Background characteristics of participants
A total of 64 participants took part in this study. Up to 26.6% (17) were key informants and 73.4% (47) participated in the focus group discussions. Up to 29.7% (19) were males and 70.3% (45) were females.
Key informants included three (03) officers from the District health office/ department, eleven (11) Local Leaders /community opinion leaders and three (03) managers and staff of the Kisiizi CBHI scheme. Focus group participants were members of the Kisiizi Hospital Health Insurance Scheme for at least 2 years - 46.8% (22) and Non insurance members - 53.1% (25).
Up to 38.3% (18) were from ‘moderate participation’ village, 34% (16) were from ‘low participation’ village and 27.6% (13) were from a ‘very low participation’ village.
No participant was selected from the high participation village since no village fulfilled this criteria.
Assessing desirability of scaling up the Kisiizi Hospital CBHI scheme
In this section, the researcher aimed at assessing whether the CBHI scheme attracts popular support from the local communities. This study focussed on assessing; acceptability and support to the scheme, level of awareness and understanding about the scheme, availability of other health financing alternatives, conformity with national health policies/guidelines, acceptability of the benefits package, stake holders’ interests and conformity with local society values.
Community acceptability and support to the Kisiizi Hospital CBHI scheme
It was established that Kisiizi hospital CBHI scheme is largely accepted and supported in the local community. This was attributed to the scheme’s ability to offer financial support to the members to fund hospital care. This was evidenced by testimonies from participants.
For instance, in Member FGD 1, Joseline mentioned that;
“The scheme helped us to clear a bigger part of the hospital bill when my daughter delivered by ceasarian section”.
On the same note key Informant 5, an opinion leader affirms as follows;
“We have seen the scheme helping some people who would not have managed to pay hospital bills especially for complicated healthcare services” (KI 5).
It was further established that financial contributions from the scheme has helped families from selling of family land and property or borrowing at very high interest rates to pay hospital bills.
For instance, Key informant 8 (opinion leader) mentioned that
“Most of the people in this community no longer sell family land or borrow from dubious money lenders to finance hospital care”
Conformity with national, regional and international laws/ policies/ instruments
It was established that the Kisiizi Hospital CBHI scheme is in line with the Uganda Vision 2040, which identifies universal health insurance as one of the key strategies for alleviating the high cost on health care by households and enhancing access to affordable health services for all [17].
At international level, the Ministry of Gender, Labour and Social Development, (2015) report further highlights the Ouagadougou Declaration which calls for parties to improve and strengthen the existing social protection schemes and extending it to workers and their families. It was evident that the Kisiizi hospital CBHI scheme is in line with the provisions of this declaration.
In addition to the above, the local leaders testified that the methods of work and processes of Kisiizi hospital CBHI scheme are in line with local and national government priority of promoting universal health coverage.
For instance, Key informants 2, 3, and 5 mentioned that;
“The government priority is to promote universal health coverage. The people should be able to access quality healthcare service at low cost”.
In addition, Key informant 7 mentioned that;
“The Kisiizi hospital CBHI provides an opportunity to all people especially the very poor to get quality services at Kisiizi hospital, at a very low cost”
The results of this study indicate that Kisiizi Hospital CBHI scheme conforms to, and contributes towards attainment of the national and international agenda of promoting social protection and fundamental human rights. The scheme has provided an opportunity for all people especially the poor to access quality healthcare at low cost.
Conformity with society values and culture
It was established that the Kisiizi hospital CBHI ideology and methods of work are reportedly similar to the methods, practices and objectives of the local community associations which offer financial and material support to grieving families in times of death of loved ones or even in times of illness.
In support of the scheme, key informant 11 (Opinion leader) mentioned that,
“The scheme works more like our engozi groups, where we support each other with finances and food items during funerals”.
