Health financing reform in Uganda: How equitable is the proposed National Health Insurance scheme?

<p>Abstract</p> <p>Background</p> <p>Uganda is proposing introduction of the National Health Insurance scheme (NHIS) in a phased manner with the view to obtaining additional funding for the health sector and promoting financial risk protection. In this paper, we have assessed the proposed NHIS from an equity perspective, exploring the extent to which NHIS would improve existing disparities in the health sector.</p> <p>Methods</p> <p>We reviewed the proposed design and other relevant documents that enhanced our understanding of contextual issues. We used the Kutzin and fair financing frameworks to critically assess the impact of NHIS on overall equity in financing in Uganda.</p> <p>Results</p> <p>The introduction of NHIS is being proposed against the backdrop of inequalities in the distribution of health system inputs between rural and urban areas, different levels of care and geographic areas. In this assessment, we find that gradual implementation of NHIS will result in low coverage initially, which might pose a challenge for effective management of the scheme. The process for accreditation of service providers during the first phase is not explicit on how it will ensure that a two-tier service provision arrangement does not emerge to cater for different types of patients. If the proposed fee-for-service mechanism of reimbursing providers is pursued, utilisation patterns will determine how resources are allocated. This implies that equity in resource allocation will be determined by the distribution of accredited providers, and checks put in place to prohibit frivolous use. The current design does not explicitly mention how these two issues will be tackled. Lastly, there is no clarity on how the NHIS will fit into, and integrate within existing financing mechanisms.</p> <p>Conclusion</p> <p>Under the current NHIS design, the initial low coverage in the first years will inhibit optimal achievement of the important equity characteristics of pooling, cross-subsidisation and financial protection. Depending on the distribution of accredited providers and utilisation patterns, the NHIS could worsen existing disparities in access to services, given the fee-for-service reimbursement mechanisms currently proposed. Lastly, if equity in financing and resource allocation are not explicit objectives of the NHIS, it might inadvertently worsen the existing disparities in service provision.</p

Cost of malaria morbidity in Uganda

Background: The high burden of malaria, among others, is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The economic dimension focuses on three types of effects, namely: direct, indirect and intangible effects which are felt at both macro and micro levels. The objective of this study was to estimate the costs of malaria morbidity in Uganda using the cost-of-illness approach. Methods: The study covered 4 districts, which were selected randomly after stratification by malaria endemicity into Hyper endemic (Kamuli and Mubende districts); Meso endemic (Mubende) and Hypo endemic (Kabale). A survey was undertaken to collect data on cost of illness at the household level while data on institutional costs was collected from the Ministry of Health and Development Partners. Results: Our study revealed that: (i) in 2003, the Ugandan economy lost a total of about US$658,200,599 (US$24.8 per capita) due to 12,343,411 cases malaria; (ii) the total consisted of US$49,122,349 (7$ 609,078,209 (92%) indirect costs or productivity losses; (iv) the total malaria treatment-related spending was US$46,134,999; out of which 90$2,987,351 was spent on malaria prevention; out of which 81% was borne by MOH and development partners. Conclusion: Malaria poses a heavy economic burden on households, which may expose them to financial catastrophe and impoverishment. This calls for the upholding of the no-user fees policy as well as increased investments in improving access to quality of health services and to proven community preventive interventions in order to further reduce the cost of illness borne by patients and their families

Cost of malaria morbidity in Uganda

The high burden of malaria, among others, is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The economic dimension focuses on three types of effects, namely: direct, indirect and intangible effects which are felt at both macro and micro levels. The objective of this study was to estimate the costs of malaria morbidity in Uganda using the cost-of-illness approach. The study covered 4 districts, which were selected randomly after stratification by malaria endemicity into Hyper endemic (Kamuli and Mubende districts); Meso endemic (Mubende) and Hypo endemic (Kabale). A survey was undertaken to collect data on cost of illness at the household level while data on institutional costs was collected from the Ministry of Health and Development Partners. Our study revealed that: (i) in 2003, the Ugandan economy lost a total of about US$658,200,599 (US$24.8 per capita) due to 12,343,411 cases malaria; (ii) the total consisted of US$49,122,349 (7$ 609,078,209 (92%) indirect costs or productivity losses; (iv) the total malaria treatment-related spending was US$46,134,999; out of which 90$2,987,351 was spent on malaria prevention; out of which 81% was borne by MOH and development partners.  Malaria poses a heavy economic burden on households, which may expose them to financial catastrophe and impoverishment. This calls for the upholding of the no-user fees policy as well as increased investments in improving access to quality of health services and to proven community preventive interventions in order to further reduce the cost of illness borne by patients and their families. Key words: Cost of illness, malaria, Ugand

Intestinal schistosomiasis in Uganda at high altitude (>1400 m): malacological and epidemiological surveys on Mount Elgon and in Fort Portal crater lakes reveal extra preventive chemotherapy needs

