Background
These Policy Guidelines, which focuses on the Private-for-Profit (PFP) Independent Health Subsector, are developed in the context of providing guidelines and tools for self-regulation of this subsector and also to serve as instruments to Public-Private Partnership and regulation by the government. One of the consequences of these policies was that the independent health subsector, which mostly provides curative care in Uganda, is expanding, fragmented, uncoordinated and inadequately regulated.
The outlets for the independent private health sector include the ‘solo clinics’ run by the individual practitioners and or institutions like hospitals, polyclinics, health centers, maternity and nursing homes, dental clinics and hospitals, diagnostic labs etc. According to recent health survey reports, the independent private health subsector is mostly concentrated in urban areas, especially in Central Uganda. There is limited information available about the access and utilization of health services by the people. But, most surveys showed that out of all patients seeking health care, between 40% -60% consulted private sector facilities.
The Rationale
While there is an increasing role of the independent private health subsector, the situation calls for provision of guidelines and tools to strengthen its management and self regulation. These policy guidelines will aim to serve these purposes by advocating better coordination, encouragement and regulation of the independent private health subsector with the objectives to enhancing the investment opportunities, increasing the geographical coverage, attaining equity in distribution, promoting quality and decreasing the gap between the served and the underserved areas of the country.
The National Health Policy, taking stock of the emerging private ‘for profit’ health sector requires the Ministry of Health, in addition to recognizing the role of the private v/s public sector, to institute mechanisms for the regulation of health services delivery, setting up and monitoring of the minimum standards of care, and bring into fold the private sector in reporting within the defined parameters of the National Health Information System. These policy guidelines aim at contributing to the Public-Private Partnership in Health (PPPH) Policy and the National Health Policy vision.
The Methodology for Development of theses Policy Guidelines
Uganda National Association of Private Hospitals (UNAPH), recognizing the role of the private-for-profit health subsector as complementary to the public sector in providing quality health services, considered it imperative to develop policy guidelines for this subsector.
Several policy documents have been reviewed and stakeholders interviewed as part of these Policy Guidelines formulation. The main themes that emerged from the experiences, interviews, fieldwork, policy briefs and document reviews by the task team formed the basis for articulating these policy guidelines. This document takes into account the views that emerged from the exercise and comments by the different stakeholders.
Policy Guidelines for Independent Private Health Subsector (PFP Health Subsector)
While drawing a guidelines and defining the roles and responsibilities of the government vis‐à‐vis the independent private health sector in the overall context of the health system, it is useful to do it in relation to its core elements: governance, organization, funding, and service delivery.
The governance is about assuring the stewardship or oversight which is the responsibility of the Government and the Uganda National Association of Private Hospitals (UNAPH). Likewise, Ministry of Health would determine how the health system is organized for different levels of care (specialized, tertiary, secondary, primary and community care) and geographical regions. But, the sharing of the responsibility between the state and the private sector and the mechanisms for the discharge or implementation of other elements can however, vary and may take following forms:
(i) Public Financing and Delivery;
(ii) Public Financing and Private Delivery;
(iii) Private Financing and Delivery
(iv) Public-Private Partnership and Self-Regulation
These policy guidelines are for the health care modality, whereby the private sector finances as well as delivers the health care. But, it also deals with the issues surrounding other alternate mechanisms, i.e. Public financing and private sector delivery of health services. The focus of these policy guidelines is on health care including diagnostics, medical and surgical procedures, both invasive and non‐invasive provided by the private ‘for profit’ (PFP) health subsector, but exclude the pharmacy and allied services.
The Values and Principles
These policy guidelines are framed, within the provisions of the National Health Policy, National Public-Private Partnership in Health Policy and other such guiding documents, laws and national and international commitments, for the health services financed and/or delivered by the private sector.