Acceptability of the benefits package
The Kisiizi hospital CBHI scheme offers a benefits package which provides cover for acute and life threatening illness, including trauma and maternity cover. It was however established that the benefits package does not include out-patient services for chronic diseases like Hypertension and diabetes. According to the study participants, this package meets the health needs of the majority of the people in the local communities.
For instance, there was majority support in member FGD 2 that, the benefits package meets the needs of most of the people in local communities. However, Anna requested that
“Members with hypertension and diabetes should also be given a significant subsidy”
Alternative available health financing mechanisms
It was established that no government – owned hospital is located in Rubabo County and free healthcare services can only be accessed from lower health facilities, although limited to basic health care services. It was established that hospital care can only be easily accessed at Kisiizi hospital, a non-government hospital, where all clients and patients are required to pay user fees.
It was mentioned in Non-member FGD 1 that
“For simple illness, we visit local health centre III, and for illness that requires advanced care, we normally go to Kisiizi hospital”.
In agreement, Key informant 5, 8 & 9 mentioned that
“There is a strong network of government and non-government owned lower health facilities in Rubabo County, and only one general private-not-for profit hospital”.
In relation to how households mobilise funds for healthcare, it was established that, most families either borrow or sell family property especially land.
For instance, in Non-member FGD 2, it was mentioned that
“It is difficult to raise adequate funds to pay off hospital bills without borrowing or selling family property”.
In a similar way, Asaph, participant in non-member FGD 3 mentioned that
“I had to sell part of my banana plantation to settle hospital bills when my wife delivered our first borne”.
Assessing feasibility of scaling up the Kisiizi Hospital CBHI scheme.
This section reports about the practicability of CBHI implementation in the context of existing constraints. The study categorised the feasibility parameters as either enablers or barriers towards scaling up CBHI in the local communities.
Enablers to scaling up Kisiizi hospital CBHI scheme in local communities
Existing community associations or groups
It was established that the existing community associations/groups enabled community penetration and member enrolment. Several development-oriented associations do exist in the local communities either as women, youth or neighbourhood associations locally known as Bataka /Engozi groups. Most of these groups provide financial and material support to members during times of illness or death of a beloved one. The Kisiizi hospital CBHI works through these community groups to promote the health insurance agenda and to enrol members.
For instance, Key informant 2 mentioned that;
“It was easy to penetrate the community through the “Engozi” groups, which had to add health insurance into their development agenda”
Given the above findings, the Kisiizi hospital CBHI scheme can continue to work through existing community associations to increase coverage.
Trusted Quality of services at Kisiizi hospital
It was established that the community holds strong trust and confidence in the quality of services at Kisiizi Hospital.
For instance, Benard in Member FGD 1 mentioned that,
“Kisiizi hospital offers the best healthcare services in and around Kigezi region”.
In the same way, Justus in Non-member FGD 3, mentioned that
“Kisiizi hospital has good doctors and machines. Most people get healed from Kisiizi hospital”
According to Key informant 2,
“Trust in the quality of services offered by Kisiizi hospital has been a key factor to the success of the scheme”.
Therefore, scaling up the Kisiizi hospital CBHI is very feasible since the community still holds positive perceptions, trust and confidence in the quality of services offered at Kisiizi hospital.
Affordable premium fees and co-payment fees
It was established that the annual premium fees and the co-payment fees are affordable to majority of the households in the communities. Kisiizi hospital CBHI scheme charges premium fees between 11,000 ugx – 17,000 ugx (USD 3 – 4.7) per year for each member in the family. In addition, the members are required to contribute a co-payment fee of 3,000 ugx (USD 0.8) for out-patient visit, 150,000 ugx (USD 41.7) for Major surgery including a caesarean section, 10,000 ugx (USD 2.8) for paediatric admissions and 30,000 ugx (USD 8.3) for non-surgical adult admissions.
It was established that established that, the fees were set by members and administrators of the scheme basing on affordability as the only key factor. For this reason, the scheme has not registered significant drop out rates. For instance, dropout rates have been as low as 2% since 2018 (Key informant 4).
