Research Article
Leveraging on traditional practices to address contemporary healthcare inequities: a case of Kisiizi Community-based Health Insurance Scheme.
https://doi.org/10.21203/rs.3.rs-1971005/v1
This work is licensed under a CC BY 4.0 License
posted
You are reading this latest preprint version
Community-based health insurance
Universal health coverage
Traditional health insurance
Healthcare inequities
Early development practitioners minimized the importance of cultural values and traditions on economic development (Jenkins, 2000). Contemporary development practitioners however, have perceived culture as a key factor in development (Dube, 2011; Daskon, 2010; Van Der Borg, & Russo, 2005), and urge that people’s values, customs, knowledge, capabilities, choices and perceptions are fundamental for the realization of a lasting development (Daskon, 2010).
UNESCO defines culture as the set of distinctive spiritual, material, intellectual and emotional features of society or a social group, which encompasses not only art and literature but lifestyles, ways of living together, value systems, traditions and beliefs (UNESCO, 2001). Culture has been categorized into (a) intangible; consisting of non-material and non-observable elements like values, customs, beliefs, networks and norms; or (b) tangible; pertaining to materialistic and observable aspects such as crafts, historical buildings, locations and heritage sites (UNESCO, 2003; Daskon, 2010). This paper focuses on the intangible aspects of culture to explore their significance in addressing contemporary healthcare challenges.
Uganda – History, People and Culture
Uganda is a landlocked country bordered by South Sudan in the North, Democratic Republic of Congo (DRC) in the West, Kenya in the east, Rwanda in the Southwest and Tanzania in the south. Uganda features a total acreage of 241,559 sq.Km with a total populace of 44.3 Million people (UBOS, 2016). Uganda is classified as a low-income country (World bank. 2016), and among countries with a low human development index (HDI of 0.544, ranked at 159 out of 189 countries (UNDP, 2020). Up to 21.4% of Uganda’s population is classified as poor, living below the national poverty level of less than US$ 1.30 per person per day (World bank. 2016).
Uganda’s population is formed from numerous ethnic groups with differing customs and norms (Laruni, 2015). The Ugandan culture consists of faith, tribe, traditions and beliefs, value systems and language which shape the behaviour and ways of life of the people. Consistent with the (MoGLSD, 2019), the colonial and post-colonial periods introduced new socio-economic, political and religious ethos and led to the dilution of culture. This has been exacerbated by the rapid urbanization and industrialization as a result of migration and intermarriages.
Kisiizi Community and therefore the Kisiizi CBHI scheme
The Kisiizi community consists of six sub-counties that form an extended catchment basin of Kisiizi hospital. These sub-counties include Nyarushanje, Nyakishenyi & Kebisoni in Rukungiri district; Rutenga and Rugyeyo sub-counties in Kanungu district; and Kashambya sub-county in Rukiiga district; all located in South Western Uganda. This is a rural area with an estimated population of 178,750 people, predominantly poor with over 85 per cent being peasant farmers (UBOS, 2016).
A traditional health and social services system, organized through community associations called engozi, has existed in this community for centuries (Katabarwa,1999). The engozi system promotes caring for the sick that would not support themselves and their families. Twenty to fifty households, mainly kinsmen or neighbours, join up to make one engozi group, and household heads are under obligation to enroll their families. Literature indicates that engozi members contribute funds for health care, gather food, offer psychosocial support and provide transport for patients to hospitals It is in history that,instances, some engozi members volunteered to take care of the children or cultivate the gardens of the sick colleague. Engozi also organize burial ceremonies for its members. Lastly, the engozi is governed under strict rules and non-compliance attracts heavy penalties including dismissal from the association (Katabarwa,1999).
