Elsevier

Health Policy

Volume 87, Issue 2, August 2008, Pages 172-184
Health Policy

Community health insurance in Uganda: Why does enrolment remain low? A view from beneath

https://doi.org/10.1016/j.healthpol.2007.12.008Get rights and content

Abstract

Community Health Insurance (CHI) in Uganda faces low enrolment despite interest by the Ugandan health sector to have CHI as an elaborate health sector financing mechanism. User fees have been abolished in all government facilities and CHI in Uganda is limited to the private not for profit sub-sector, mainly church-related rural hospitals. In this study, the reasons for the low enrolment are investigated in two different models of CHI. Focus group discussions and in-depth interviews were carried out with members and non-members of CHI schemes in order to acquire more insight and understanding in people's perception of CHI, in their reasons for joining and not joining and in the possibilities they see to increase enrolment. This study, which is unprecedented in East Africa, clearly points to a mixed understanding on the basic principles of CHI and on the routine functioning of the schemes. The lack of good information is mentioned by many. Problems in ability to pay the premium, poor quality of health care, the rigid design in terms of enrolment requirements and problems of trust are other important reasons for people not to join. Our findings are grossly in line with the results of similar studies conducted in West Africa even if a number of context-specific issues have been identified. The study provides relevant elements for the design of a national policy on CHI in Uganda and other sub-Saharan countries.

Introduction

Community Health Insurance (CHI) is seen as a promising mechanism to increase access to health care and to generate additional financial resources for health services [1]. It has an important comparative advantage over user-fees through the pooling of risks and resources it implies [2]. The World Health Organisation has pointed out that in those countries with a small formal sector, the only viable way of promoting pooling of financial reserves is at community level [3].

The current coverage of CHI remains low. There is need to have more insight on why this is so. We hypothesize that people may have rational and understandable reasons for not joining CHI. Studies carried out in West Africa have tried to investigate the causes of this low enrolment. In a study in Burkina Faso, for instance, the low demand for CHI was attributed to institutional rigidities in the timing of the collection of the premium rather than to poverty per se [4]. Another study conducted in Guinea Conakry pointed to the poor quality of care in the health services as one of the main causes of the low and even declining enrolment in CHI despite initial enthusiasm at the set up of the scheme [5]. There are, however, no similar elaborate studies that have been conducted in Uganda or in any other East African country for that matter.

In this paper, the findings of a qualitative study investigating the reasons for the low enrolment are presented. The study explored people's perception of CHI. It also provides useful policy lessons concerning the place and role of CHI in Uganda. This study presents useful insights in the design of interventions aimed at increasing enrolment in CHI.

The paper is structured as follows; the first part of the paper situates Ugandan CHI schemes in a wider international perspective. In the second part, the Ugandan health system is briefly presented and the main features of Ugandan CHI schemes are highlighted. In the third part, we present our research questions in more detail and describe the methodology used in the study. The results and their discussion are then presented in the fourth and fifth part respectively. In our conclusion, we present some of the areas that still remain to be explored in more detail.

Section snippets

Context

The Uganda health care system is pluralistic in nature; it has a public owned sub-system providing 60% of the health units, the Private Not for Profit (PNFP) providing 30% and the remainder (10%) is by the private for profit sub-sector. The PNFP health units are often in remote underserved areas and often the only provider. The total health expenditure in Uganda is estimated to be US$ 20 per capita per annum. Of this, 58% is private out of pocket expenditure, 22% from the government and the

Research questions and methodology

Prior to this research, we carried out a case study evaluation in early 2005 to explore the possible causes of this low enrolment rate in both Ishaka and SHU schemes. Out of this evaluation, we identified five mutually inclusive hypotheses based on users’ perceptions of CHI that could explain the low enrolment in the two Ugandan schemes:

  • (a)

    Lack of information and poor understanding of the concept of CHI (prepayment of the CHI premium, risk pooling of contributions, redistribution of benefits among

Results

The results of all 19 focus groups per scheme were consolidated, except for enumeration, which was done only with the initial 15 focus groups and in-depth interviews per scheme. The responses were quantified, and the figures given in brackets indicate the number of direct quotes that were collected. The quotes in the text are followed by an index in the brackets, which indicate the discussion or interview from which they were collected2

Discussion

There were some methodological limitations in this study. First, there were gender concerns where females could not express themselves freely in presence of father-in-laws or husbands. Nevertheless, in-depth interviews provided a one-on-one session with female interviewees, who brought out most of their concerns. There were difficulties in gathering supplementary discussion groups for sub-population 5 from both schemes. However, the tool used for supplementary focus groups was the same for all

Conclusion

The study provides some elements for inclusion in the development of a national policy on CHI in Uganda, and possibly in other low- or middle-income countries. Such CHI policy could be part of health financing strategic plan with a clear roadmap of how it plans to transit from the current health financing state dominated by inequitable, catastrophic and impoverishing direct out-of-pocket payments to a visionary scenario of universal coverage [20].

The study has validated/invalidated the initial

References (24)

  • Uganda Ministry of Finance Poverty Assessment Report: Government of Uganda;...
  • World Health Organisation. Community based health insurance schemes in developing countries: facts, problems and...
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