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Open Access Research article

Players and processes behind the national health insurance scheme: a case study of Uganda

Robert K Basaza12*, Thomas S O’Connell3 and Ivana Chapčáková3

Author affiliations

1 Planning Department, Ministry of Health Uganda, P.O. Box 27450, Kampala, Uganda

2 Institute of Health, Policy and Management, International Health Sciences University, P.O. Box 7787, Kampala, Uganda

3 Health Section, Programme Division, United Nations Children’s Fund, 3 UN Plaza, New York, NY 10017, USA

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Citation and License

BMC Health Services Research 2013, 13:357  doi:10.1186/1472-6963-13-357

Published: 22 September 2013

Abstract

Background

Uganda is the last East African country to adopt a National Health Insurance Scheme (NHIS). To lessen the inequitable burden of healthcare spending, health financing reform has focused on the establishment of national health insurance. The objective of this research is to depict how stakeholders and their power and interests have shaped the process of agenda setting and policy formulation for Uganda’s proposed NHIS. The study provides a contextual analysis of the development of NHIS policy within the context of national policies and processes.

Methods

The methodology is a single case study of agenda setting and policy formulation related to the proposed NHIS in Uganda. It involves an analysis of the real-life context, the content of proposals, the process, and a retrospective stakeholder analysis in terms of policy development. Data collection comprised a literature review of published documents, technical reports, policy briefs, and memos obtained from Uganda’s Ministry of Health and other unpublished sources. Formal discussions were held with ministry staff involved in the design of the scheme and some members of the task force to obtain clarification, verify events, and gain additional information.

Results

The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the three phases of development: from 1995 to 1999; 2000 to 2005; and 2006 to 2011. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Stakeholders, notably the private sector, played an important role in influencing the pace of the development process and the currently proposed design of the scheme.

Conclusions

This study underscores the importance of stakeholder analysis in major health reforms. Early use of stakeholder analysis combined with an ongoing review and revision of NHIS policy proposals during stakeholder discussions would be an effective strategy for avoiding potential pitfalls and obstacles in policy implementation. Given the private sector’s influence on negotiations over health insurance design in Uganda, this paper also reviews the experience of two countries with similar stakeholder dynamics.

Keywords:
Health insurance; Stakeholder analysis; Context analysis; Policy reform; Health financing; Case study; Uganda