After lying in wait for more than a decade, the National Policy on Public Private Partnership in Health (PPPH) has been drafted and submitted for Cabinet and Parliamentary approval.
Health experts say the private sector’s role in public health has been essential but informal, and that guidelines around existing economic liberalisation in the Ministry of Health agenda are long overdue.
Though unregulated, the private system provides the majority of training for health workers and its facilities make up more than 30 per cent of Uganda’s total.
“The relationship is already ongoing – we are sharing human resources, we are developing and monitoring policy together,” said Uganda National Health Consumers Organisation (UNHCO) national coordinator, Ms Robinah Kaitirimba.
“There was no legal framework – it was just a memorandum of understanding, on good faith. Now, we want to enforce it by law.”
After initial collaboration fell apart with the rest of Uganda’s health system throughout the turmoil of the 70s, private partnership resurfaced in public health dialogues of the late 80s, and again in the early 90s.
A PPPH desk was created along with the beginnings of the draft bill in 2000. The Ministry of Health now expects the bill to be passed before the end of this parliamentary session in May.
The main struggle for PPPH will be to successfully integrate the interests of all affected parties – accommodating for traditional practitioners was said to have been a stalling factor in its becoming a bill.
Private-for-Profits (PFPs) and Traditional Complimentary Medicinal Practitioners (TCMPs) are often overlooked in health policy while seen as vital for achieving longer-term goals such as increasing access to under serviced rural areas.
However, private care is still focused in urban centres. Few are dispersed into rural areas effectively, and fewer still provide tertiary care.
“Access is a challenge – the private sector does a lot of things but because they are not registered, they are not regulated, it leads to poor service,” said Ms Kaitirimba.
She said the common misconception that poor service is provided by the public sector alone is false, saying both sectors can benefit from the other by sharing available resources.
“But the biggest thing for the policy is for government to take up a role of responsibility,” Ms Kaitirimba said.
“And I think that patient engagement and empowerment is going to be a critical part.”
Costs for patients continue to climb in the face of private user fees and consistent drug stock outs at public centres.
Households spend about 9 per cent of their expenditure on health, and the ministry estimates that 2.3 per cent of Ugandans are impoverished due to their medical bills.
Though the ministry says the National Health Insurance Scheme is in an “advanced stage” - critics say it could easily be doomed to repeat the corruptive practices of the National Social Security Fund.
The Deputy Permanent Secretary for the Ministry of Health, Dr Asuman Lukwago, said putting profits back into public service is the next logical step. “Money which is generated (by the private sector) should be used to support the public sector,” he said.
He cited Mulago referral hospital’s private wing as a failed example of this intended benefit. “They (Mulago’s private providers) generate about Shs7 billion per year, but maybe it has not been used to address some of the internal issues,” said Dr Lukwago.
Competition between public and private has also proven counterproductive in the past, and unequal salaries between the two sectors have seen Private Non-For-Profits (PNFPs) lose large quantities of staff. But positive examples exist too. For instance, a number of districts have installed PPPH point where people have been credited with increased monitoring at lower levels, by working more closely with PNFP facilities.
PNFPs have also seen government subsidies since 1998, under the Primary Health Care Conditional Grant – a consistent non-wage grant that goes through local levels.
But funding for the subsidy has stagnated, and the ministry has said the arrangement is in need of “urgent revision” in light of the continued benefits it says the private sector has brought.