DOI: https://doi.org/10.21203/rs.2.11192/v1
Community-based health Insurance (CBHI) schemes, sometimes referred to as rural health insurance schemes, Community mutual health organizations or community health funds [1] are known to contribute greatly towards promotion of equitable access to healthcare services especially in the low-income populations, and contribute to raising additional revenue for the health sector [2]. These schemes are characterised by solidarity, voluntary membership, and prepayment for health care and non-profit making agenda [3-4]. Literature indicates that CBHI concept developed out a need for a financing mechanisms that offers financial protection against catastrophic health expenditure to the poor and promote access to services for all, after failure of user fees, tax-based systems and social health insurance systems [5-6].
CBHI schemes are famous world over. For instance, a number of countries in Sub Saharan Africa including Ghana and Rwanda, as well as developed countries including Germany, Japan and China have implemented CBHI schemes as initial steps towards attainment of the National Health Insurance coverage [7].
Background of the Kisiizi Hospital Health Insurance Scheme
Kisiizi Hospital, a faith based hospital in South Western Uganda, established a community-based health insurance scheme in 1996. By the end of 2018, the scheme had 41,500 active members registered through 210 community mutual groups from communities in and around Rubabo County. This was estimated at about 30% of the total population in Rubabo County. The scheme was a strategy of reducing the unpaid hospital debts which had risen to about 2.5% of the total annual recurrent hospital costs [8]. Secondly, the struggle to maintain quality of services led to an attempt to increase prices of services which would significantly affect service utilization by local community members. Therefore, the establishment of the Kisiizi hospital health insurance scheme was aimed at; (i) improving access to quality health care services at a low cost, and (ii) reducing the problem of bad debts. Membership to the Kisiizi hospital health insurance scheme is only through already existing mutual community-based societies called ‘Bataka’ or ‘Engozi’ societies found in local communities. These community societies form a base for the insurance scheme due to strong organisation, leadership and rules. The scheme members pay annual premiums and an affordable co-payment fee before service utilisation.
Problem statement
In Uganda, health inequities in access to healthcare services have continued to exist. The poor and vulnerable have lower access to healthcare services than their rich counterparts [9]. In addition, health sector reforms like abolition of user-fees in all government health units have not been successful in promoting equitable access to healthcare services [10], and cost of services is still a key barrier to access to healthcare services [9]. CBHI is being fronted as a mechanism to address these inequities as well as facilitate introduction of the proposed National Health Insurance scheme in the future and promote universal health coverage especially for the large population in informal sector.
Main objective
To explore whether scaling up CBHI in Rubabo County, Rukungiri District is feasible and desirable considering local community dynamics including funding constraints and society values.
Specific objectives of the study
Summary of existing Literature
Literature offers numerous frameworks that can be applied to study feasibility and desirability of scaling up a CBHI. Nomand and Weber (1994) framework, emphasizes assessment of the conditions in the community, providing critical considerations for making decisions to introduce health insurance (Figure 1). On the other hand, Van Ginneken (2003) suggests that scaling up health insurance requires an assessment of social-economic and political situation of the country such as; the size of the informal sector, administrative and management capacities of the health sector, social capital and the existing health infrastructure. Rannan-Eliya et al (2013) suggests that an assessment of feasibility and desirability of health insurance requires generating answers to the following questions; (i) How well does the current financing strategy meet the country‘s overall goals? (ii) Will health insurance help improve achievement of the overall goals, including improving risk pooling and financial protection, and improving citizen‘s satisfaction? (iii) Will health insurance improve efficiency and equity in financing and service delivery? (iv) What other options exist for improving healthcare financing, and how do they compare with the introduction of health insurance?
In another perspective, Bowen et al, (2009), proposes eight general areas of focus that should be addressed in feasibility studies, including; Acceptability, Practicality and Expansion.
This paper adapts a framework developed by Normand and Weber (1994) and applies the considerations highlighted in the decision making phase, in conjunction with the Bowen’s key areas of focus to assess the feasibility and desirability of scaling up a CBHI in Rubabo County, Rukungiri district.
Significance for the study
First, the study is expected to contribute to the body of knowledge that other researchers might find helpful in designing their studies. Secondly, the information generated could be valuable to policy makers and technocrats in designing and implementing successful CBHI. Thirdly, the information generated could be used in development of appropriate health financing policies that promote universal health access. Communities in Uganda could benefit because the subsequent policies and interventions that would be developed could be more responsive to their needs and aligned to their circumstances and contexts.
