towards Universal Health Coverage (UHC) with essential health and related services needed for promotion of a healthy and productive life. UHC makes it possible to ensure that all people receive essential and good quality health services they need without suffering financial hardship.

6.2. The Plan sets key objectives to be attained during the 5-year period. These include:

• contributing to the production of a healthy human capital for wealth creation through provision of equitable, safe and sustainable health services

• increasing financial risk protection of households against impoverishment due to health expenditures

• addressing the key determinants of health through strengthening intersectoral collaboration and partnerships

• enhancing health sector competitiveness in the region and globally 6.3. To achieve these objectives, the health sector will work towards strengthening the national health system including governance; disease prevention, mitigation and control; health education and promotion, curative services; rehabilitation services; palliative services; and health infrastructure development.

6.4. The Plan builds on the achievements registered under the Health Sector Strategic and Investment Plan (HSSIP) 2010/11 - 2014/15. The HSSIP containing targets and planned investments for major policy implementation steps, although it does not plan for the implementation of new health financing arrangements.

6.5. With health infrastructure, physical access to health facilities (proportion of the population leaving within 5 km of health facility) is currently at 72%. Despite this, there are also still major inequities in availability of facilities, ranging from a low of 0.4 facilities per 10,000 population (Yumbe district) to a high of 8.4 facilities per 10,000 population (Kampala). Several health facilities were renovated and equipped though we still face challenges of inadequate and poorly maintained medical equipment.

6.6. The health workforce is still a key bottleneck for the appropriate provision of health services, with challenges in adequacy of numbers and skills, plus retention, motivation, and performance challenges. Efforts by the GoU and Partners have facilitated recruitment of much-needed staff increasing the proportion of approved posts from 56% in 2010 to 69% in 2013/14.

6.7. Looking at sector governance, the sector stewardship has been changing at the highest level, leading to frequent changes in stewardship direction. To effectively partner and coordinate with the private sector in health service delivery, the GoU enacted a national policy on public-private partnership in health. Using mTRAC, mechanisms for client feedback / redress were established under the anonymous hotline and U- Report. This has improved on accountability in service delivery.

6.8. The Plan prioritizes investment in seven health systems areas including; health governance and partnerships; service delivery systems; health information; health financing; health products and technologies; health workforce and health infrastructure.

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6.9. Under health financing the sector will work towards mobilising, and allocating resources to implement planned services in an efficient, effective and equitable manner by introducing reforms in systems for revenue generation, risk pooling and strategic purchasing of services; improving the public financial management system, procurement system and the governance and regulatory system for the National Health Insurance Scheme.

6.10. This HSDP is part of the overall health sector planning framework. It provides the strategic focus of the sector in the medium term, highlighting how it will contribute, within the constitutional and legal framework, to the second National Development Plan (NDP II), and to the second National Health Policy (NHP II) imperatives of the country, and so to the overall Vision 2040.

6.11. The HSDP provides overall strategic direction for the stakeholders in health, together with outlining their expected roles and responsibilities in attaining this strategic agenda. It in addition lays down the implementation framework within which the stake holders contribute towards improving the health of the population. Furthermore, HSDP lays down clear coordination mechanisms for the various stakeholders.

6.12. The plan gives an overview of the NHP, overview of the second NDP and overview of the Vision 2040 which has been discussed in previous sections in this document.

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7. PRIVATE HEALTH INSURANCE IN UGANDA

7.1. Uganda Healthcare Federation (UHF) is an umbrella body, established in 2011 to champion the interests of the private health sector. UHF has sister federations in Kenya, Tanzania, Ethiopia, Burundi and Rwanda together forming the East Africa Healthcare Federation.

7.2. As the umbrella body for the Uganda private health sector, UHF has a growing membership of over 55 non- state health sector Associations and health-related organizations in Uganda, including Health Membership Organisations (HMOs).

7.3. The activities of UHF over the last five years have increased in scope to include health sector program implementation, development of human resources in health, promotion of innovation in health while actively lobbying for a Uganda National Health Insurance Scheme (NHIS) and rising awareness for Community Based Health Insurance Schemes. Recent legislation and regulations directly addressed structural and operational elements of the HMO and Health Insurance Organisations (HIO) fraternity, resulting in a drop from eleven to seven registered and licensed HMOs in 2016.