The establishment of “free public healthcare services” led to the decline of the engozi system, and a few groups narrowed the scope of services to burial arrangements. However, with inadequate annual health budget allocation of a mean of 9.8% and a limited per capita spending of USD 12 (Lukwago,2016), and other limited health sector in-puts (MOH, 2020), the government health services cannot meet the requirements of the rural communities. The Kisiizi community while building on the engozi traditions came up with a CBHI scheme in 1996; as a self-help innovation to removing financial barriers and promoting access to quality healthcare services. The Kisiizi CBHI allowed families to join through community associations of not but twenty families. At the end of 2018, the scheme had 41,500 active members; about 23% of the extended catchment population, enrolled through 210 engozi groups (Kisiizi Hospital, 2018). The scheme members paid an annual premium that ranged from UGX 11,000 – UGX 17,000 (USD 3– 4.71) per person. Besides, the members were required to pay a co-payment fee of UGX 3000 (USD 0.8) per outpatient visit; UGX 150,000 (USD 41.7) per operation including a caesarean section; UGX 10,000 (USD3.8) per paediatric admission and UGX 30,000 (USD 8.3) per non-surgical adult admission.
Conceptualizing Community – based Insurance (CBHI)
Community-based insurance is an emerging and promising sort of insurance, developed out of a need for financial protection against catastrophic health expenditures faced by especially the rural poor, originating from community social support systems (Criel et al, 2004). Literature indicates that CBHI schemes started within the 1980s in resource-poor countries where tax-funded and other insurance platforms were either struggling or non-existent (Carrin et al 2005; Ekman, 2004). Later on, CBHI strategy gained more ground after the failure of user fees, tax-based systems and social insurance systems to offer protection to the poor from the impoverishing effects of ill-health (Doetinchem et al 2006; Savedoff, 2004). CBHI schemes are formed on common principles of risk-sharing, voluntary membership, community solidarity and non-profit making (Doetinchem et al 2006).
CBHI has been related to positive finance - related and health-related impacts on members. On a financial aspect, CBHI schemes reduce out-of-pocket payments, a rise in household income, and a 13% decline within the probability of borrowing for health care (Yilma et al, 2015; Poletti, et al, 2007). In health-related impacts, membership to CBHI is related to 40% higher chances of making outpatient visits (Smith & Sulzbach, 2008; Jutting, 2004) reduces the probability of stunting by 4.3 percentage points (Nshakira-Rukundo et al, 2020); and increased use of maternal health services including use of skilled deliveries (Smith & Sulzbach, 2008). All in all, CBHI is understood to be an efficient approach to improving the welfare and health status of entire household members.
Problem Statement
Equitable access to healthcare in Uganda has not been realized even after the abolition of user fees in government health facilities. The cost of services remains a key barrier, and therefore the poor and vulnerable have limited access to quality healthcare services. CBHI has been fronted as one strategy to addressing health access inequities. The CBHI strategy has been successful in reducing household vulnerability to out-of-pocket health expenditure, obtaining financial protection against catastrophic health expenditures and improving access to healthcare in low-income communities and facilitated universal health coverage (Carrin & Chris, 2004; Wang & Pielemeier. 2012). A huge number of studies on CBHI have focused on scheme design, enrolment and retention, financial protection and health-related impacts (Bennett, 2004; Kamau & Njiru, 2014; Agyepong et al, 2016; Kakama et al, 2020.). However, little has been documented on how cultural values and traditions influence CBHI implementation in a given community. This study, therefore, seeks to reply to the present research gap.
The aim:
To explore the importance of community values and traditions in addressing healthcare inequities through a CBHI approach. In particular, we explored community values and traditions that relate to health and social services; assessed the influence of community values and traditions on CBHI implementation and sustainability and explored the views and perceptions of community members on the contribution of CBHI on addressing healthcare challenges within the Kisiizi community; and documented lessons learnt regarding CBHI introduction and implementation in a given community.
Design and setting of the study
This study embraced an interpretivist research paradigm approach, employing a case study methodology to investigate the importance of community values and traditions in addressing healthcare challenges; a case of the Kisiizi CBHI scheme. This study was explorative and descriptive in nature applying qualitative methods.