Background Intestinal schistosomiasis is of public health importance in Uganda but communities living above 1400 m are not targeted for control as natural transmission is thought unlikely. To assess altitudinal boundaries and at-risk populations, conjoint malacological and epidemiological surveys were undertaken on Mount Elgon (1139 m–3937 m), in Fort Portal crater lakes and in the Rwenzori Mountains (1123 m–4050 m). Methods Seventy freshwater habitats [Mount Elgon (37), Fort Portal crater lakes (23), Rwenzori Mountains (8) and Lake Albert (2)] were inspected for Biomphalaria species. Water temperature, pH and conductivity were recorded. A parasitological examination of 756 schoolchildren [Mount Elgon (300), Fort Portal crater lakes (456)] by faecal microscopy of duplicate Kato-Katz smears from two consecutive stool samples was bolstered by antigen (urine-CCA dipstick) and antibody (SEA-ELISA) diagnostic assays. Results Biomphalaria spp. was found up to 1951 m on Mount Elgon and 1567 m in the Fort Portal crater lakes. Although no snail from Mount Elgon shed cercariae, molecular analysis judged 7.1% of snails sampled at altitudes above 1400 m as having DNA of Schistosoma mansoni; in Fort Portal crater lakes three snails shed schistosome cercariae. Prevalence of intestinal schistosomiasis as measured in schoolchildren by Kato-Katz (Mount Elgon = 5.3% v. Fort Portal crater lakes = 10.7%), CCA urine-dipsticks (18.3% v. 34.4%) and SEA-ELISA (42.3% v. 63.7%) showed negative associations with increasing altitude with some evidence of infection up to 2000 m. Conclusions Contrary to expectations, these surveys clearly show that natural transmission of intestinal schistosomiasis occurs above 1400 m, possibly extending up to 2000 m. Using spatial epidemiological predictions, this now places some extra six million people at-risk, denoting an expansion of preventive chemotherapy needs in Uganda

Assessing Water, Sanitation and Hygiene Access and Use in Nabilatuk District, Uganda: A Cross-Sectional Study of Different Data Collection Methods

Good access and appropriate use of Water, Sanitation and Hygiene (WASH) is important in the control, elimination and eradication of a number of neglected tropical diseases (NTDs). Poor WASH access and use may explain continued high trachoma prevalence in Nabilatuk district, Uganda. This study aimed to investigate the level of WASH access and use through different WASH data collection methods and the triangulation of their results. A mixed-methods cross-sectional study was conducted in 30 households in Nabilatuk district, from 10 households in each of three nomadic villages. The data collection methods used were: (1) direct observations of routine WASH behaviours; (2) structured quantitative household questionnaires; (3) demonstrations of specific WASH behaviours. With regards to access, observations indicated less WASH access and use compared with questionnaire responses: the questionnaire indicated all households had access to an improved water source, but 70% had a >30-min round-trip, and no households had access to an improved latrine, whereas some observations indicated longer water collection times. In terms of behaviour, there were also differences between the data collection methods, with demonstrations revealing knowledge of good practice, such as thorough handwashing, but this was not routinely observed in the observations. Further systematic investigation of barriers to appropriate WASH access and use in the local context is needed, as is the development of feasible, valid and reliable WASH access and use assessment methods for use in national NTD programmes

Interpreting ambiguous ‘trace’ results in Schistosoma mansoni CCA Tests: Estimating sensitivity and specificity of ambiguous results with no gold standard

Background The development of new diagnostics is an important tool in the fight against disease. Latent Class Analysis (LCA) is used to estimate the sensitivity and specificity of tests in the absence of a gold standard. The main field diagnostic for Schistosoma mansoni infection, Kato-Katz (KK), is not very sensitive at low infection intensities. A point-of-care circulating cathodic antigen (CCA) test has been shown to be more sensitive than KK. However, CCA can return an ambiguous ‘trace’ result between ‘positive’ and ‘negative’, and much debate has focused on interpretation of traces results. Methodology/Principle findings We show how LCA can be extended to include ambiguous trace results and analyse S. mansoni studies from both Côte d’Ivoire (CdI) and Uganda. We compare the diagnostic performance of KK and CCA and the observed results by each test to the estimated infection prevalence in the population. Prevalence by KK was higher in CdI (13.4%) than in Uganda (6.1%), but prevalence by CCA was similar between countries, both when trace was assumed to be negative (CCAtn: 11.7% in CdI and 9.7% in Uganda) and positive (CCAtp: 20.1% in CdI and 22.5% in Uganda). The estimated sensitivity of CCA was more consistent between countries than the estimated sensitivity of KK, and estimated infection prevalence did not significantly differ between CdI (20.5%) and Uganda (19.1%). The prevalence by CCA with trace as positive did not differ significantly from estimates of infection prevalence in either country, whereas both KK and CCA with trace as negative significantly underestimated infection prevalence in both countries. Conclusions Incorporation of ambiguous results into an LCA enables the effect of different treatment thresholds to be directly assessed and is applicable in many fields. Our results showed that CCA with trace as positive most accurately estimated infection prevalence