7.4. Regulation of HMOs in neighbouring Kenya simply forced HMOs to transform into insurers or brokers, while in Uganda, the HMOs businesses that opted not to renew their licenses as HMOs, shed off the costly arm of insurance and continue to provide health services through their facilities for walk-ins and as health insurance service providers. Undoubtedly appreciating the simpler life of not having to tussle with perpetually problematic providers’ upcountry with fraudulent claims or poly pharmacy amongst other issues.

7.5. During the year 2015, the Insurance Regulation Authority issued revised Guidelines to HMOs. The objectives of the new Guidelines are to:

• offer the basis upon which the Authority shall oversee and provide clarity on the regulation of HMOs.

• outline the licensing requirements and procedure parties for interested in the provision of Health Insurance services.

• stipulate roles and responsibilities of parties to ensure that the HMOs are run professionally, funds are accounted for and appropriate treatment is provided timely.

• foster protection for Members/Clients of the HMO.

• promote the advancement of quality and affordable private healthcare in Uganda.

• ensure alignment with GoU’s efforts towards the achievement of MDGs.

7.6. Universal health coverage through a national health insurance scheme in Uganda would do well to observe the experiences and learning from HMOs. Especially as their structure would be a hybrid of the HMO model.

7.7. The government would be the insurer, with some owned facilities (the government facilities) and a network of preferred providers. Consumers will undoubtedly behave the same; prefer to go outside of the network of public facilities where claims do tend to cost more, due to variances in operational dynamics and few concessions.

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7.8. Ideally, the new NHIS scheme would be mandatory and would as HMOs do, have to compete with the health insurance companies and community based health schemes, each of which has a unique appeal intrinsic in their structure, pricing, and scope.

7.9. Even with economic dynamics considered, Uganda’s out of pocket expenditure on health is high at 53%, while Rwanda which has a government owned health insurance scheme called RAMA managed by their social security parastatal (RSSB) stands at 18%.

7.10. The private health stakeholders including Uganda Healthcare Federation, together with the Private Sector Foundation Uganda (PSFU), Federation of Uganda Employers (FUE) and Uganda Insurers Association (UIA) have systematically lobbied and advocated for some adjustments to the proposed NHIS highlighting several key considerations to the proposed NHIS bill.

7.11. The recommendations by this bloc proposed legislation mandate all employers to provide medical insurance alleviating the burden on government resources.

7.12. Additionally, the basic health package is stipulated following an actuarial study and reconsideration of increasing the tax burden on employee salaries to cater for NHIS. Finally, existing health insurance companies should be inculcated intimately into the planned structures due to their experience and understanding of the consumption of health insurance in Uganda, which remains unique. It is suggested that the scheme considers administration through the National Social Security Fund, not only due to their compliance increases but because of their established collection mechanisms. There continue to be deliberations of the exact format of the phased approach to be adopted however, it is agreed implementation must be phased.

7.13. UHF goes further to consider a supplementary proposal for an NHIS roll out using a phased approach which includes children aged 13 and below, adults aged over 70 and persons with disabilities, through a basic healthcare package. While these segments of society can contribute to the financial basket, it is prudent to consider that the bulk of healthcare spending both out of pocket and by the government is in these two categories.

7.14. There needs to be further dialogue on the benefits and implications contributions by the entire population to build a fund, to provide health to these vulnerable groups. This phased approach scaling up over a period of 15 years would gradually increase the age ranges covered as well as the scope of cover, at a pace that is financially sustainable. Discussions on the various dynamics of the financing of a sustainable NHIS system are on-going and the conclusive position will likely determine the scope of cover that can be given.

7.15. While health insurance in Uganda trudges along the trail to National Health Insurance, current provider pillars namely HMOs, health insurers and community-based health schemes all have a valuable contribution to make a viable and sustainable NHIS. Experiences from each pillar in product design, claims experience and premium calculations provide a mass pilot, with invaluable data that would be a travesty to not be utilized.

7.16. The Ugandan Insurance market has been on the rise for the past two years; mainly due to a favourable investment climate that has encouraged foreign players to join the market through mergers and acquisitions.