This study applied Woolcock’s social capital hypothetical structure (Donfouet, & Mahieu, 2012). Our choice for this theoretical framework was guided by the literature argument that; networks and communities characterized by solid intra-community ties are bound to succeed with CBHI than those without such ties (Donfouet, & Mahieu, 2012).
Theoretical framework
According to Putnam, (1995), as cited in Mladovsky and Mossialos (2008), social capital refers to a ‘stock’ that is the property of a group or community, district or even nation and constitutes features of social organization - networks, norms, and social ties that facilitate coordination and cooperation for mutual benefit. Similarly, Fukuyama, (1995) as cited in Donfouet and Mahieu, (2012) defines social capital as the existence of a certain set of informal values or norms shared among the members of a group that permit cooperation among them. Soumyananda, (2006) contends that social capital is a broad term containing the social networks and norms that generate shared understandings, trust and reciprocity, which underpin cooperation and collective action for mutual benefits, and creates the base for economic prosperity.
Nonetheless, consistent with Woolcock’s theoretical framework, Social capital is assessed as either Bonding social capital ('Solid ties’) or Bridging social capital ('Feeble ties') (Woolcock & Narayan, 2000). Bonding social capital also called intra-community social capital; alludes to an in depth relationship between an individual and his family, friends, and ethnic group. It incorporates cooperation that exists within a specific group. Proponents of intra-community networks urge that social capital might be a significant determinant of willingness to pay for CBHI, and accordingly the more prominent the social capital the more individuals will prepay for CBHI (Hsiao as cited in Mladovsky & Mossialos, 2006). On the other hand, bridging social capital also called extra-community social capital; alludes to the individual’s contacts outside the ethnic group or family; involving interactions across multiple groups. While holding onto the argument that strong intra-community ties are identified with CBHI achievement, we began to investigate applicable community values and traditions within the Kisiizi community that have fundamentally impacted CBHI execution.
The study population
Included within the study were scheme members and non-members, local and opinion leaders, managers, leaders and staff of the scheme. Primary participants were selected from two villages with different levels of insurance coverage, classified as: ‘low coverage’ (39% and below insurance coverage) and ‘moderate coverage’ (greater or equal to 40% insurance coverage) (Kisiizi Hospital, 2018). The consideration of participants from a spread of settings pointed toward expanding the validity and credibility of the findings (Mays & Pope, 2000).
Participants were selected purposively, using the criterion sampling technique. The criterion for selection of Focus Group Discussion (FGD) participants was that; one must have lived within the selected village for a minimum of 10 years. Ten years were viewed as a satisfactory period for resident to know the cultural values and practices. Mixed-gender FGDs were conducted; two per village: one for scheme members and another for non-members. Each FGD was composed of nine - twelve participants. The selection of key informants depended on administrative roles the target office or the community and their availability and willingness to be interviewed. Secondary participants were interviewed through face-to-face key informant interviews (KI) utilizing a key informant guide. These included community leaders, managers, leaders and staff of the scheme. Both male and female members were chosen for interviews and accordingly the greater part (82%) was over forty years and lived locally for their lifetime. The various experiences of both male and female participants provided an upscale collection of knowledge.
Data collection, management, analysis and internal control
Eleven (11) key informant interviews and four (04) focus group discussions were conducted by the investigators employing a topic guide. Each FGD had nine to twelve participants (n = 45) and discussions were held at community centers. The key informant interviews were held at the homes or offices of the respective participants. The discussions were moderated by one among the investigators who introduced himself and therefore the goal of the project before the discussion. The discussions were audio-recorded and took 1–2 hours. The entire process of knowledge collection happened from 5th March 2021 to 11th April 2021. The investigators used a grounded theory in arising with research tools. The theory further aided the investigators in exploring the community values and traditions and understanding the systems of the scheme.
Data analysis was based on the individual or group participant’s opinions and views on the values and traditions, and therefore the scheme policies and operations. Data analysis followed a scientific process of; transcribing and checking, open coding, identification of patterns/themes and eventually summarizing the information (Sutton & Austin, 2015).
