The feasibility analysis of integrating community-based health insurance schemes into the national health insurance scheme in Uganda

Abstract

Background Uganda has a draft National Health Insurance Bill for the establishment of a National Health Insurance Scheme (NHIS). The proposed health insurance scheme is to pool resources, where the rich will subsidize the treatment of the poor, the healthy will subsidize the treatment of the sick, and the young will subsidize the treatment of the elderly. However, there is still a lack of evidence on how the existing community-based health insurance schemes (CBHIS) can fit within the proposed national scheme. Thus, this study aimed at determining the feasibility of integrating the existing community-based health financing schemes into the proposed National Health Insurance Scheme. Methods In this study, we utilized a multiple–case study design involving mixed methods. The cases (i.e., units of analysis) were defined as the operations, functionality, and sustainability of the three typologies of community-based insurance schemes: provider-managed, community-managed, and third party-managed. The study combined various data collection methods, including interviews, survey desk review of documents, observation, and archives. Findings The CBHIS in Uganda are fragmented with limited coverage. Only 28 schemes existed, which covered a total of 155,057 beneficiaries with an average of 5,538 per scheme. The CBHIS existed in 33 out of 146 districts in Uganda. The average contribution per capita was estimated at Uganda Shillings (UGX) 75,215 = equivalent to United States Dollar (USD) 20.3, accounting for 37% of the national total health expenditure per capita UGX 51.00 = at 2016 prices. Membership was open to everyone irrespective of socio-demographic status. The schemes had inadequate capacity for management, strategic planning, and finances and lacked reserves and reinsurance. The CBHIS structures included promoters, the scheme core, and the community grass-root structures. Conclusion The results demonstrate the possibility and provide a pathway to integrating CBHIS into the proposed NHIS. We however recommend implementation in a phased manner including first providing technical assistance to the existing CBHIS at the district level to address the critical capacity gaps. This would be followed by integrating all three elements of CBHIS structures. The last phase would then involve establishing a single fund for both the formal and informal sectors managed at the national level.

Unravelling patient pathways in the context of antibacterial resistance in East Africa

“…Kenya has higher per capita health care expenditure than Tanzania or Uganda, and while out-of-pocket costs are reducing year on year, they still make up a substantial share of spending in all three countries [ 15 ]. Health insurance coverage is far from universal [ 16 ], but is highest in Kenya, lower in Tanzania [ 17 ], and lowest in Uganda, where development of a national health insurance scheme is ongoing [ 18 ]. Finally, while drug sellers and pharmacies play a vital role in providing access to medication in all three countries [ 19 ], access to ABs without prescription through these outlets is relatively common [ 10 , 18 , 20 – 22 ].…”

“…Health insurance coverage is far from universal [ 16 ], but is highest in Kenya, lower in Tanzania [ 17 ], and lowest in Uganda, where development of a national health insurance scheme is ongoing [ 18 ]. Finally, while drug sellers and pharmacies play a vital role in providing access to medication in all three countries [ 19 ], access to ABs without prescription through these outlets is relatively common [ 10 , 18 , 20 – 22 ].…”

Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda

“…Although the MBUSO scheme has been in existence since 2006, the scheme officials indicated that enrollments were still sub-par and that there was a trust deficit from potential members. We recommend interventions aimed at promoting enrollment in community-managed health insurances schemes such as grass root demand creation campaigns, financial incentives for enrollment and the use of social media innovations to increase uptake in the informal sector as well as promoters such as civil society organizations [ 17 ].…”

“…In Uganda, the CBHI schemes which are relatively well documented are those which are provider-based [ 15 , 16 ]. On the other hand, there is comparatively less empirical attention towards CBHI schemes initiated and managed by community members themselves in Uganda which account for 14% of all CBHI schemes in Uganda [ 17 , 18 ]. This paper begins to fill this gap.…”

Perspective Chapter: Public health insurance in developing countries

“…As it has been mentioned above, the coverage of healthcare insurance is suboptimal, this means that access to quality healthcare is also limited, especially among the rural poor people. This leaves the majority with high out-of-pocket health expenditures in trying to access healthcare [8]. Those that may not afford to pay, may end up losing their lives before seeking or even receiving appropriate healthcare.…”