Enrolment of beneficiaries.

Regarding member enrolment, the study team found out that there was no harmonized way of enrolling members across the schemes; even within the same type of CBHIS. However, it was established that the unit of enrolment was family (household) and group. In this context, a family is defined as a group of people who eat from the same pot [10]. Individual enrolment was not encouraged except if someone was living alone. Individuals were also allowed to join CBHIS which uses Savings and Credit Cooperatives Organizations (SACCO) to enroll members such as Munno Mu Bulwadde Cooperation Mechanism. Enrolment is voluntary in all types of schemes, and it’s done quarterly, bi-annually, or annually.

Irrespective of scheme type, the promoters first sensitize the target community about general health insurance. The target audience would be informed about the different packages when they agree to join. It was noted that the premium payments and amounts differ across the schemes; the situation was not different even within the same type of schemes. For example, within the provider-managed schemes, some schemes pay quarterly, bi-annually, and annually. The premium payment is charged per person but sometimes, a family premium is designed. Also, to encourage families not to hide some members (adverse selection), they try to reduce the premium of say the 5th plus the additional members. Enrolment was different where a CBHI targeted groups. In a group, families and their members still pay the premiums. However, within groups, its members were allowed to start accessing healthcare if they paid at least 60% to 80% of the expected premiums of all the families and its members. At this time, the families are issued the healthcare access identification card as they pay the balance. It was noted that premiums depended on the existing cost of care. However, the increase is capped at UGX 1,000 = (USD 0.3) and it does not occur every year. Sometimes a CBHI would spend two to three years without changing the premium.

Timing and terms of contributions.

There were differences in the timing of payment across the schemes. The enrolment approach determined the timing for premiums. It was noted that those collecting the premiums on an annual basis, would target to collect premiums during the September to December season. The in-kind payments were not allowed in any type of CBHI because of reported difficulties in computing equivalents in cash. It was also noted that all schemes accept payment in installments.

Accessibility of CBHIS across the different population groups.

The study aimed to explore the accessibility of the CBHIS across different population groups, such as persons with disability, women, children, and other vulnerable populations. The findings showed that all types of CBHI allow everyone to join irrespective of socio-demographic status. Despite this, it was reported that vulnerable and poor people were often left out because they couldn’t afford to pay the premium. Also, the children were not allowed to join independently. It was noted that even though the schemes allowed all families to join; almost all schemes never keep the socio-demographic records. For example, it was difficult to ascertain the actual number of beneficiaries with disability across the board.

Performance of Memorandum of Understanding.

All CBHIS had a formal Memorandum of Understanding (MOU) with service providers. With exception of one scheme, which had delayed paying the provider (had not paid and at the same time did not communicate), other schemes and the service providers were satisfied with the performance of the MOU.

One of the administers for health facility noted that:

“The MOU agreement highlights terms of services including the price. Then after the facility starts to offer the services……they pay based on the service contract and MOU that we have with them. We have never had any problems with them until this year when they delayed paying for 3 months without any communication. But they later paid ……” (Health Facility Administer, 1).

All Memoranda of Understanding were reviewed on an annual basis. It was reported that some beneficiaries complain about the schemes when the terms in MOU are not respected.

“… ..we come here and directly complain. One time I came here, and they billed me wrongly, so I refused to pay. As a leader, if a member gets a problem while here, they phone me, and I came over to a meeting with administrators. We agreed that the facility sends us a monthly invoice within 14 days after the end of the month, so if they do, we scrutinize the bills and pay through the bank.” (Scheme Leader, 2).

Functionality of CBHIS governance, management, and legal structures.

The functionality of the governance structures of CBHIS was assessed in terms of the Board composition and responsibility. The study team assessed whether the external boards of CBHIS were comprised of members drawn from a broad spectrum and were independent of management. The study team also assessed whether the board organized regular and documented meetings with quorum.

Findings from the assessment indicate that generally, the schemes had functional external boards that were comprised of members drawn from a broad spectrum. To a larger extent, the boards were reported to be independent of management. However, among the third party-managed schemes, the independence of the board from management was very limited. It was also reported that in all CBHIS, the boards often held meetings.

