Policy Guidelines for the Private-for-Profit (PFP) Independent Healthcare Subsector in Uganda
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 set and 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.
Uganda National Association of Private
Hospitals (UNAPH)
P.O.Box 29324 Kampala, Uganda.
Tel: +256 772 632211, 0704 762575
Email: unaph22@yahoo.com, unaphserv@gmail.com, unaph@doctor.com
www.ugandaprivatehospitals.blogspot.com , www.unaph.com
Sir Apollo Kagwa Road, Opp. Gold Trust Bank
P.O.Box 29324 Kampala, Uganda.
Tel: +256 772 632211, 0704 762575
Email: unaph22@yahoo.com, unaphserv@gmail.com, unaph@doctor.com
www.ugandaprivatehospitals.blogspot.com , www.unaph.com
Sir Apollo Kagwa Road, Opp. Gold Trust Bank
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