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Uganda’s proposed National Health Insurance Scheme (NHIS) may increase the use of preventive healthcare interventions which can impact the health and welfare of people living with, or at-risk of developing, chronic diseases. The development and implementation of Uganda’s NHIS is a critical move forward to meet Sustainable Development Goal (SDG) 3, ensure healthy lives and promote well-being for all at all ages. 

As part of a collaboration between (Dorit Talia Stein, CID PhD Affiliate), (Freddie Ssengooba), and the Ugandan (Aliyi Walimbwa), we are undertaking a participatory simulation modeling exercise to co-produce context specific evidence with stakeholders regarding the potential health, welfare, and equity impacts of a proposed NHIS in Uganda. Our goal is to support evidence-based policymaking and to advance the use of simulation modeling for health policy decision-making in Uganda.

In this article, we share information on Uganda’s current health system, our research project motivation, and reflections from the first stakeholder engagement workshop. 

‘Free’ public healthcare and private out-of-pocket payments 

By policy in Uganda, health care services are available for free at government-run health facilities (except in private wings of government hospitals). However, chronic underfunding of the public healthcare sector means many households seek care at better-resourced private facilities and pharmacies. Private healthcare providers dominate healthcare markets in urban areas – more than in the capital of Kampala are privately owned.

Private healthcare providers require out-of-pocket payments. There is currently no national pre-payment (risk and revenue pooling) system in place to protect Ugandans from the financial risk associated with paying out-of-pocket for healthcare. of the population is enrolled in any type of voluntary health insurance, with the majority being enrolled in private employer-provided or community-based insurance plans. 

Social protection scheme for health as national priority 

As Uganda develops and its population ages, the demand for healthcare and associated financial risk will only increase. Uganda’s health and development plans cite NHIS as one of the to improve the quality of life of its citizens. So far, however, insurance advocates have not been successful in getting health insurance legislation signed into law, with on the proposed scheme design relating to enrollment of the informally employed (comprising most of the employed population in the country) and concerns from private sector stakeholders. 

Using insurance to generate demand for preventive healthcare 

Although the leading causes of death in Uganda are still infectious diseases, Uganda is experiencing a growing burden of chronic, noncommunicable diseases such as cardiovascular diseases, diabetes, and cancers. We know from that health insurance can generate demand for healthcare, especially preventive healthcare such as  screening and treatment of hypertension or diabetes. Implementing and scaling up NHIS in Uganda may generate demand for preventive interventions if insurance is well designed and targeted. Scheme enrollment requirements, health services and providers included in the scheme, and cost-sharing rules are some examples of health insurance design choices that may influence whether people with health insurance will use more healthcare (which, in the context of underutilization of care in settings such as Uganda, can be beneficial).

Participatory health system simulation modeling 

There are critical evidence gaps regarding quantifying and comparing the potential benefits, costs, and trade-offs of different health insurance design choices in Uganda. Simulation modeling can help demonstrate the potential impacts of alternate policy proposals across various policy-relevant population sub-groups (such as socioeconomic status, geographies, and employment status). Simulation modeling can support evidence-based policymaking by comparing, for example, alternate financing mechanisms, benefits packages, and provider networks as “what-if” simulation scenarios. As Uganda tackles dilemmas on structuring national health insurance to maximize inclusive gains, evidence on the distribution of benefits and costs can play a role in developing a national health insurance scheme that can provide adequate financial risk protection and improved health.  

In this project, we are implementing a participatory and collaborative model-building process with government, academic, and private sector stakeholders. Co-production of simulation models with stakeholders is to build trust in the model and its outputs among end-users and is best suited for complex topics with multiple intervention options.

Facilitating dialogue through stakeholder workshops 

Our first in January 2024 aimed to engage stakeholders in the research and model design process through participatory sessions and activities. Over 30 participants attended from institutions and organizations such as the Parliamentary Forum on Noncommunicable Diseases, Ministry of Health, Insurance Regulatory Authority of Uganda, National Planning Authority, Uganda Healthcare Federation, World Health Organization, World Bank, and Uganda NCD Alliance, among others. 

The process of the participatory workshop proved to be a valuable collective learning exercise. Workshop sessions facilitated discussions across stakeholder groups – including those in clinical, policy, and practitioner roles – regarding incentives within the proposed NHIS to use primary and preventive healthcare. By the end of the workshop, stakeholders were able to build a shared understanding of the link between NHIS design and chronic disease prevention in the context of Uganda’s population and health system. 

Next steps for our project include further stakeholder engagement to prioritize insurance policy scenarios to model and to validate model inputs and assumptions. We will then disseminate our findings to inform ongoing discussions around how to design an effective and equitable national health insurance program.