Regarding the management structures, the provider-managed CBHIS generally had well-documented organizational structures that were being followed. Both the community and third-party managed schemes had well-documented organizational structures. However, some need to be updated. The organizational structures of the third-party managed schemes were not usually followed.

The study team found that due to financial constraints, both the governance and management structures of the Uganda Community-Based Health Financing Association, at the time of this study, had limited functional capacity. Between March 2014 and 2017, the secretariat was manned by one volunteer staff, and since then, it has been none functional despite the existence of a filled association’s governance structure. The current board (which has 9 members) last held meetings in 2015 and the general assembly was last held in 2013. The organization has a constitution but it’s not being implemented because there are no funds to run the activities.

When asked about the role of the association, one of the key informants narrated:

“……of course, we miss the UCBHFA platform in bringing together the schemes, and right now we are lost like each promoter is doing what they want to do and there is no mechanism for bringing us together. However, UCBHFA was playing a big role and was a platform for regulation, a voice for us as schemes, and giving CBHIS technical support” (Scheme Promoter, 2).

On legal structures, only one out of the seven schemes was fully registered with the district as a Community-Based Organization. The other schemes lacked explicit legal registration and standalone entities. Of these, one scheme had applied for legal status but had not yet been granted at the time of the study. The study found out all seven schemes had constitutions that were amended.

Financial management and internal control structures.

The CBHIS were not managed by registered accountants on a day-to-day basis. However, the schemes relied on accountants from the promoting organizations or the health facility. The study team also found that in the third-party and community-managed CBHIS, the staff of the promoters always audit the CBHIS on an annual basis. Regarding provider-managed schemes, the auditing was part of general health facility auditing and this is mainly external. In the same vein, the provider-managed budgets are incorporated into the health facility’s annual budget.

Strategic planning and sustainability.

The study assessed the existence of reserves, guarantors and re-insurance plans, pooling, and purchasing practices. Each of the provider-managed schemes was found to have a provision for a reserve fund, although more than three-quarters of them were empty.

Only one provider-managed scheme had a guarantor, which was the service provider itself. In this case, it was discovered that when the scheme’s healthcare and reserve funds are depleted before the required period, the facility continues to provide the same services on credit until the expiry of the period. The scheme is then made to pay the debt in the subsequent period of premium payment.

The other schemes depend on the general assembly’s resolution as noted by one of the scheme managers:

“The scheme has a reserve account. However, in case it happens the general assembly and Board of Directors can decide to lobby for other funding from members to top up. It is the responsibility of the secretariat to ensure it does not happen for they are indicators and alert the board; in any case, services must continue to be offered” (Scheme Manager, 3)

All the schemes lacked a re-insurance policy. However, most of the schemes were pooling the funds into one healthcare fund irrespective of the benefit packages.

“It happened to one group, and we asked them to pay a premium top up. We have reserve fund but no re-insurance” (Scheme Manager, 5).

All CBHIS employed a Scheme Manager. Part of the work of this manager is to monitor the healthcare fund utilization on a daily and or monthly basis. Despite this, it was reported that all CBHIS always had their healthcare funds depleted before the required period would end and they rely on reserve funds to enable beneficiaries to complete the coverage period. The depletion was mainly attributed to: (i) the inclusion of mainly the sick; (ii) the increasing cost of healthcare; (iii) and not charging actual premiums due to affordability challenges among other issues.

The practice of risk-pooling and subsides to CBHIS.

Regardless of the unit of enrolment, the amount charged, and the benefits package, all the schemes maintain one pool for all their beneficiaries. This is evidence of both vertical and horizontal subsidization among CBHIS. This was confirmed by several respondents:

“We have a single pool for all groups” (Scheme Manager, KI-7).

“…………we do pool or network the healthcare scheme fund. We have small schemes at the parish level. But, in every region, these come together in a network, and in doing so, they put together all their money into one pool on one account.……. So, this helps to build a bigger pool that is able to pay the healthcare bills of their members without caring much about which scheme has contributed how much. Today, we are able to track and see who is consuming what amount and how much” (Scheme Promoter, KI 17).

Some contracted providers subsidized schemes. Kiwoko hospital gives a 10% deduction on all bills of healthcare from scheme members. It was so far, the only facility that does this.

