Feasibility and Desirability of Scaling up Community – based Health Insurance (CBHI) in rural communities in Uganda. Lessons from Kisiizi hospital CBHI scheme. ALEX KAKAMA AYEBAZIBW ( [email protected] ) Kisiizi Hospital UGANDA Research article Keywords: Community-based Health Insurance, Universal Health Coverage, Health nancing, Enrolment Posted Date: July 10th, 2019 DOI: https://doi.org/10.21203/rs.2.11192/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Version of Record: A version of this preprint was published on July 17th, 2020. See the published version at https://doi.org/10.1186/s12913-020-05525-7. Page 1/21 Abstract Abstract Background Community-based health Insurance (CBHI) schemes have promoted equitable healthcare access and raised additional revenue for health sector, in addition to forming foundations for National Health Insurance schemes in many countries. Non-prot making organisations characterised by solidarity, voluntary membership and prepayment for health care. Kisiizi hospital CBHI scheme has 41,500 registered members since 1996, organised in 210 community associations known as ‘Bataka’ or ‘Engozi’ societies. Members pay annual premium fees and a co-payment fee before service utilisation. This Study aimed at exploring the feasibility and desirability of scaling up CBHI in Rubabo County, with objectives of; exploring community perceptions and determining acceptability of CBHI, identifying barriers and enablers to scaling up CBHI and documenting lessons regarding CBHI expansion in a rural community. Method: Descriptive study using qualitative methods. Key informant interviews and Focus Group Discussions (FGD) were used in data collection. Participants were selected from three villages with differing levels of insurance coverage. Twenty two key informant interviews were conducted using semi-structured questionnaires. Three FGD for scheme members and three for non-scheme members were conducted. Data was analysed using thematic approach. Results: Scaling up Kisiizi hospital CBHI is desirable because; it conforms to the national social protection agenda, conforms to society values, offers a comprehensive benets package, and is a better healthcare nancing alternative for many households. Secondly, scaling up Kisiizi hospital CBHI is largely feasible since a strong network of community associations exist, trusted quality of services at Kisiizi Hospital, affordable fees, and trusted leadership and management systems. However, scale up of the Kisiizi hospital CBHI is still limited by; long distances and high transport costs to Kisiizi hospital, low levels of knowledge about insurance, overlapping nancial priorities at household level and inability of some households to pay insurance fees. Conclusions CBHI scheme implementation requires the following considerations; Conformity with local society values, conformity with national policies/guidelines, a comprehensive benets package, trusted quality of healthcare services, affordable fees, and trusted leadership and management systems. Key words Community-based Health Insurance, Universal Health Coverage, Health nancing, Enrolment Background 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-prot making agenda [3-4]. Literature indicates that CBHI concept developed out a need for a nancing mechanisms that offers nancial 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 Page 2/21 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 signicantly 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. Specic objectives of the study 1. To explore perceptions and determine acceptability of CBHI by community members and leaders. 2. To identify major barriers and enablers to scaling up CBHI across Rubabo county in Rukungiri district. 3. To document lessons learnt regarding CBHI expansion in rural communities in Rubabo county, Rukungiri district. 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 nancing strategy meet the country‘s overall goals? (ii) Will health insurance help improve achievement of the overall goals, including improving risk pooling and nancial protection, and improving citizen‘s satisfaction? (iii) Will health insurance improve eciency and equity in nancing and service delivery? (iv) What other options exist for improving healthcare nancing, and how do they compare with the introduction of health insurance? Page 3/21 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. Signicance for the study First, the study is expected to contribute to the body of knowledge that other researchers might nd 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 nancing policies that promote universal health access. Communities in Uganda could benet because the subsequent policies and interventions that would be developed could be more responsive to their needs and aligned to their circumstances and contexts. Methods 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