Players and processes behind the national health insurance scheme: a case study of Uganda

Abstract

BackgroundUganda is the last East African country to adopt a National Health Insurance Scheme (NHIS). To lessen the inequitable burden of healthcare spending, health financing reform has focused on the establishment of national health insurance. The objective of this research is to depict how stakeholders and their power and interests have shaped the process of agenda setting and policy formulation for Uganda’s proposed NHIS. The study provides a contextual analysis of the development of NHIS policy within the context of national policies and processes.MethodsThe methodology is a single case study of agenda setting and policy formulation related to the proposed NHIS in Uganda. It involves an analysis of the real-life context, the content of proposals, the process, and a retrospective stakeholder analysis in terms of policy development. Data collection comprised a literature review of published documents, technical reports, policy briefs, and memos obtained from Uganda’s Ministry of Health and other unpublished sources. Formal discussions were held with ministry staff involved in the design of the scheme and some members of the task force to obtain clarification, verify events, and gain additional information.ResultsThe process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the three phases of development: from 1995 to 1999; 2000 to 2005; and 2006 to 2011. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Stakeholders, notably the private sector, played an important role in influencing the pace of the development process and the currently proposed design of the scheme.ConclusionsThis study underscores the importance of stakeholder analysis in major health reforms. Early use of stakeholder analysis combined with an ongoing review and revision of NHIS policy proposals during stakeholder discussions would be an effective strategy for avoiding potential pitfalls and obstacles in policy implementation. Given the private sector’s influence on negotiations over health insurance design in Uganda, this paper also reviews the experience of two countries with similar stakeholder dynamics.

Evidence for informing health policy development in Low-income Countries (LICs): perspectives of policy actors in Uganda

“…Mubyazi and Gonzalez-Block (8) documented a case of malaria treatment change in Tanzania where the decision to change the first anti-malarial drug given high resistance levels was protracted, characterized by the MoH commissioning more studies to gather more evidence on different aspects of the policy change and implementation including cost, implementation feasibility and community acceptability. Similarly Basaza et al (23) documented a case of designing a health insurance scheme in Uganda emphasizing the need for comprehensive evidence encompassing financial feasibility, political acceptability, popular support, impact on employment and private sector growth to guide decision-making. This emphasizes the need for evidence informing different aspects of decision-making and policy implementation.…”

Integrative review; identifying the evidence base for policymaking and analysis in health care

“…There exists limited evidence on how policymakers take account of contextual issues. At a national level, a stable political system has a positive impact on policy development (Basaza, O'Connell, & Chapcakova, ; Mbachu et al, ) where the converse was found to hinder policy development (El‐Jardali, Bou‐Karroum, Ataya, El‐Ghali, & Hammoud, ). Health policymaking must sit comfortably within the wider national health strategic framework which can either act as a roadmap for policymaking or constrain attempts at policy reform (Mc Hugh, Perry, Bradley, & Brugha, ; Onwujekwe et al, ).…”

“…A push for policy reform has also come from within healthcare professions (Archer, Regan de Bere, Nunn, Clark, & Corrigan, ). This includes the need to implement standards from regulation agencies (Blaauw et al, ) or because of health system restructuring and reform (Basaza et al, ; Mc Hugh et al, ).…”

“…International best practice recommends setting an agenda driven by practitioners rather than by political agendas (Vos, Lagasse, & Levêque, ). During the process of making policy, engagement with policy holders in other countries provides valuable information to avoid challenges other countries may have encountered previously (Basaza et al, ). Where there is a lack of communication, consultation and planning, delays may be experienced (Tumwesigye, Nakanjako, Wanyenze, Akol, & Sewankambo, ; Valaitis et al, ).…”

“…If key stakeholders are not consulted, a policy decision may receive low support and have a decreased likelihood of successful implementation (Basaza et al, ; Nabyonga‐Orem et al, ). Inclusion of a range of stakeholders in policymaking can build support through several different mechanisms.…”