Specifically, it shares the guiding principles and the values as stipulated in the National Health Policy:
– Partnership and Collaboration for Health
– Quality in Healthcare and Assuring the Clinical Governance
– Social Determinants of Health
– Optimum Response to Consumer Needs and Assuring Patients’ Rights
– Gender mainstreaming and equal opportunities
While the details provided for these above mentioned values and principles enunciated in the National Health Policy apply also to these policy guidelines, the ‘quality in health care’ and ‘patients’ right’ are explained further in the subsequent sections of this document to highlight their importance.
Although these guidelines promote the priority ‘patient first’, it does not deny the private sector of its profit oriented direction. In this regard, wherever there is a conflict with the existing laws/acts, the position in the latter will prevail.
Vision
The independent private health subsector is seen as complementary to the public health sector and crucial for building a healthy nation, achieving the Millennium Development Goals and contributing to the overall social and economic development of the country.
Mission
The mission of these policy guidelines on Independent Private Health Subsector is to ensure the provision and availability of universal and optimum quality health care at a reasonable cost, which responds to the needs of the citizens of Uganda. It emphasizes on the ‘win‐win’ situation between the public and the private health sectors in the provision of these services. The role of the state, as envisaged in these policy guidelines for the private health sector, is focused on, but not exclusive to, its regulation and creating environment conducive to improving the efficiency, quality and equity in health services. The government expected to devise measures to encourage the private sector to increasingly invest in the health sector.
Policy Implementation, Monitoring and Evaluation
Policy implementation
The Ministry of Health (MOH) through PPPH Unit and the Uganda National Association of Private Hospitals (UNAPH) will oversee and steer the implementation of these policy guidelines; including conducting advocacy and harnessing the political commitment to ensure that the vision and mission of these policy guidelines are translated into strategic and operational plans.
Monitoring and Evaluation
The objectives of these guidelines, enshrined as policy guidelines, will be systematically monitored. The Ministry of Health is expected take measures, including the provision of adequate support and transparent partnership, to institutionalize the monitoring of the achievements towards the policy objectives. For this purpose, appropriate indicators will be selected and mechanisms will be installed to measure and monitor the achievement of the objectives of the policy.
Policy Guidelines
1. Certificates of Suitability and Compliance
MOH already has a Certificate of Suitability and Compliance mechanism. Under this mechanism through relevant medical councils, it will be incumbent upon the applicant (private sector investor) intending to establish a health care facility or to add or expand service(s) in the existing health facility, to obtain prior approval of the competent authority.
This process is required in order to ensure that the services proposed by the private healthcare providers, are needed for the availability of quality patient care within a particular region or community. In this manner, unnecessary duplication of services may also be discouraged.
2. Governance and Categorization of Service Level
Since in the independent private health subsector, the market forces guide and determine the level of the service provided, it is imperative to set certain criteria, codes of practice and minimum standards. Effective and efficient healthcare delivery is dependent on the availability of the right mix of healthcare technologies and personnel required for the delivery of specific health interventions.
Integrated Health Technology Package (iHTP) is a tool devised by the World Health Organization (WHO) to ensure that all resources needed for any particular medical/health intervention are available in an adequate mix that is specific and particular to the local needs and conditions.
The sector will be expected to establish a system for using the iHTP for undertaking a comprehensive technology gaps analysis as a means to assessing and regulating the health services for its efficiency and quality in provision.
3. Employment of Health Workforce
The health workforce constitutes the backbone of any health service, be it in the public or private sector. For the purpose of these policy guidelines, different categories of health workforce include:
(i) Health professionals, like doctors and nurses;
(ii) Associate professionals, like medical assistants and technicians;
(iii) Health management professions, like hospital/ health managers and accountants;
(iv) Associate management professions, like administrative staff; and
(v) support staff, like clerks and drivers.
The health facilities in the independent private health subsector shall be required to have the required number of qualified independent health workforce according to the set norms and minimum standards set for the type and level of health facility.
