Barnabas Natamba
28 July 2008
opinion
Kampala — I thank the management of the National Social Security Fund (NSSF) for the decision to introduce medical insurance as one of the benefits for NSSF members.
In an article published in The New Vision of May 25, the NSSF managing director, David Chandi Jamwa, observed that medical insurance is considered a core component of social security benefits the world over.
I agree with Jamwa that NSSF members should not be charged extra fees by the Ministry of Health for running the National Health Insurance Scheme. Given that 15% of salaries go to NSSF and about 30% to Pay as You Earn, any additional charge on workers' earnings, like the 8% proposed under the National Health Insurance Scheme, would leave them with very little disposable income (take-home income). Therefore, NSSF's proposal to extend medical insurance to NSSF members at the current contribution (15% of salary) is a positive development.
I agree with Jamwa's observation that in order to ensure best practices in the provision of medical insurance, there is need to outsource the financial and medical management of the scheme to competent firms. Through competitive bidding, contributors to the NSSF should expect best medical services.
Differentiation between health and medical insurance
However, I have some reservations. There is a difference between medical insurance and health insurance. I wonder whether NSSF is only interested in extending medical services (diagnosis and treatment of sicknesses) or comprehensive health insurance (for example, disease prevention, diagnosis and treatment). Health insurance (not medical insurance) should encompass disease prevention, diagnosis, treatment and rehabilitation of those disabled by the disease. Much of the disease burden in Uganda could be reduced through appropriate health education and promotion messages targeting disease prevention. This would reduce the cost of medical procedures.
Most NSSF members, given their terms of employment and conditions of work, may require forms of care such as counselling that may not be included in the proposed National Health Insurance Scheme.
Outsourcing
There is need to distinguish between outsourcing insurance services and outsourcing medical service provision. Most of the health insurance providers in Uganda and probably East Africa have experience in running private health insurance schemes rather than social health insurance schemes.
Whereas in private health insurance membership is voluntary, in social health insurance, including the proposed NSSF scheme, membership is mandatory. Private health insurance providers, unlike social insurance providers, are driven by the desire to make profits. I wonder whether outsourcing health insurance provision to private insurance firms may not lead to spiralling costs of care and overcharging the NSSF. If so, does the NSSF board have the expertise to contain costs of care as these tend to increase every year with a corresponding effect on health insurance premiums?
If after engaging the private insurance firms it is realised that the cost of sustaining medical insurance cannot remain at the proposed 2% of members' 15% monthly contributions, what will the NSSF board do? I hope it will not increase charges to members to cater for increased premiums.
The beauty of social health insurance schemes is that they are managed by a Board of Trustees (assumed to be individuals of high integrity) who contract accredited health service providers directly rather than through third parties. In this case, the NSSF should have the expertise to deal with medical service providers rather than contracting another firm. This is because, for a greater period, it is assumed that premiums will remain constant even when the basket of services provided changes.
Alternatively, private insurance providers should be more than one to allow competition and offer choice to members of the scheme.
Contracts for medical service providers
It should also be clear whether NSSF members will have a say in how medical service providers (private or public) are contracted. In case of poor service provision (or abuse of the same), will members have the means to raise complaints to NSSF or the contracted insurance providers? Who will take corrective action, NSSF or the contracted insurance firm?
Will medical service providers be required to undergo an accreditation system to assure their quality of service and how it is to be delivered? Will members be allowed to switch between providers in the same year and if yes, how? Will members who prefer to go to private departments in public hospitals be allowed to do so?
Nature of membership
Some NSSF members are already insured by their employers or have privately-sponsored policies. It should be clear whether these people who are fully covered elsewhere can opt out of the NSSF scheme.
The Ministry of Health should continue with the National Health Insurance Scheme for non-NSSF members such as civil servants, those employed in smaller companies with less than five employees and the self-employed.
Together with private health insurance providers, the NSSF scheme can increase the level of insurance coverage. This way, our sick public health system will be relieved of the burden of caring for everybody.
The writer is a lecturer in public health.
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