The audio-recorded data was converted into transcription to facilitate analysis. Coding was done manually. The investigators read through the transcripts 3 times to form meaning of the whole story before generating themes. The investigators made memos within the margins which helped to spot common words, phrases and differences which helped to get common themes, patterns within the responses. The generated themes were later matched with the study objectives.
The investigators chose to present empirical data with both verbatim quotes from individual participants and excerpts of the discussions between the participants. This was aimed at making the results a more valid reflection of the empirical data. The investigators decided to mark the excerpts from the discussions 'member FGDs' or 'non-member FGDs' to represent focus group discussions for insurance members or non–insurance members respectively. Besides, for reporting purposes, the authors have maintained the anonymity of the participants.
Quality control included pre-testing in Rugarama sub-County, Ntungamo District. This area was picked on the grounds that; (a) it is close to Kisiizi hospital and falls outside the study area, (b) It has both scheme members and non-scheme members. The tools were altered to dispose of mistakes, vagueness, and repetitions, and made respondent friendly. During interviews, the investigators would recite back the responses to seek participant's clarification before the end of the interview. More so, the investigators listened several times to the audios after the primary draft of the script was written to make sure that whatever each participant said was fully captured. Also, the investigators adopted a technique of bracketing, where the investigators’ experiences, beliefs, values and feelings were deliberately put aside to accurately describe participants' opinions, views and perceptions. Triangulation was obtained through separate focus group discussions with the scheme and non-scheme members to match their views. Also, the utilization of KII and FGDs provided triangulation.
Background characteristics of participants A total of fifty-six (56) participants took part in this study. Up to 20% (11) were key informants and 80% (45) participated in the focus group discussions. Up to 59% (33) were males and 41% (23) were females. Key informants ranged in age from 31 to 69. Key informants included three (03) managers, leaders and staff of the Kisiizi hospital CBHI scheme and eight (8) community leaders. Up to 53 % (24) of the participants in the FGDs were members of the Kisiizi Hospital Insurance Scheme for a minimum of 2 years and 47% (21) were Non-scheme members. Up to 52% (27) were from a village with moderate insurance coverage, and 48% (25) were from a village with low insurance coverage.
Assessing community values and traditions associated with Health and Social services
This section presents findings on traditions and social values within the Kisiizi community, which were associated with health and social services.
Belonging, Cooperation, Solidarity and brotherhood
Participants stated that, it is a custom for each family to belong to a particular engozi. Key informant 6 stated that: “every family subscribe to a particular engozi otherwise it might feel isolated from the community”. Similarly, members in Member FGD 1 mentioned that: “it was a custom that each family belonged to engozi therein village”. Besides, non-member FGD1 stated that: “families that do belong to any engozi find difficulties in situations of illness, funerals, and marriage ceremonies”.
In regard to cooperation, it was stated that “we collect money per annum to shop for timber to make coffins and facilitate burial arrangements for members” (Member FGD 2; Non-member FGD1). In a related way, Key informants 4, 9, and 11 stated that: “It is a requirement for each household head to contribute a particular set amount of cash to the emergency fund for the group”. In related way, it was mentioned across the groups that “We gather beans, and millet every season, into a central store as a backup for food during funeral in case of death of a member (Member FGD 1 & 2; Non-member FGD1 & 2).
In regard to Solidarity and brotherhood, it was revealed that, every able-bodied man and woman participate in aiding transportation of patients to the hospital in a local stretcher (‘engozi’). The women walked along carrying refreshments and food to support the men who carry the patient in a local stretcher (key informants 4, 5, 7, and 9). Similarly, participants in Member FGD 1 asserted that: “It is a custom to visit the sick in hospitals, and one has to carry food or other materials to support the sick and family”. In another perspective, Non-member FGD 2 reported that: “It is a requirement for members to visit grieving families, collect food items and other materials and participate in the funeral activities, including postponing personal works until end of funeral period”. Men are required to participate in building a grave while women participate in preparing meals and refreshments at the funeral (Member FGD 2).