“… . they give us a discount on each bill when we are paying. So, we don’t pay 100% of the issued bill but 10% less. We deduct it at the time of payment. The scheme managers calculate it. It was initially 5% but it has kept increasing over the years” (Scheme Leader/Beneficiary, KI 11).

Across the schemes, it was reported that promoters support the schemes with some start-up funds. The study also established that the schemes are heavily subsidized by their promoters, especially for administration costs. Apart from one scheme in the Southwestern, the rest had their Scheme Managers paid by the promoters. In addition, the promoters were covering utility bills, equipment, and office and rental space among others. The promoters’ subsidy costs are either from donor funding or facility revenues. The percent deducted from the premiums for administrative costs was generally used to procure scheme identify cards, take pictures of beneficiaries, enrolment costs, and leaders transport costs among other minor expenditures.

The practice of strategic purchasing.

Strategic purchasing was assessed in terms of whether benefit packages were well defined, the existence of gatekeeping, and the prior agreement to the pricing of services. The schemes had a Memoranda of Understanding (MOU) that stipulated the roles and responsibilities of each party in managing, running, provision paying for healthcare and the risks involved. Except in one facility (located in Mubende district) where the CBHI is paying flat fees, the rest of the MOUs don’t pronounce themselves on the pricing of the service. The community and third payment-managed CBHIS presented a clear definition of roles concerning purchasing and service provision. One of the scheme managers had this to say about the MoUs:

“It is the service provider that prepares the package in the MOU and thereafter it is discussed by all parties” (Scheme Manager-KI 5)

With exception of the provider-managed schemes that keep the scheme money, the others pay for service provision every month. The payments would be made after the issuance of bills by the facility, verified by the scheme managers, and approved by scheme leaders or fund managers in the case of community and third-party management respectively. Cheques were normally issued, or money was directly deposited into the facility account. There was no scheme paying cash to the facility as stated by one of the respondents:

“We don’t give money or cash directly; we pay through the bank” (Scheme Leader/Beneficiary, KI 12).

With respect to the benefits package, all three types of CBHIS had well-defined packages. On the other hand, health centers have CBHIS covered for all services provided at the facility. Also, the provider-managed schemes had no gatekeeping. Gatekeeping is used in this study to refer to the principle of when a member of the scheme falls ill or needs to be referred to a higher level of care, he or she contacts the lower level or primary care level first, which in turn authorizes care at a higher level within the scheme network of providers. The scheme member needs a referral from the lower level before seeking care outside the primary care level. In the community and third-party schemes, gatekeeping was feasible. The gate-keeping mechanism was incorporated into the package design. On gatekeeping, one of the Scheme Managers narrated as follows:

“……the beneficiaries choose which lower facilities they will go to first and they also choose the a higher-level facility and, in this case, it’s a hospital. They cannot go to the hospital before they are referred. Otherwise, if they go without a referral, the higher-level facility charges them by increasing the amount of co-payment depending on the cost of care. Say for example if the bill was UGX 50,000 = (USD 13.51) and the co-payment is meant to be UGX 7,000 = (USD 1.9), the provider can choose to charge such a beneficiary around UGX 30,000 = (USD 8.1) for skipping the lower facility. It is working ………the referral network is within our system of healthcare and is discussed with the scheme. It starts from facilities at the lower level of care to our hospital. A referral card is given to the member to help him access the services from one level to another”. (Scheme Manager-KI 13).

Why was integration considered necessary?

When asked about integration and whether they thought it was necessary, all respondents felt that the integration of CBHIS into NHIS was urgently needed. Most of the reasons pointed to the need to accelerate achieving universal health coverage for the majority of the population.

Some of the national and district-level key informants had this to say:

“This country is striving to achieve universal health coverage, but it has failed with the free healthcare provision in public facilities. One way to quicken this is by integrating CBHIS in the proposed NHIS so as to make a contribution to broadening the coverage” (National level, KI 6).

“There are funding gaps in the healthcare system. Yet, the CBHIS provide evidence that a certain population within the informal sector can pay for their healthcare. So, they should be integrated to tap into those resources. Their contribution though small will form additional funds to ameliorating the funding gaps in the health sector” (National level, KI 7).