The private sector can employ public sector health workforce, provided that such an employee works with the private sector in their off hours and that by taking this job in the private sector, their public sector assignment is not affected in terms of the quality and quantity. This is an uphill task, yet the sector will help develop mechanisms to achieve and streamline this objective of the private ‘for profit’ health sector.
4. Quality in Healthcare
Quality in health care is important tenet and one of the values on which hinges this policy. Therefore, while it was mentioned as part of the values above, it is reiterated as a specific policy statement. In order to ensure good quality health care, the Ministry of Health (MOH), in collaboration with Uganda National Association of Private Hospitals (UNAPH) will develop National Minimum Standards for all levels of care—primary, secondary and tertiary—and for specialized medical, surgical, paramedical, nursing care, etc. In addition, standard operating procedures, clinical practice guidelines and protocols, including for health management,
will be developed and /or adapted.
The MOH and its medical councils will be responsible to regulate private sector. These council enforce rules for registration, licensing, re‐licensing and inspection of private facilities in order to insure compliance with the specified standards. However, such assistance shall essentially be supportive and not coercive. The Ministry of Health, in collaboration with UNAPH, will develop mechanisms, to measure performance against the pre-established agreed‐upon national minimum standards, and will devise means for measuring the selected indicators.
5. Response to the Patients’ Needs and Rights
The policy for the Private ‘for profit’ (PFP) health subsector shares the values and principles as laid down for the national health policy. These values and principles require the fulfillment of patients’ needs with maximum competency and to preserve their rights.
This program emphasizes on UNAPH to take the stewardship role and institute measures, including enforcing the Patients’ Rights and Obligations to provide, inter‐alia, the information on people’s rights in relation to the information disclosure; choice of providers and management plans; access to emergency services; participation in treatment decisions; respect and non‐discrimination; confidentiality of health information; complaints and appeals. Special considerations will be given to vulnerable groups like children, handicapped, mentally ill patients, minorities, etc.
6. Services First
Given that the independent private health subsector works for profit, patients may be denied health care because of their inability to pay. This denial of services is particularly dangerous in cases where the patient is in critical condition and land up as an emergency. In such situation,
it is incumbent upon the private sector health facility that received such patient(s) to provide initial treatment and after the condition of the patient(s) is stabilized, transfer to the public sector facility.
This policy emphasizes on the health care provider that they should calculate profit on the overall business and not for each individual case it deals with. In addition, it calls on the ministries of social welfare, with close collaboration with ministries of health, for establishing a safety net through which, to pay for the poor and destitute who seek heath services from private sector in emergencies e.g road accidents.
7. Health Information
Health information is vital for monitoring the health status and also managing the health services. This includes health statistics to derive information about health status, health
care, provision and use of services and their health impact.
Currently, only few health facilities in the private sector link their statistics with the public sector health information system. As a result, it is not possible to assemble data about the status of the health of the population and the services offered either at the district or national level.
This policy emphasizes the importance of the health information and linking of the independent
private sector health facilities with public sector health information system or a sector based information system. In addition to reporting on the cases of public health concern for epidemiological surveillance, the independent private health subsector will be responsible for reporting on an agreed set of indicators according to the defined format and parameters. For this purpose, the Ministry of Health will devise or adapt its system.
8. Incentive to the Private Sector for Investing in Health
The Government of Uganda and development partners will be expected to encourage and incentivize investment in private health sector in order to provide an environment that is conducive for the increasing investment. Under this program, a range of incentives in terms of the concessions, facilities and guarantees will be provided to the private investors. The government shall extend incentives to the private domestic as well as foreign investment in the health sector, particularly in the tertiary and secondary care, health professional training and the acquisition of new technologies.
This policy emphasizes the Ministries of Health both at the district and national levels to devise incentive regimen, essentially complementary to attract the investors in the rural districts and localities.
9. Cost of Health Service
The health services are sometimes offered at higher cost in the private sector; and there is currently no check or regulation governing the level of tariff. This situation, in addition to limiting the access of many to the health services, leads to many households facing catastrophe, pushing them to poverty.