Voluntarism and reciprocity
It was stated that “historically, women helped one another in planting, weeding and harvesting sorghum or millet” (Non-member FGD 1; KI 9). Besides, participants in Member FGD 1 stated that: “men accepted to assist a colleague or a neighbour to place up a house for his family, expecting no pay, but hoping to be helped similarly at a particular time". In another perspective, it was mentioned across the different groups that some members of the engozi would voluntarily offer to take care of the children of the sick colleague, and others would offer to assist in the farming activities; planting, weeding, and harvesting crops of the sick member” (Member FGD2, Non-Member FGD 1, KI 8, KI 9).
Respecting and honour for authority and elders
It was mentioned that part of the work of engozi leaders and elders was dispute resolution and reconciliation, between members or families (Non-member FGD 2). in conformity Key Informant 6 mentioned that “part of my work as a leader of engozi group involves reconciling married couples” .In a related way Key informant 9 and 10 stated that: “engozi leaders and members help in settling land disputes”. Also, participants in member FGD 2 stated that: "low-level civil disputes like obliteration of gardens by a neighbour’s animals and land matters were presented to the engozi leadership and members for a hearing and remedy”.
Assessing the influence of community values and traditions on CBHI implementation and sustainability
This section presents findings on how society values and traditions have affected the implementation of the Kisiizi CBHI scheme.
Community mobilization and Member Enrollment
Participants referenced that the engozi structures facilitated community entry, mobilization and member enrollment for the CBHI scheme. Key informant 2 and 4 mentioned that: “the leaders of the community associations help in mobilization of their members, and sensitization campaigns are conducted during engozi meetings”. In support, participants in the Member FGD 1 stated that: “we first heard of insurance from our group leader inviting us for a meeting with visitors from Kisiizi insurance scheme”. In addition, Key informants 1 and 2 mentioned that: "we prefer to register members and families of already existing engozi to attenuate the danger of adverse selection, where only the high-risk individuals and families are registered". Similarly, participants in member FGD 2 stated that: “we enrolled into the scheme as a whole group. The requirement was to register all our family members with the group leader and pay a particular amount of cash consistent with the family size”. Besides, it was mentioned that: enrolling a large number of people into the scheme was not difficult, since almost every family belonged to a particular engozi” (Key informant 5).
It was revealed that some engozi groups provide a significant contribution from the emergency fund, and members are asked to top up a little amount to satisfy the premium requirements for his or her family. In Member FGD 1, participants mentioned that: “we get a bigger a part of our premiums from the group emergency fund and then top up a little amount to boost all the premiums for a family”. In a related way, Key informant 6 said that: "In my group, we can raise the premium enough to cover only two members of the family; we ask members to top up according to their family sizes". In a similar way, Key informant 2 & 3 mentioned that: “we encourage groups to start out saving schemes and use the savings to pay premiums for the members at the end of the year”.
CBHI Leadership and governance
Participants stated that the engozi leaders form up the leadership and governance structures of the CBHI. Key informant 1 & 3 stated that: “the scheme is led and governed by members through an elected committee, representing the various villages in this community”. Similarly, member FGD 1 mentioned that: “the group chairman and the secretary are our representatives at the scheme meetings”. In a related way, Key informant 4 stated that “I have been elected for the last three years by other engozi leaders to be a member of the governing board of the scheme”. In addition, Key informant 5 stated that, premium and co-payment fees rates are regulated by the scheme governing board, which is composed of the members’ representatives”. In another perspective, it was revealed that, the governing board conducts staff recruitment and periodically assess scheme performance” (KI 9).
Perceptions of community members on effects of Kisiizi CBHI on healthcare
This section presents the findings on the opinions and views of the participants regarding the effects of the CBHI scheme on healthcare concerns within the community.