“The CBHIS are improving access to healthcare for their beneficiaries. But the purpose of NHIS is social protection. So, the government should ensure that CBHIS are integrated into the NHIS to provide social protection to those people in the informal sector” (District level, KI).

However, some views were against the full-scale integration. They felt that integration should be gradual. That is, it should come later after the NHIS has operated for some time as government improves the capacity of service delivery at health facilities.

Some respondents also thought that sharing of resources would be encouraged through cross-subsidization (both vertical and horizontal). Those who have few resources would benefit from those who have much. This would however be realized if one fund is maintained for both formal and CBHIS. On the side of the government, the integration would benefit from building on existing structures that have been around for over 20 years.

“The CBHIS are already trusted, and government can be part of it instead of us coming from NHIS to try to establish from national to the district and lower level which does not enhance ownership. Yet if we work with CBHIS, the ownership sense will be maintained by the grassroot people. This will also be efficient on side of government- since there are certain structures that can be worked on to ensure that the the scheme work well” (Central level, KI 1).

How the integration of CBHIS into NHIS can put on the national agenda?

The majority of the KIIs (65%) felt that this was an important national issue that could easily be mixed up by the politics of the day. Thus, it would be good to discuss the integration of CBHIS into NHIS after election time. At the time of data collection, Uganda was in the process of holding national and local government elections. One of the national level KI explained as follows:

“No one including the members of parliament and the president will allow to discuss such issues at this critical time. No political leader will want to associate with such a discussion at this time. Keep it until after the elections in March 2021, and then bring it. All politicians from local to central level will support it then” (National Level, KI 1).

However, a section of some respondents thought the timing was perfect to present such an issue to the politicians. They noted that the NHIS issue was sighted in the Manifesto of the current president during the three previous presidential election campaigns. Also, experiences from Ghana show that NHIS which includes CBHI was on the political manifesto of one party during the presidential candidate’s campaign at the time. The winning party automatically embraced it as a way of fulfilling its pledge to its people.

“The population can get this issue of integration. They should push for it now and that approach might try to help, after all, user fees abolition was a political pledge also” (National level, KI 1).

Another KI at the National level noted that:

“Even when people think it’s not feasible to present such issues to politicians at this time, I believe it is. Something happens during this political period; sometimes it’s the right period to bring something on the agenda and it gets passed… .… . so, if it’s the agenda of the electorates why do you keep it after elections, yet people are asking, and the politicians are making promises of what to do”.

Also, a National level KI from the civil society supported the idea that integration should be pushed now, and this is how it should be done:

“… . if CBHIS work with Civil Society Organizations (CSOs) and they push the candidate to include CBHIS into the NHIS this might work”.

Several respondents emphasized the need to avail compelling evidence to policymakers about the importance of integrating CBHIS into the NHIS and how feasible it is.

Increasing social acceptability after integration of CBHIS into NHIS.

Among the suggested ways to increase acceptability after the integration of CBHIS into NHIS was to design a specific and attractive benefits package for the formal sector to ensure quality services. The reason given was that this group is comprised of a young population that does not often fall sick, yet the group can contribute more. More suggestions included the need for government to continue investing in community sensitization for demand generation for health insurance and primary health care. Particularly, there were ideas to have well-packaged campaign messages to reach out to the formal sector. It was noted that proper messaging is important to have the formal sector accept subsidizing the informal sector. Some of the respondents at the national level emphasized this point as follows:

“…………. design a message that is easily acceptable to the formal sector. There is no need to tell them outwardly that your premiums will subsidize the informal sector. The emphasis should be on the benefits the formal sector will get yet at the same time you develop a mechanism of having a percentage of every premium paid by the formal sector population to subsidize the informal. The dynamics of how you calculate and subsidize each other should be behind the system but sensitize the formal sector on the benefits of the NHIS” (National level, KI 1).

“The other way is to conduct advocacy; a lot of it with the formal sector to make government and donors appreciate the need for cross-subsidization. Use the CSOs in health to help with this task. Also, sensitize the local communities to understand the purpose of the scheme and its benefits (National level, KI 2).

Suggestions on technical integration.