This policy requires the sector to set up a system for controlling the cost of the health care. This is important given the imperfect conditions that prevail in the health care market. Control measures would include engaging the private sector in providing service at lower prices. But, direct price control may also be resorted to, albeit at a limited scale as an anti monopoly measure.
10. Patient Referral
Referral of patients from one level of care to the other within a particular sector and between the private and public sectors is essential for providing comprehensive health services to the population. There is currently an ad hoc system, whereby the patients are referred informally and on voluntary basis. This practice is fraught with unintended complications and possibly deaths.
This policy therefore emphasizes the sector to devise a mechanism for the public sector to accept patients from private sector and vice versa for services, including for diagnostic, transfusion, invasive and non‐invasive procedures, and intensive care. Also, mechanism will be set up for the referral of patients from private to private providers.
11. Contracting out/in Health Services
Contracting out is a mechanism of combining the public sector financing with the private sector delivering the services. The private sector may be asked, at the expense of the public sector, to provide services like the laundry and central sterilization room, kitchen and catering, gardening and cleansing, etc. But contracts may also be made with private providers to organize and manage health services using the public sector infrastructure.
The contracting out arrangement is a sort of public‐private‐partnership, which this policy supports. The government will develop a detailed mechanism for instituting arrangements to contract out support services. Also, the private sector may be contracted in for providing a defined health services package. This intervention will include the contracting process and contract management, including the monitoring and evaluation of the services being provided.
12. Collaborations and Partnerships with Area Health Interventions by NGOs, Companies and Development Partners
Independent private health facilities will be encouraged to collaborate with Health NGOs, companies and development partners during their healthcare interventions in their catchment areas. However, they will also be encouraged not to interfere with their internal financial logistics.
This policy guideline is intended to sustain and monitor the results and benefits of the health interventions carried out in private providers’ catchment areas and also help to provide future points of reference for long-term sustainability and monitoring of programs and sometimes avoid duplication.
13. Accreditation
Accreditation will be carried out based on voluntary participation by private facilities and may be conditional in health insurances programs. Accreditation provides achievable quality standards, supportive consulting, and benchmarking scores, all of which assist private facilities to improve the quality of their operations. However, Accreditation should not be confused with licensure, certification, mandatory minimum standards and codes of practice, which are quite different.
This policy guideline therefore supports the quality improvement strategies and also mechanism for assessing quality in the private health insurance industry.
14. National Minimum Standards and Codes of Practice
Medical Councils have the responsibility for the registration and inspection of independent health care services. This includes the regulation of independent hospitals, independent health clinics, independent medical agencies, and private dentists. UNAPH in collaboration with MOH will set National Minimum Standards for the Independent Private Healthcare subsector in Uganda. Minimum standards will be setand private providers will be encouraged to meet them.
This policy guideline is to ensure that patients and people who choose private healthcare are assured of safe and quality services. The regulatory framework, within which they operate, will be part of UNAPH’s mission and efforts to improve the quality of care to ensure that patients receive treatment and services that are safe and of an assured quality. Creating awareness and educating the public on the minimum standards that should be expected from the independent healthcare industry will be a key element to UNAPH’s programs.
15. Medical Ethics, Bioethics and Health Law
The increased recognition of ethical problems has contributed to the resurgence of ethics, bioethics and health laws in relation to healthcare and to the emergence of medical ethics as a new collaborative discipline through-out the world.
This policy guideline will deal with issues related to: the physician/patient relationship; ethics in research; medical ethics philosophy; private health consumer protection; information and education in the field of medical ethics; allocation of resources (human resources, financial credits, and equipment); health law, ethics in education; reproductive health (abortion, AIDS, infertility, and family planning); organ transplantation; medical ethics related rules and regulations; the economy and medical ethics; brain death; genetics and biotechnology; euthanasia; supervision, assessment approaches and others.
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