East African governments are walking a tightrope in their quest to provide universal health coverage for their populations.
In Kenya, Uganda and Tanzania, governments are grappling with not just the needed laws but also indifference – sometimes outright opposition – from key stakeholders.
A Bill in Uganda that would have resulted in a national health cover is pending review after President Yoweri Museveni declined to sign it into law following opposition from private sector employers.
The draft law required private sector employers to match contributions by employees but the players argued that was an added cost to doing business.
In Kenya, the push for universal health coverage (UHC) has faced numerous challenges ranging from lack of a proper financing mechanism, poor implementation by the government to the inability of the National Health Insurance Fund (NHIF) to cover the entire population.
UHC was one of the “Big Four” strategic pillars declared by former President Uhuru Kenyatta to ensure everyone has access to quality and affordable medical care.
His successor William Ruto has said he is keen on reforming NHIF to provide better healthcare for citizens.
“Our health agenda is premised on fundamental reforms in the way healthcare is financed and provided. Contributions to the National Health Insurance Fund will now be graduated and will depend on people’s income,” President Ruto said in his inauguration speech.
But a court order filed by the employers’ organisation stands in the way of the decision by the government to use the NHIF Act as a vehicle towards universal health coverage.
Dr Ruto has backed the push to have the rich pay higher monthly contributions to the NHIF as the matter awaits resolution in court.
NHIF Kenya early this year proposed that contributions of workers earning more than Ksh100,000 ($819) should be calculated at 1.7 percent of their pay.
But this was rejected by the previous Parliament as well as by the employer’s body, the Federation of Kenya Employers (FKE), forcing the health insurer to go back to the drawing board.
Currently, workers earning over Ksh100,000 pay a fixed monthly contribution of Ksh1, 700 ($13.93) to NHIF.
“UHC is a journey and as NHIF we have been on that journey from the time NHIF was set up in 1966,” Peter Kamunyo, the fund’s chief executive, told The EastAfrican.
Shield low income earners
In Tanzania, Parliament is debating the Universal Health Insurance (UHI) Scheme Bill meant to shield low income earners and old citizens from financial burdens of ill health, especially in the face of high costs of treating non-communicable diseases.
One of the proposals is to make the scheme mandatory for all Tanzanians, with an annual fee of Tsh340,000 ($146) for a standard package that would benefit a family of four dependents.
This is informed by figures from the Ministry of Health that show that 85 per cent of Tanzanians are not covered by health insurance of any kind. Only 8.2 million Tanzanians (14.7 percent) are registered with a health insurance scheme.
Tanzania says it is targeting 15 million people, but it will have to pay for 4.5 million people, mostly the elderly, according to Health Minister Ummy Mwalimu.
But the issue of forcing citizens to enrol has elicited debate, especially after it was suggested that services would be denied to those who fail to enroll.
Opposition ACT Wazalendo leader Zitto Kabwe called for more time to debate the proposed law.
Officials at the Health ministry said the burden of treating non-communicable diseases has informed the campaign to reform the national scheme.
Cancer cases in Tanzania have increased by 42,060 cases per year and treatment costs for patients receiving chemotherapy through NHIF coverage increased from Tsh9 billion ($3.8 million) in 2016 to Tsh22.5 billion ($9.6 million) between in 2021-22, the ministry of health said.
NHIF also spent Tsh35.44 billion ($15 million) in 2022 on kidney ailments and Tsh4.33 billion ($1.8 million) on treatment of cardiovascular diseases.
The Amendment Act sought to expand NHIF’s mandate to offer universal health coverage for all by increasing its methods of raising revenue by, among others, requiring all government and private employers to match contributions made by employees.
In Kenya, the amended Act required healthcare service provider to first charge private insurers before charging NHIF where a person has both covers.
However, the Employment and Labour Relations Court in Nairobi on April 22 temporarily suspended the law’s enforcement in a petition filed by the Federation of Kenya Employers.
The petition challenged the amendments on the basis that sufficient public participation was not conducted prior to enactment.
Further, they argued the amendment provisions violate employer rights to fair administrative action, property and equality and freedom from discrimination.
Early this month, President Ruto said Kenya will employ technology to roll out the UHC programme.
“UHC is a top priority for this administration. We need to reconfigure how we deliver health services and technology is the solution,” he stated.
“This will ensure efficiency, stop pilferage and secure access for all Kenyans, especially those at the bottom of the wealth pyramid,” said Dr Ruto when he met the Africa director of the Bill and Melinda Gates Foundation, Cheikh Oumar Seydi, at State House on November 3.
NHIF Kenya’s CEO is optimistic that despite the challenges facing its initial implementation, UHC will soon take off strongly.
“The UHC scheme was initially designed for formal sector workers and was restricted to financing in-patient care through a fixed bed rebate,” Kamunyo said.
“It has undergone several changes over the years to include more benefits, target informal sector households and, recently, to introduce out-patient care.”
Overall, each of the East African countries has identified that the cost of managing the schemes will lie in bringing in as many people as possible.
In Uganda, the draft law proposes enrolling every person over 18 years.
However, the country also needs to address the shortage of medical personnel and salaries.
“The three days we gave the ministry to address the pay discrepancy ended without being addressed,” Dr Musa Lumumba president of the Federation for Uganda Medical Interns (FUMI) told The East African on November 10, referring to a strike they had called.
“The Ministry of Health has failed to solve the salary disparities that exist in the allowances of intern doctors, nurses, and pharmacists,” said Lumumba, even as President Museveni directed ministry health to pay interns half of what their established senior counterparts earn.
Museveni's directive would see an intern’s gross earnings increase from Ush750, 000 ($198.4) monthly to Ush2.5 million ($661.4), half the pay of a medical officer.
Reporting by Luke Anami, Kabona Esiara and Apolinari Tairo