How the NHIS bill was passed

On 31st March 2021, Parliament passed the National Health Insurance Scheme (NHIS) Bill 2019 into law, waiting for assent by the President.

In a spectacular show of great fortitude, Members of Parliament overwhelmingly rejected a move by the Minister of Health to withdraw the bill from Parliament.

Hon. Robinah Nabbanja, the Minister of State for Health (General Duties) had requested to withdraw the bill from Parliament citing disagreement of stakeholders in the private sector with some provisions of the bill.

Several MPs who objected to the Minister’s request questioned government’s commitment to improve people’s access to healthcare arguing that Ugandans need health insurance urgently because they spend a lot of money on medical bills.

The bill was passed in the absence of Hon. Nabbanja who walked out of Parliament during the debate. The Minister of State for Planning Hon. David Bahati represented cabinet in the discussions and proposed passing of the bill by Parliament after the debate.

MPs including the former Minister of State for Health Hon. Sarah Opendi argued that the Ministry of Health consulted widely for over 10 years during formulation of the bill.

A report presented by Dr. Michael Bukenya, the chairperson of the Health Committee of Parliament, indicated that while scrutinizing the bill, the committee received views from 30 stakeholders, held six regional consultative meetings and conducted three benchmarking visits in Kenya.

Next steps

Article 92 of the Constitution of Uganda provides that a bill passed by Parliament has to be presented to the President for assent as soon as possible and the President has to take action within 30 days. The actions include assenting to the bill, returning it to Parliament for reconsideration or refusing to assent to it. The President is deemed to have assented to a bill once the specified period elapses without taking any action. The bill also becomes a law if the President returns it twice and Parliament passes it for the third time.

Key provisions passed by Parliament

  • Any person who has attained the age of l8 years and who is a citizen and resident in Uganda will contribute to the NHIS.
  • The Government will be liable to make contributions on behalf of indigents. Indigent persons will be required to register under regulations to be issued by the Minister of Health.
  • A person’s contribution to the Scheme will depend on his/her total income.
  • An employer will contribute 50% of the employee’s total contribution to the Scheme.
  • Benefits under the Scheme will be accessible from any accredited health service provider in Uganda.
  • It will be mandatory for all health facilities, both government and private, to be accredited to provide services under the scheme.

New clauses introduced by Parliament

Parliament incorporated new clauses into the bill. The new clauses introduced provisions on the following:

Community health insurance schemes: the proposal is that the NHIS law shall not affect the existence and operations of the community-based health insurance (CBHI) schemes but the minister may issue guidelines for their proper functioning. The justification given is to acknowledge the existence and give visibility to CBHI schemes.

Government’s Obligations in National Health Insurance: government will have an obligation to ensure access to health care services for all including children, women and people with disabilities in addition to developing, implementing, promoting awareness, and providing adequate funding for NHIS. This was intended to provide for continuity of state obligations in the health sector during implementation of the NHIS.

Government to contribute for indigents: government will pay health insurance premiums for indigent persons. Parliament defined an indigent person as a person who is deemed by the Board of the NHIS to be unable to pay a contribution and is registered as such.

Contribution by employer: both the employer and employee will each pay 50% of the employee’s contribution to the NHIS. The bill was originally silent on the rate of contributions by the employers and employees.

Registration of indigents: the Minister is required to issue regulations to determine and register persons who qualify as indigents within six months of coming into force of the NHIS Act.

Portability of benefits: Contributors to the scheme will access benefits from any accredited health service provider in Uganda subject to regulations by the Minister while the Board of the Scheme will prescribe the procedure for accessing healthcare benefits outside Uganda.

Functions of the Board of the NHIS:

Parliament proposed the following functions of the board:

  • ensure the effective implementation of the policies of the Scheme;
  • manage the Scheme in accordance with this Act;
  • cause to be carried out audits of the funds of the Scheme;
  • determine the mission and strategy of the Scheme;
  • appoint, support and evaluate the Chief Executive Officer of the Scheme;
  • ensure the proper management and protection of assets of the Scheme; and
  • carry out any other function as may be necessary to meet the objects of the Scheme.”

Changes to some clauses in the bill

NHIS as a complementary health financing mechanism: Parliament revised the first object of the bill to provide for developing the NHIS as a complementary mechanism of healthcare financing. The original clause implied that health insurance would be the only mechanism of financing healthcare in Uganda.

Accreditation of health facilities: it will be mandatory for all health facilities, both government and private, to be accredited to provide services under the scheme. This will guarantee quality of services. The bill had proposed accreditation of only private health facilities which would make government facilities automatically qualify to provide services.  

Composition of the Board of Directors: While the bill had proposed appointment of board members except representatives of ministries, basing on professional qualifications, Parliament changed the clause to allow different stakeholders to nominate representatives. Institutions to be represented are:

  • Ministries responsible for Finance, Gender, Labour and Social Development and Health.
  • Trade unions
  • National Social Security Fund
  • Private health insurance providers
  • Federation of Uganda Employers
  • Insurance Regulatory Authority

The Ministry of Health is committed to implementing the proposed National Health Insurance Scheme (NHIS) in Uganda to increase health insurance coverage in Uganda from 2% to 25% by 2025.

While opening the 5th National Community Health Financing Conference organised by Save for Health Uganda (SHU) at Sheraton Kampala Hotel, on 19th November, 2020, Dr. Olaro Charles, the Director of Clinical Services in the Ministry of Health who represented the Minister of Health, said one of the planned interventions for human capital development in the third National Development Plan is implementation of the National Health Insurance Scheme.

Dr. Olaro noted that the high out of pocket expenditure on healthcare at 40% coupled with high poverty levels at 21.4% were worrying. He commended promoters of community health financing (CHI) initiatives for spearheading the transition from out of pocket to prepayments for healthcare especially in the informal sector.

Community health insurance (CHI) schemes in Luwero Nakaseke and Nakasongola districts marked 20 years of existence at a grand ceremony held on 6th December, 2019 at Butuntumula Sub-county headquarters in Luwero district. The schemes also launched their new year of accessing healthcare services under insurance which begins on 10th December.

Speaking at the function, the Executive Director of Save for Health Uganda (SHU), Mr. Makaire Fredrick, thanked leaders of CHI schemes for exhibiting a very high degree of integrity in managing funds contributed as annual premium, which led to the growth of the schemes over the years.

He added that proper financial management and transparency was crucial to the continued survival of CHI schemes because it helped to build the confidence of community members.

Mr. Makaire informed the gathering that SHU was closely following the process of enacting the National Health Insurance Scheme (NHIS) law and had submitted a position paper to Parliament calling for inclusion of CHI schemes as enrolment and collection agents for the informal sector.

Currently, there are 80 running CHI schemes in the three  districts covering 26,789 individuals from 3,850 families. Members of the schemes receive healthcare services from 12 healthcare providers ranging from HCIII to hospitals. Members are treated for all illnesses that can be managed by the contracted health facilities.

Nearly a thousand members of CHI schemes and other residents attended and benefitted from free healthcare services offered by healthcare providers contracted by the schemes. A total of 80 individuals tested positive for malaria and received free treatment and mosquito nets from St. Mary’s Kasaala HCIII. All the 70 people tested for HIV were negative while 18 received dental care services. Kiwoko hospital screened 187 people for diabetes and high blood pressure while the Red Cross conducted a blood donation exercise at the event. The event started with a health education session for all.

Several members of CHI schemes shared testimonies about the history of their schemes and the healthcare benefits they have enjoyed over the years.

The function was attended by political and traditional leaders in the area.