Access to quality care at a low cost
It was asserted that, “the scheme has assisted people with taking care of hospital bills particularly for sophisticated services like surgery, which they might not have managed to pay for” (KI 11). Additionally, it was mentioned in Member FGD 1 that: "People who couldn't manage the cost of surgery can now catch on through the scheme”. Similarly, participants in Member FGD 2 expressed that: “In our group, people no longer sell family land or property to cover emergency medical bills”. We identified that even non-scheme members appeared to realize this benefit. It was stated within the non-member FGD that: “We are told that some scheme members get free services and others pay little money at Kisiizi hospital” (non-member FGD 2). Likewise, one local leader expressed that "we are glad that our people particularly the poor can get good services at Kisiizi Hospital, at a reasonable cost”. It was also mentioned that “it costs scheme members only 3000 ugx (less than USD 1) to obtain out-patient care services at Kisiizi hospital” (Member FGD 2). It was referenced in the non-Member FGD 1 that: "We are told that pregnant women get free antenatal care".
Early healthcare-seeking behaviour
It was established that the CBHI scheme has influenced the behaviour of seeking care at an early stage of the disease cycle. Key informant 2 expressed that: ""we presently don't get scheme members with very severe forms of illnesses because the vast majority of them report early". In agreement, Key informant 4 expressed that: “a greater number of scheme members are treated at out-patient clinics with fewer admissions”. The members expressed a sense of being liberal to seek healthcare services without any worries over medical bills. Participants in Member FGD 1 stated that: “we are glad to travel to the hospital for services any time”. In a related way, Key informant 3 mentioned that “our members have responded to our call of seeking medical services at an early stage because it saves finances of the scheme”.
Increased healthcare services utilization
Participants believed that the numbers of community members utilizing healthcare services at Kisiizi hospital have significantly increased. Key informant 2 stated that: “the hospital sees a lot more scheme members than non-scheme members; particularly at Out-patient clinics, Antenatal clinics and maternity ward”. Besides, Key informants 7 an area leader stated that: “women who used to deliver from their homes are now afford to deliver from the hospital”. More so, it was expressed in Member FGD 2 that: “People who could not afford services are now able to get on through the scheme”. In a related way Key informant 4 stated that, the free antenatal care services offered to CBHI members, has led to a significant increase in the numbers of pregnant mothers returning for antenatal visits”.
Values and Traditions associated with Health and Social services
For the value of Belonging; families in the Kisiizi community pledged allegiance to the engozi groups and any family that never belonged to a particular group faced social isolation. Customarily, an African man was identified in, by and through his community, and security trusted personal identification with the community (Kanu, 2010). Besides, African culture emphasized community life; community identity and community interests were held superior to individual interests (Aborisade as cited in Etta et al, 2016). In a related way, CBHI scheme creates a method of protection from potentially impoverishing health expenditures. The Kisiizi community comprehended this component and embraced the CBHI scheme.
In regard to Cooperation, engozi members pooled funds and food items for the motivations behind supporting families confronted with a tragedy. This value emphasizes the importance of interdependence and working together for a common goal. In accordance with this finding, Kigongo (2007) affirms that African culture included willful pooling together of endeavors and abilities that made life meaningful. In a related way, Etta et al (2016) affirm that African culture is a social association where every member intentionally collaborates. Similarly, Awoniyi (2015) affirms that African practices recognized that man was not self-sufficient and it was distinctly through collaboration with populace that the prerequisites and objectives of the non-self sufficient individual may be satisfied. Families in the Kisiizi community intermittently pooled funds and food items for keeping a rainy-day account, a fallback position in circumstances of sickness or death. Therefore, the requirement for yearly commitments of funds into the CBHI was not alien and was effectively acknowledged and generally welcomed.
