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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
2
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
3
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
4
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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• 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)
7
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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