The study was descriptive in nature, exploring the possibility and attractiveness of CBHI in a rural community, employing majorly qualitative research methods.
The study was carried out in Rubabo county, Rukungiri district in South Western Uganda. Rubabo County is composed of four sub-counties; Buyanja and Kebisoni sub-counties each with 2.3% insurance coverage, Nyarushanje sub-county with 35.9% insurance coverage, and Nyakishenyi sub-county with 47.2% coverage [14]. This county was selected because it forms the primary catchment area of Kisiizi hospital, the home to Kisiizi hospital CBHI scheme. Rubabo County has an estimated population of 136,200 people, with an estimated average household size of 4.8 people. The area is served by one private-not-for –profit hospital, thirty three lower health facilities that offer primary health care services [14].
The study population included members and non-members of the Kisiizi hospital CBHI scheme living in the selected villages, local leaders and opinion leaders, staff and managers of the Kisiizi hospital CBHI scheme, and staff and managers of the Rukungiri district health department.
Participants were selected from three villages categorised as ‘very low participation’ (up to 19% insurance coverage), ‘low participation’ (20% to 39% insurance coverage) and ‘moderate participation’ (40% to 50% insurance coverage). No participant was selected from the ‘high participation’ village (Above 50% insurance coverage) since no village fulfilled this criteria. This arrangement of participant selection was considered with a purpose of maximizing variability to attain research credibility and validity. Data analysis was based on the individual participant opinions and perceptions of the Kisiizi hospital CBHI scheme.
Participants were further selected purposively, using criterion sampling technique. The criteria for selection of FGD participants was that one must have lived in the selected village for at least two years. The criteria for selection of key informants was based on leadership positions in the target office or in the community and availability and willingness to give detailed interviews.
Face - to - face key informant interviews (KI) were conducted, using semi-structured questionnaires. Participants included; officers from the District Health department, local leaders /community opinion leaders and staff and managers of the Kisiizi hospital CBHI scheme.
Mixed gender Focus Group Discussions (FGD) were conducted. One FGD for members of the Kisiizi hospital CBHI and another for non-members were conducted in each of the three selected villages. Each FGD was composed of six-eight participants.
Ethical considerations
First, the Kisiizi Hospital research committee approved the study. Secondly, prior to the interviews, an explanation was given in verbal form to each of the study participants and an informed consent was attained. The participants were informed that the information provided would be used by Kisiizi hospital CBHI leadership to design appropriate strategies to scale up CBHI in the local community. The participants were informed of their right to walk out of the interview if they wished to withdraw. The participants were also informed of the likelihood of publishing the results of this study in international journals. Finally, both the researcher and the participant appended their signatures on the consent form.
Process of data collection
A total of seventeen (17) face - to - face key informant interviews and six Focus groups were conducted. Each focus group had six-eight participants (n = 47) and discussions were held at community centres. The key informant interviews were held at the offices of the respective officers.
The discussions were moderated by the researcher, who introduced himself and the goal of the project before the discussion. The participants were invited to speak freely by arguing that there are no right or wrong answers or opinions in this type of research. They were also assured of their anonymity in the use of the collected data. The only rules stated were that the participants let each other finish, for both the clarity of the discussion and also to make transcription and analysis easy. Prior to the beginning of the interviews, an explanation was given in verbal form to each of the study participants and an informed consent was attained. Both the researcher and the participant appended their signatures on the consent form. Sodas and water were provided for the focus group participants and the discussions were 1-2 hours long, were audio recorded and were later transcribed. The whole process of data collection took place from 11th December 2018 to 20th March, 2019.
The researcher used a grounded theory in coming up with research tools. This study focussed on appropriate key areas for conducting feasibility studies, especially; acceptability, practicality and expansion [16].
The research tools were pre-tested in Rugarama sub-county, Ntungamo district, before the commencement of the data collection process. This village was chosen because; (a) although it is close to Kisiizi hospital, it falls outside the catchment area, (b) it represents both insurance members and non- insurance members living in the same village.
Data management, analysis and interpretation
Data was organized into texts in form of stories and stored as computer files and folders. The researcher read through the texts several times so as to make meaning of the entire story before breaking it into parts. The researcher made memos in the margins, which later helped in subsequent data analysis. Concepts were then generated and classified into categories for easy interpretation and comparison. From the different categories, themes were developed and interpreted basing on the researcher’s views and the views expressed in previous studies.
