Covid-19 Pandemic in Uganda – A demonstration of the need to address the regulatory gaps in the country's health system for equitable access to health care

Uganda has, over the years, made progress in increasing access to health care and attaining development aspirations such as universal health coverage. For instance, the scrapping of user fees in public health facilities in 2001 is considered a significant landmark on that journey. Working with the private sector has been considered a significant aspect of the Ugandan health system to addressing the gaps in the public health facilities. Statistics show that almost 50% of health services in Uganda are delivered by the private sector (PNFPs and PFPs), and up to about 40% of health care expenditure happens through the private sector. This implies that the private sector plays a crucial role in providing care. As the second wave of the Covid-19 pandemic ravaged several countries in the developing world, including Uganda, the capacities of public health facilities were exposed, especially in managing increased cases of Covid-19 patients, the last resort remained with the private sector. However, given several reasons, including high costs of managing patients, especially in ICUS, private facilities charged "high costs/fees" for managing these patients.

 It is against this background that the Health Economics & Policy Program (HEPP) at the Makerere School of Public Health (MakSPH) , in collaboration with the Ministry of Health and University of York -Thanzi la- Onse organized a dialogue on 5th  August  2021  under the theme; "Regulating health service delivery in Uganda's Pluralistic health system" to discuss how the costs of using and providing private health care services can be effectively managed in  Uganda.

 The dialogue explored the policy remedies (e.g., price regulation, subsidies, litigation & legal remedies) available to the government, service providers and users, and their applicability to the Ugandan context.  With a distinguished panel of experts, ranging from policymakers at Ministry of Health and Parliament of Uganda, academic institutions, to civil society organizations shared knowledge and advice on the topic. The following emerged as key takeaways from the discussion.

The government is obliged to provide health services to all its citizens.

Basing on the 1995 Constitution of the Republic of Uganda, the government is obliged to provide quality health care to its citizens. It is expected that the government ensure healthy living of its people, where it falls short, it invites the private sector. "You provide the health services comprehensively or you invite other people to help you" Mr. Moses Mulumba[1] emphasized.  However, the private sector is expected to work within the set guidelines and regulations developed by the government. Full involvement of the government in the provision of health services reduces the effects of health care market failures and contributes to increasing equity in accessing health care services by all citizens without financial hardships.

Regulation of the health sector cuts across all players (public and private players)

Although the outcry of high costs charged for covid-19 treatment was pronounced in the private sector, regulating only the private sector is not feasible. Uganda, through the Public Private partnership (PPP) arrangement, allowed the private sector to work in public health facilities (Private wings). This implies that the regulation should not only  work on the private sector alone but also on the public sector since the same facilities co-exist in both sectors. "Private sector is difficult to distinguish as long as we have private wings in public facilities" Dr Juliet Nabyonga Orem[2]  noted. The covid -19 pandemic revealed the importance and weaknesses within the two players providing healthcare services in Uganda. "Covid-19 has opened our eyes, first of all ,to the inadequacies of the health sector regulation both in the public and private sectors….".Dr. Timothy Musila[3] mentioned. Effective implementation and enforcement of the laws is missing, and the self-regulation provision left to the private sector through their umbrella and association/ Bureau seems ineffective. Therefore, the government need to strengthen its capacity to regulate all players in the health market at all levels regularly.

Health insurance and substantial support to private facilities is necessary to keep the costs of health care affordable to the population

Uganda is in the process of adopting the National Health Insurance Scheme (NHIS). To this effect,  the panel recognized that financial protection to the patients is key to ensuring UHC and equity in accessing health care. However, reflecting on lessons from other countries, it was proposed that NHIS should be adopted in a phased manner, with priority given to critical conditions. Another option for reducing health costs is increasing the government subsidy provided to private facilities. The current Primary health care Grant (PHC) grant is small and cannot substantially reduce health facilities' costs. "Government subsidy provided to Private facilities – faith based is still small- 1% of the budget. It cannot significantly reduce hospital costs" Dr Ian Clarke[4] .

Facilities that received support from the government testified to have kept their costs low even during covid-19 pandemic. "During this pandemic, the government gave us some support for ICU equipment (5 beds and monitors) and this helped to sustain the low price that you heard of in the media, that we charge our patients who enter our ICU"- Dr Opira Lacor Hospital noted. This was in addition to the hospital's mission, which is inclined to provide affordable health services to the community.

Health service providers to demonstrate value for money for services provided to the citizen

Whereas it is acceptable that the market for health services is different for other goods, the health providers must ensure full or partial demonstration of value for money for the services citizens buy. The covid-19 revealed an "information- mismatch" between the citizens and health facilities. This, in some cases, contributed to the high fees demanded from patients due to lack of information on services a covid-9 patient received. "When consumers say regulate the private sector, the costs are very high; what we are saying is that we are not getting value for money". Ms. Robinah Kaitiritimba[5] revealed.  Without clear information to citizens, health-seeking behaviours for health services are greatly affected.

Regulation needs to go beyond health because health is affected by other factors beyond the health sector.

There are a number of determinants of health beyond the health sector. For instance, environmental, socio-economical and individual factors that contribute to the healthy wellbeing of people.  The panel recognized that regulating health sector alone, might not contribute to improved health outcomes. "Regulation needs to go beyond health, because health can't stand alone" Hon Dr Charles Ayume[6] noted. "The regulation should be comprehensive enough to address all factors affecting health even beyond the health sector. The regulations must be comprehensive and clear." Mr. Moses Mulumba highlighted. This should however do not undermine the expected role of the government to ensure that citizens are healthy. The fundamental purpose of government to my understanding, is to manage market failure- Dr. Patrick Kadama[7] emphasized.

Other key issues included,  1) the need to a comprehensively  understand  the nature of the private sector in health to devise an appropriate package of policy tools; 2) Improving the public sector so that it can be prepared to handle high demand arising from epidemics;3) emphasis on prevention and health promotion to address high costs of curative care, and 4) revitalizing public-private partnership for health including provision of subsidy support to private providers to cushion them against high input costs

Over all, although the discussion alluded to the need to regulate private sector, applying only a market approach and regulating price for health care services might not have a significant impact on the general provision of health care in Uganda. What is needed is to re-organize the institutions and public finance be directed to those institutions with prospects for best returns, considering both licensing and accreditation as factors in allocating public finance.