Presentation Theme

Innovative models for community healthcare financing

Topic Community Health Insurance in

Uganda – successes and challenges Dr. Sam O. Orach

Executive Secretary Uganda Catholic Medical Bureau

Feb 24th 2015

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ACHAP BIENNIAL CONFERENCE - NAIROBI

Innovation • Introduction of new ideas / techniques • The application of better solutions that meet new

requirements, unarticulated needs, or existing market needs

• More effective products, processes, services, technologies

• It should be something new and original coming to that market.

• The idea might not be new but being tried in a new context – Therefore the innovation is the new context. – Or the new context considers the idea / proposed

solution an innovation

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Community Health Financing

• Known by different names:

– Community Health Insurance

– Rural Health Insurance

– Revolving drug funds

– Micro-insurance

– Etc

• Will focus on Community Health Insurance in Uganda

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Innovation in Community Health Financing should aim at:

• Increasing funding for health care while reducing the burden on the individual or family (Financial protection) – Keeping cost-sharing / user fees low

• Increasing population coverage and reduce social exclusion

• Increasing the service package covered • Enable health providers break even or

have surplus • Increase the population’s voice / control

over health care • Enable sustainability of the financing

scheme

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Community Health Insurance in Uganda

• Origin:

– Mainly in western and south-western Uganda

– Now a few cases central region and part of eastern region

– Originated among “Burial groups”

• Instead of collecting for burial to collecting to prevent burial (death)

– Among rural poor

– Also joined by some working class in the rural areas.

– Membership is voluntary

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Four main economic zones

Source: GoU; National Development Plan 2010/11 – 2014/2015

• Providers are non-government facilities

• Mainly the Private-not-for-profit facilities under:

– Uganda Catholic Medical Bureau (UCMB) and

– Uganda Protestant Medical Bureau (UPMB)

• Three types:

– Provider-based or Provider-managed

– Community-based or Community-managed

– Managed by independent agency (micro-finance)

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Types of CHIS in Uganda • But all started as Provider-managed schemes:

– Members pay premiums to the facility / provider

– Provider is able to use the money in advance to procure medicines and supplies (“trade with it”)

– Challenge of this: Situation of abuse observed in some cases

• Provider making high claims to absorb the money collected

• Some providers set high management costs

– UCMB advised against providers managing the schemes – stopped in UCMB facilities

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• Community-managed schemes

– All schemes linked to UCMB facilities

– Challenge of this: Risk of some schemes not paying in time for members treated.

– More cases of health facilities subsiding for scheme members

• Schemes paying less than the poor who could not subscribe to the scheme.

(Study done by Cordaid and UCMB in 2009)

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Benefits experienced

• Communities report reduction in catastrophic health expenditures in households enrolled in CHIS

• Members do not delay in seeking medical care when sick – better health seeking behaviours among CHIS members

• The relationship between communities and health service providers reported to have significantly improved – more participation in health facility decision making

• Relatively reduced rate of patients escaping from hospitals – better completion of payment for treatment

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Community Health Insurance • Challenges

– Poor political will leading to:

– Lack of local / in-country support to provide subsidy to the schemes • Donor dependence

– Inability of communities to match premium with increasing costs of services – resist any rise in premium level

• Premiums often do not cover operational and administrative costs e.g.: – Community mobilisation

– Staff salaries

– Office costs • The financial coverage rate (incl. administration cost) is about 73%

• If administration costs were excluded it could reach 97% coverage

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• Challenges (cont…) – The most poor not able to join the schemes

– Replicability in absence of external support to bridge operational costs is difficult esp. in regions of higher poverty levels (North and East)

– Lack of costing studies to guide reimbursement claims and setting of premiums

• Many health facilities subsidizing for CHIS members

• Esp where the scheme is managed by the communities

• Poor enrolment rates / penetration rates

– A result of poor population understanding and appreciation of health insurance

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• Operating in a “free health care” policy environment – “Free” health services in government facilities

• Leading to Reduced willingness, especially among the rural community to join insurance schemes

• Potential threat from the upcoming National

Health Insurance Scheme (Even though CHIS is part of it) – The formal employed sector will mandatorily

contribute to the Social Health Insurance Scheme – Rural contributors (teachers, nurses etc) may find it

difficult to continue with CHIS (dual subscription) – Leading to lowering of subscriber numbers

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What innovations? • Community Health Financing is itself an

innovation – Amidst inadequate government funding of health

care

• Possible innovations to improve on it: – Introduce performance-based-financing (PBF) in it

• PBF already successfully tried in Uganda

• Will make it more responsive to priorities agreed between providers and scheme members

– Encourage members to form / join community saving and lending schemes

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Conclusion

• Community Health Insurance increases involvement in mobilising resources for their health care

• It is easier to scale up in communities with more expendable money

• Its success so far indicates that if supported by national governments it may be more replicable

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God Bless

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