The researcher chose to present empirical data with both quotes from individual participants as well as with excerpts of the discussions between the participants. This was aimed at making the results a more valid reflection of the empirical data. The researcher decided to mark the excerpts from the discussions ‘Member FGD’ or ‘Non-Member FGD’ to represent Focus Group Discussions for insurance members or Non – insurance members respectively. In addition, pseudo names of participants were used, in order to maintain the anonymity of the participants.
Quality control methods
First, the strategy of member checking was applied, where the researcher would recite back the responses in order to seek participant’s clarification before the end of the interview. The second strategy was participant review, where, transcribed information was sent back to some of the participants to seek for their approval if that was a true copy of what was discussed. Thirdly, the researcher adopted a strategy of bracketing, where the researcher’s experiences, beliefs, values and feelings were deliberately put aside in order to accurately describe participants’ opinions and perceptions.
Ethical approval and consent to participate
The study was submitted to and was approved by the Kisiizi Hospital research committee.
Prior to the interviews, an explanation was given in verbal form to each of the study participants and an informed consent was attained. The participants were informed that the information provided would be used by Kisiizi hospital CBHI leadership to design appropriate strategies to scale up CBHI in the local community. The participants were informed of their right to walk out of the interview if they wished to withdraw. Both the researcher and the participant appended their signatures on the consent form.
Consent for Publication
Participants were also informed of the likelihood of publishing the results of this study in international journals.
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.
Desirability of scaling up the Kisiizi Hospital CBHI scheme
First, results show that the Kisiizi hospital CBHI (‘the scheme’) is popular and attracts large support from the local community. This relates to the scheme’s ability to offer financial support to the members in settling hospital bills. Results indicate that membership to the scheme replaced the undesirable traditional methods of raising funds for hospital bills, that is, through sale of family land and property or borrowing at very high interest rates. The study findings agree with Anderson et al (2017) that 53% of the patients getting surgery in Uganda hospitals borrow money to finance their care and 21% sell family property.
Secondly, results indicate that Kisiizi Hospital CBHI contributes towards attainment of the national and international agenda of promoting social protection and fundamental human rights. At national level, the scheme is in line with the Uganda Vision 2040, which identifies 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. At international level, it fulfils the Ouagadougou Declaration which calls for parties to improve, strengthen and extend social protection to all families [17]. The Kisiizi CBHI scheme has provided an opportunity for all people especially the poor to access quality healthcare at low cost.
Thirdly, it is evident that the Kisiizi hospital CBHI ideology and methods of work are similar to the methods, practices and objectives of the local community associations, ‘Engozi groups’ which offer financial and material support to grieving families in times of death of loved ones or even in times of illness. The schemes promotes solidarity, trust and social cohesion within the local community with the aim of eliminating financial barriers to accessing health care. The findings of this study agree with Hendryx et al (2002), that community social capital enables better access to care.
In addition, results indicate that the benefits package offered by Kisiizi hospital CBHI scheme is fairly comprehensive in nature including in-patient, out-patient, maternity and emergency cover and addresses the healthcare needs of the majority of the people in the local communities, although communities continue to demand for cover for chronic illnesses. The findings of this study agree with the findings of Onwujekwe et al (2010) that people in rural areas preferred a benefit package which is comprehensive in nature, offering inpatient, outpatient and emergencies services.
It was established that free hospital services are not available in Rubabo County, since it requires user fees to access services at Kisiizi hospital. However, community members can access free basic healthcare services from the lower health facilities widely available. Scaling up the Kisiizi hospital CBHI scheme gives an opportunity to community members to access Kisiizi hospital services without user fees. It was also evident that most families have to sell family property or borrow funds to finance hospital care. The study findings continue to agree with Anderson et al (2017) that 53% of the patients getting surgery in Uganda hospitals borrow money to finance their care and 21% sell family property. Therefore, scaling up the Kisiizi hospital CBHI scheme provides a favourable health financing alternative to many households which will ultimately save families from selling family property/land or borrow in order to settle hospital bills.
Feasibility of scaling up the Kisiizi Hospital CBHI scheme.
First, it was evident that several development - oriented community associations / groups do exist in the local communities in the form of women, youth or neighbourhood groups. These associations enable community penetration, member enrolment and promotion of the Health insurance agenda. The findings of this study agrees with Mladovsky et al, (2014) that CBHI schemes can build on social capital to increase coverage by enrolling households through community associations.