In a related way, Key informant 3 mentioned that,
“All insurance fees are set by the executive committee in collaboration with hospital management, but approved by the Annual general assembly of members, with an agreement that the set fees are affordable to majority of the households in our catchment area”.
In a related way, Joseph in Member FGD 3 mentioned that,
“The premium fees are affordable to many families in this village”.
Therefore, scaling up the Kisiizi hospital CBHI is feasible since the premium fees and co-payment fees are considered fair and largely affordable. Secondly, involvement of the members in setting scheme fees is key to fees regulation and creates a sense of ownership.
Strong governance and management structures
It was established that the Kisiizi hospital CBHI scheme is governed by scheme members through an elected executive committee of eleven members. The main duties of this committee include; making policies, proposing insurance fees reviews, auditing scheme finances, and providing regular feedback about the services.
For instance it was mentioned that,
“The scheme belongs to the members and Kisiizi hospital helps to administer it” (Key informant 1).
In addition Key informant 7, mentioned that
“The hospital management consults with the executive committee in case of need to review fees. Secondly, all fees changes are presented to the members in the annual general meeting for approval”.
In addition, it was established that the management team is trained in health financing and insurance principles and practices, and the scheme office operates an electronic data management system which facilitates member registration, member verification, report processing and control of fraud.
It was mentioned that,
“We use an electronic system to register and identify valid members whenever they come to the hospital for healthcare services. We are also able to monitor prescription patterns which is key in controlling unnecessary use of services through this electronic system” (Key informant 4).
Barriers to scaling up the Kisiizi hospital CBHI scheme in local communities
Long distance and high transport costs to Kisiizi hospital
It was identified that long distance to Kisiizi hospital is a strong barrier to member enrolment especially for households from distant villages. Secondly, the unreliable public transport means associated with high public transport costs to Kisiizi hospital mask the visible advantages of scheme membership. Kisiizi hospital is located over 30 Km away from the main road, over 50 Km from the urban centre.
For instance Shallon in non-member FGD 2 mentioned that
“It is difficult to travel to and from Kisiizi in the afternoon and night hours”
In non-member FGD 3, Timothy mentioned that;
“Public transport costs to Kisiizi Hospital for a patient and care taker are higher than costs of medical care in a nearby clinic”
Therefore, long distances associated with high transport costs to Kisiizi hospital create a barrier to scaling up the scheme. Secondly, a single service provider, located in an isolated community poses a significant barrier to member enrolment especially from distant communities.
Low levels of knowledge, negative attitude and beliefs about health insurance
It was established that non-members of the scheme were relatively less knowledgeable about the scheme and held negative beliefs and attitudes towards the scheme.
For instance, in Non-member FGD 1, George mentioned that
“The health workers at Kisiizi hospital offer better services to patients who pay cash than those in health insurance”.
In addition, Miriam and Tina in Non-member FGD 1, asked that
“Where does the money go if one does not get sick at the end of the year?”
The researcher considered the above questions and remarks as originating from inadequate levels of knowledge on the objectives, policies and methods of work of a CBHI scheme.
Inability to pay Premium and co-payment fees.
It was established that very poor households and large families often find difficulties in raising subscription fees. Results further revealed that some families fail to renew membership whenever renewal period overlaps with the period when children are returning to school and parents have to pay school fees first.
For instance
Key informant 3, 5, 7 and 11, mentioned that
“Some families have dropped out of the scheme due to failure to pay premium fees, especially during periods when children are returning to school”.
In addition, Key informant 6 mentioned that
“The very poor families especially those that do not belong to community associations cannot afford to pay premium fees”.
It was therefore concluded that not all households in the local community can afford to raise the required insurance fees. Secondly the overlap of school fees period and premium fees period are threats to the Kisiizi hospital CBHI scale up.