In regard to Solidarity and brotherhood, it was a moral obligation for all community members to support the sick and grieving families. Community members relied on one another in times of incredible difficulty. Researchers showed that African traditions prescribed some social and moral roles, duties, responsibilities and obligations to each individual within the society, requiring each individual to exhibit concern for the interests of others (Awoniyi, 2015). Furthermore, all populace belonged to one universal family, and therefore the recognition of all citizenry as siblings demanded everyone to be his brother’s keeper (Etta, et al, 2016). In a similar wave, Kimmerle (2016), composed that conventional African social orders showed agreeable types of life, guided by morals of shared assistance and care for one another. Consequently, since the CBHI philosophy depends on solidarity and mutual support (Schneider & Diop, 2001), the introduction of the CBHI scheme was viewed as an important expansion of the engozi system.
In respect of the value of Voluntarism and reciprocity, engozi members deliberately helped one another in several activities including house construction and farming; without anticipating any monetary or material gain. Every community member was willing to assist, and help did not depend on prompt or a specific identical compensation yet it could come later in terms of reciprocity (Kanu, 2010). In a related way, Shorter 1978 as cited in Etta et al (2016) expressed that the African culture was a mutual society, coordinated to fulfill the fundamental human needs of all its members; where both men and women would help in house construction for a colleague and the able-bodied accepted responsibility for tending and harvesting the gardens of the sick and deformed.
In terms of respect for authority and elders, it was established that the elders administered justice, facilitated reconciliation and restored harmony and discipline within the community. This finding is in concurrence with Kigongo (2007) who affirms that the elders were considered to have all information and insight, and what they said must be accepted without questioning. However, Kanu (2010) composed that that the submission was not to the individual but rather to the institution, although the elders were believed to speak words of guidance, advancing appropriate conduct among community members. Obtaining commitment and support from the community leaders and elders was consequently of central significance to the accomplishment of scheme. This, along these lines, clarifies why community leaders were effectively associated with the initiative of the scheme straightforwardly from its beginning.
Impact of engozi values and traditions on CBHI implementation
The engozi structures facilitated community entry, mobilization and member enrollment for the CBHI scheme. The engozi meetings offered a platform for community mobilization and advancement of the insurance agenda. Likewise, the engozi leaders aided the community mobilization exercise. In concurrence with this study, Hendryx, et al (2002) state that CBHI schemes are often built on existing social capital to extend coverage by enlisting families through community associations. It is additionally contended that community leaders are critical change agents and have the power to positively impact community development (Rami et al, 2017). More so, Ricketts (2005), suggests that effective community leaders are important in developing important relationships, establishing communication and providing the community with direction. In addition, the value of solidarity and cooperation towards a common good held by engozi members, in addition to peer influence was a drive into enrollment with the CBHI. This finding concurs with the findings of Cofie et al, (2013) that influence by family, companions, or relatives was associated with enrollment into the CBHI scheme. More so, a high sense of solidarity found in community associations was a critical factor to enrollment into CBHI schemes (Schneider & Diop, 2001; Mulupi et al, 2013). Furthermore, some engozi groups use group reserve funds to add to premiums for members. Likewise, the practice of regular contributions to engozi reserve rhymed well with the premiums policy and made the collection of premiums easier. In a previous study Fadlallah et al (2018) identified that positive past experience with systems of local groups, influenced enrollment and sustainability of CBHI schemes, while negative experience contributed to low enrollment.
In another perspective, the community leaders are enormously engaged in scheme leadership. The community leaders were included in the introduction, advancement and execution of the scheme, which influenced the trust and confidence of the community members and eased acceptability of the scheme. In line with this finding, Criel & Waelkens, (2003) recognized that that the contribution of community heads and religious leaders assisted to tailor services to needs, decreased complaints and facilitated implementation of CBHI schemes. Similarly, Mladovsky and Mossialos (2008), demonstrate that trust in the management of the scheme firmly impacts a family's choice to enroll into the scheme.
Perceptions of community members on effects of Kisiizi CBHI on healthcare
First and foremost, the CBHI members can now access quality healthcare services without worrying of high medical bills. The required co-payment fees are very affordable. Previous studies have indicated that CBHI schemes have the potential to scale back out-of-pocket payments and catastrophic health expenditures while providing better quality healthcare (Jahangir et al, 2020). Another research done in Ghana indicated that folks enrolled were proud of the scheme because the scheme could pay for their healthcare bills (Jehu-Appiah et al, 2012).
