With support from donors, Uganda has implemented a variety of voucher schemes, which offer more than a decade of context-specific learning on health purchasing that could inform the proposed national health insurance scheme (NHIS). The Parliament of Uganda recently passed the 2019 NHIS Bill, which now awaits Presidential approval to establish the NHIS as a new demand-side health financing mechanism. This pivotal health reform would create a purchaser-provider split, contract public and private providers, and establish a benefits package— all essential functions that the voucher programs successfully implemented at a large scale. As the last two voucher projects drew to a close, the Ugandan Ministry of Health and ThinkWell undertook a joint study and published an extensive report that documents how these voucher schemes functioned and performed to draw lessons for future demand-side financing efforts, including the planned NHIS.
The Ugandan voucher schemes were designed to provide rural poor pregnant women with affordable access to high-quality essential RMNH services. The latest two donor-funded voucher schemes supported over 400,000 safe deliveries in just over three years. Covering 28 (out of 135) of Uganda’s districts, the second Uganda Reproductive Health Voucher Project (URHVP-II) was financed by the World Bank through the Global Partnership on Output-Based Aid and ran from June 2016 through October 2019. The USAID-funded Uganda Voucher Plus Activity (UVPA) started slightly later in October of 2016 and ran through March 2020, covering 35 districts. Set up as independent purchasers of services, the schemes fielded teams of village-based voucher distributors who identified poor women, provided them with health education, and then sold them vouchers at highly subsidized prices. Identified women then redeemed their vouchers primarily at selectively contracted private for-profit health facilities (in addition to some public and private non-profit facilities) to access a package of RMNH services. Contracted providers were then reimbursed by the voucher schemes based on the services rendered.
Within Uganda’s fragmented health delivery system, voucher schemes pioneered service networks that integrated private, public, and non-profit facilities. Selectively contracted facilities were organized into service delivery networks to ensure affordable access, accountability, and adherence to service quality standards. A critical step forward in this effort was the successful linking of private for-profit providers to both public and private non-profit facilities in the health system. The voucher facility networks of providers facilitated cooperative actions between facilities, including improved referral systems for complications and emergencies.
Providers reinvested their revenue from the voucher schemes to increase their facility capacity and improve their quality of care. By paying facilities fair rates based on the cost of care, contracted facilities had the resources and autonomy to ensure sufficient staffing and medical supplies to meet demand. The combination of clear quality standards, regular measurement, field-based technical support, and contractual consequences led to significant improvements in quality.
The voucher schemes were vivid demonstrations of what is required to establish a demand-side financing mechanism. Establishing a new financing mechanism that will purchase service outputs requires new institutional roles, modalities, contracts, and financing systems. Examples in South Korea and Taiwan have demonstrated that years of implementing voucher programs can lay the groundwork for building an NHIS to support universal health coverage efforts. As Uganda takes its first steps to establish its own NHIS, critical choices to determine the institutional setup, initial benefit package, service delivery contracts, and claims management systems need to be made. The voucher schemes provide a large-scale demonstration of what it takes to set up a demand-side purchaser. These experiences have generated hard evidence to inform Uganda’s choices as it establishes the NHIS going forward.