7.17. In 2015, a couple of foreign insurance companies entered Uganda mainly through mergers and acquisitions.

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7.18. Liberty Insurance, a South African-based company, bought 51 shares from East African Underwriters; Old Mutual and UAP merged while Prudential bought Goldstar Life Insurance. Except for Prudential, the other foreign companies are currently key players in the health insurance market.

7.19. In the same year, the insurance market registered three (3) market exits, namely: Leads Insurance Company, Africa Premier Health and Kadic. Leads and Africa Premier Health were delicensed by the Authority while Kadic voluntarily wound up its HMO business.

7.20. The gross claims paid for both life, non-life and HMOs rose from UShs 184.3bn in 2014 to UShs 214bn in 2015 representing an overall growth of 16.08%.

7.21. The licensed and registered health insurance companies in Uganda are: - (i). Liberty Health (ii). Britam (iii). UAP (iv). Sanlam (Sancare) (v). Jubilee (vi). APA

7.22. As per the Insurance Regulatory Authority of Uganda, the licensed HMOs in Uganda, as of 2017, are: (i). AAR Health Services (ii). Case Med Care Limited (iii). International Air Ambulance (iv). International Medical Link Limited (v). Kampala International Medical Centre (vi). St. Catherine’s Hospital

7.23. ICEA Uganda has a medical microinsurance product which they made accessible through Milvik Uganda Limited. It is a product that offers financial support in the event of hospitalization i.e. hospitalization income replacement insurance. On the other hand, Sanlam has developed a 3-tier product that enables policyholders to take control of their outpatient medical costs. The three tiers of benefit are: - • Tier 1- 50% of a policyholder’s outpatient premiums go into a Medical Savings Account. This portion belongs to the policyholder. Any unused balance is accumulated and returned to the policyholder after 3 years in cash or in kind.

• Tier 2 – This is referred to as a funding gap where a member on exhausting Tier 1, a policyholder is required to use their own money to meet outpatient expenses up to a certain limit.

• Tier 3- Upon exhaustion of Tier 1 and Tier 2, then Tier 3 would provide an additional outpatient cover up to a certain maximum limit. This is just one of the few product development and innovation occurring in the health insurance sector.

7.24. These are just but a few of the product innovations occurring in the health insurance sector over the years. The regulatory body has also been making changes over the years. In 2013, the IRA set a Maximum Commission Rate of 12% after noting that some players had to pay out unreasonably higher charges.

7.25. A regional health insurance office shall: (a) Perform the functions of the Secretariat within the region

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(b) Recommend the health care providers, within the region, to be accredited by the Board

(c) Verify the claims of health care providers and where certified to be proper, forward these to the Scheme for payment

(d) Handle complaints from beneficiaries and health providers

Figure 6: Uganda Insurance Industry Statistics Industry Statistics as at 2015 Ushs. Billions 2010 2011 2012 2013 2014 2015 Total Industry Gross Written Premium 239.9 296.8 352 463 504.8 612.1 Non-Life Gross Premium 216.3 262.2 313 351.4 384 464.4 Life Gross Premium (UShs. Billions) 23.6 34.6 39 55.4 74 99.8 HMOs Gross Premium (UShs Billions) 0 0 0 56 46.8 47.8 Insurance Penetration (%)2 0.65 0.65 0.66 0.85 0.86 0.76 Insurance Density ($) 3.16 3.78 3.81 5.2 5.3 5.4

2Rebasing of GDP from the Base year of 2002 to 2009 had a significant impact on the GDP which is a denominator to the computation of Insurance Penetration. In fact, as a result of rebasing which was done in Nov. 2014, the 2013/14 GDP went up by 13 percentage points. Using the rebased GDP for 2014 and 2015, penetration increases from 0.697% in 2014 to 0.764% in 2015.

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8. BIBLIOGRAPHY

Government of Uganda, Ministry of Health. (2015). Health Sector Development Plan 2015/16 - 2019/20. Ministry of Health.

Government of Uganda, Ministry of Health. (2010). 2009/2010 Health Financing Review. Kampala: Department of Planning, Ministry of Health.

Government of Uganda, Ministry of Health. (2016). Health Financing Strategy 2015/16 – 2024/25.

The National Health Insurance Bill, 2014

Uganda Vision 2040

United Nations. (2016). Transforming Our World: The 2030 Agenda For Sustainable Development.

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About Us

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Document Version

March 2017

Version 1.0

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