In another perspective, the CBHI has influenced the positive behaviour of seeking health care at the first stages of the disease. The members report back to the hospital with mild forms of disease which are cost-effective to treat. Studies have shown that insurance results in the timely and more appropriate use of health care services (Institute of Medicine, 2002). In a related way, Roetzheim et al, (1999) established that uninsured patients have poorer outcomes due to delayed diagnosis and thus more likely to die prematurely than persons with insurance.
In addition, there is a general belief that the numbers of community members utilizing healthcare services at Kisiizi hospital have significantly increased, with the bulk of patients being CBHI members. Numerous studies have demonstrated that insurance increases service utilization especially: number of outpatient visits, number of inpatient admissions, facility deliveries and Antenatal care services (Ekman,2004; Wang et al, 2017; Demissie & Negeri, 2020, NshakiraRukundo, 2021). For instance, a study in Tanzania identified that insurance may be a predictor of utilization of outpatient and inpatient health services in people aged 60 and above (Tungu et al, 2020).
While numerous studies have highlighted financial and health-related impacts of CBHI, little has been documented on the influence of community held values and traditions on CBHI implementation in a given community. The narratives of the Kisiizi community members affirm the claim that communities characterized by solid intra-community ties are more likely to experience success with CBHI.
The Kisiizi community values and traditions of; Belonging, Cooperation, voluntarism and reciprocity, Solidarity and brotherhood, held the community members together, and formed a robust foundation for the CBHI scheme. The successful introduction and sustainability of the CBHI scheme pivoted on conformity with these values and traditions. Therefore, CBHI promoters and policymakers have to first recognize the context and CBHI schemes must be custom-made to suit society values and traditions.
Second, the involvement of community leaders in promoting and management of the scheme induces trust and confidence and influences acceptability of the scheme. The leaders assist in coming up with appropriate benefits package tailored to community needs and facilitate the flow of information and feedback. Therefore, policymakers and scheme promoters must have community leaders actively involved in scheme design, promotion and execution if success is to be realized.
Our study therefore, adds that compliance to social values and traditions, and active involvement of community leaders in the planning, execution and management of the scheme are essential determinants of CBHI. Consequently, the CBHI scheme addresses contemporary healthcare inequities through; breaking financial barriers to accessing quality healthcare, promoting early healthcare-seeking behavior, and leads to increased equity in healthcare access and utilization.
Strengths and limitations of this study
The methodological approaches form the foundation of this study. First, it includes participants from different communities with contrasting degrees of insurance coverage. Second, it incorporates both insured and non-insured respondents allowing for comparisons of experiences. Likewise, triangulation provided an opportunity to compare the study findings.
This study had limitations. To begin with, the young female participants did not freely express themselves in presence of their mothers-in-law and fathers-in-law during FGDs. In any case, its impact was limited by disclosing to the whole group that the views presented were group views and matters of health affect both the elderly and young equally. Second, this was a qualitative study and might have been enhanced by quantitative inputs. The research team did not have adequate funds to complete a more profound investigation of the impacts of social values and traditions on CBHI scheme. Notwithstanding, the research team exercised strict budget control on the available funds.
CBHI: Community based Health Insurance; FGDs: Focus group discussions; KI: Key informant; UBOS: Uganda Bureau of Statistics; UGX: Ugandan Shillings; USD: United States Dollars
Competing interests: The authors declare no competing interest.
Ethics considerations and consent to participate
The study was submitted for approval to Kisiizi Hospital Research and Ethics Committee (M07/2020). Written consent was obtained from all participants before the interview. The participants were also informed of their right to walk out of the interview if they wished to withdraw. The participants were informed of the possibility of having this article published for the consumption of a wider research community.
posted
You are reading this latest preprint version