Secondly, the local community trusts the quality of services at Kisiizi Hospital. This a key factor, which the scheme can build on to enroll many more households and scale up its services. Previous studies indicate that perceptions, attitudes and beliefs about service providers and the insurance scheme strongly influence the households’ decisions to enroll and remain enrolled into the scheme [22].
Thirdly, results show that the annual premium fees and the co-payment fees are affordable to majority of the households in the communities. It was further shown that, the fees were set by members and administrators of the scheme basing on affordability as the only key factor. Existing literature indicates that ability to pay premium and co-payment fees is a strong enabling factor to scheme enrolment [23].
In addition, results indicated that the Kisiizi hospital CBHI is governed by scheme members through an elected executive committee. Through this approach, the members get actively involved in the management of the scheme and this enhances scheme ownership and members’ trust. More to that, the presence of appropriately trained managers working with robust electronic data management system gives the scheme a strong position and enhances sustainability. Previous studies have indicated that; trust in the management of the scheme especially the integrity of the scheme managers strongly influences a household’s decision to enrol into the scheme [24], and having robust management or administrative structures is essential to scheme implementation and influences sustainability of the CBHI schemes [25].
Irrespective of the above facilitators of CBHI implementation and expansion, results show that the scheme continues to face a couple of limitations.
Long distances associated with high transport costs to Kisiizi hospital create a barrier to scaling up the scheme in distant communities. Secondly, a single service provider, located in an isolated community poses a significant barrier to member enrollment especially to people from distant villages. The high costs of transport to Kisiizi hospital mask the visible advantages of scheme membership. This finding is in line with existing literature that large distance to in-network health facilities constitutes a significant obstacle to enrolment, and even a reason for non-renewal of membership into CBHI schemes [24].
More to that, the results show that non-members of the scheme were relatively less knowledgeable about the scheme and held negative beliefs and attitudes towards the scheme. This factor poses a significant threat to scaling up the Kisiizi CBHI scheme. In the same line, existing literature indicates that; scheme members have a better understanding of the mutualist principles than non-members [23], low levels of knowledge leads to doubt and influences negative attitudes towards CBHI schemes [24], and consumer awareness and understanding of the concept of health insurance are significant determinants of scheme uptake [25].
Lastly, results indicate that very poor households and large families have difficulties in meeting subscription fees. Also the requirement to pay fees in one payment and the policy to enrol entire family continue to inhibit subscription and enrolment. Results further show that some families fail to renew membership whenever renewal period overlaps with period when children are returning to school and parents have to pay school fees first. In the same way, existing literature indicates that; families drop out of CBHI schemes due to difficulties to meet subscription fees especially for large families [25], and the policy to enrol an entire family, and the policy of paying in annual premiums fees in one payment constitute significant obstacles especially for large families [24].
This study suggests that the following considerations are critical to CBHI implementation and scale up;
CBHI: Community –Based Health Insurance;
FGD: Focus Group Discussion; KI: Key Informant; UBOS: Uganda Bureau of Statistics
Ugx: Ugandan Shillings; USD: United states Dollars
Ethical approval and consent to participate
The study was submitted for approval to the Kisiizi Hospital research committee. Written consent was obtained from all participants before the interview. The participants were informed that the information provided would be used by Kisiizi hospital CBHI leadership to design appropriate strategies to scale up CBHI in the local community. The participants were informed of their right to walk out of the interview if they wished to withdraw.
Consent for Publication
Participants were also informed of the likelihood of publishing the results of this study in international journals.
Availability of data and material
The datasets used and /or analysed during the study are available from the corresponding author on reasonable request.
Competing interests
The author declares that he has no competing interests.
Funding
The study did not receive any funding
Authors’ contributions
AK analysed the data and interpreted the results, and was a major contributor to the writing of the manuscript. The author read and approved the final manuscript.
Acknowledgements
The author is grateful to God almighty for the provisions during the study. The author would also like to thank the management and staff of Kisiizi hospital health insurance scheme for the co-operation and support rendered during the study.
Author details
The author works with Kisiizi hospital as a Deputy Hospital Administrator/Human resources coordinator. P.o box 109, Kabale.
Table 1: Summary of the participants' background characteristics
|
Gender |
Participant category |
Membership to CBHI |
Village |
|||||
|
M |
F |
KI |
FGD |
Members |
Non-members |
Moderate participation |
Low participation |
Very Low level |
|
19 |
45 |
17 |
47 |
22 |
25 |
18 |
16 |
13 |