Three levels of resources or structures for CBHIS that can be incorporated into the integration were identified and presented. The first level comprises the CBHI promoters. These are the civil society organizations or the private sector that implement or support community-based health insurance schemes. Examples are: Save for Health Uganda, Community Based Health Financing Association (UCBHFA), HealthPartners Uganda (HPU), Integrated Community Based Initiatives (ICOBI), Uganda Protestant Medical Bureau (UPMB), Uganda Catholic Medical Bureau, hospitals like the Church of Uganda (COU) Kisiizi Hospital, Bwindi among others. The second level is comprised of community-based health insurance schemes themselves with their governance and management structures. While the third level comprises the community grass-root structures including local people with the necessary skills and knowledge, who are engaged in member enrolment, mobilization, and sensitization for health insurance within the communities.

The respondents made suggestions on how these structures could be integrated and what roles they could play in the integration. For instance, different respondents suggested that CBHI promoters could be taken on board in the integration to continue supporting the existing schemes and scale up their coverage within and beyond the current districts. They could also intensify efforts for health insurance education and community sensitization.

It was established that different strategies are required for the different segments in the informal sector. That is, for those in known and traceable work (organized informal sector) and those who are not easily traceable through occupation (unorganized informal sector). However, important to note is that the CBHIS are currently working with both segments (i.e., the organized groups and those hard to trace through occupation, but often reached through households). The schemes rely on the grass-root people with hands-on skills in mobilization and premium collection to reach these groups. Given this situation, it was strongly suggested that the integration should consider this arrangement and ensure that NHIS works with the current CBHIS grass-root structures to mobilize and collect premiums. They could be named the premium collection agents as one of the key informants pointed out:

“We cannot lose the CBHIS grass-root people who are knowledgeable. I’m thinking that the CBHIS would come with their beneficiaries and say these are the members. So, maybe we would enter an MOU or whichever arrangement and get them to be part of the scheme. So, we can then contract their scheme to do more work and their leaders and scheme managers would then be at the forefront of doing the work upon which we could have agreed upon. I know if the integration happens, then there will be an increased workload, so the current one will be observed but they will not even be enough. We will need more even as the enrolment increases” (Central level KI 1).

Challenges to integration.

When asked about the challenges that could limit the integration, different respondents pointed to the quality of healthcare in both public and private facilities. There were concerns that it would be difficult to satisfy the big number of contributors (from the formal and informal sectors). Further, the capacity of most facilities to manage big numbers of insured patients was reported to be inadequate. To address this, a result-based financing approach to health facilities was proposed.

One of the key informants at the national level responded as follows:

“Our facilities are not able to handle big numbers since there are staff gaps and infrastructural challenges. This is worse when you get into the countryside, as a lot of regional imbalances exist. Yet the insured expects to receive quality services. Ministry of Health needs to first work on this issue……” (National level, KI 2).

It was also reported that integration may be limited by the attitude of service providers and the target consumers themselves. Respondents noted that the commercial health insurance system has distorted the public perception of health insurance. Insurance companies have been delaying paying while peddling a lot of excuses.

Another reported challenge was that CBHIS were few and fragmented with some having very limited capacity and coverage. They also lacked standard guidelines. Moreover, their national association (UCBHFA) was not functional:

“I see challenges in agreeing on what can be integrated. Most of those CBHIS for sure they told you that for us we want to remain the way we are running, alongside the NHIS, let them give us money or let us remain there and compete or if we are to be integrated, then we need a,b,c… . giving unfeasible conditions” (National level, KI-6).

“CBHIS cannot be integrated with their current numbers. Otherwise, taking on the current CBHIS (which has less than 150,000 people) will not make sense at all. If they are to be integrated, then they should be supported to enrol more people in their catchment area to be part of CBHIS. However, the CBHIS are not paying an actual premium, and therefore, what they pay cannot cover them for a full benefits package. Besides, some of the people within their communities are left out because they cannot pay. ……. This might not be an easy task though and it’s not clear if the government has the resources” (National Level, KI-7).

Options on stakeholders and the roles they can play in the integration.

Respondents gave options on who could be involved in the process of integrating CBHIS into NHIS and what roles they can play. The details of the suggested stakeholders and their roles are in S7 Table.

Respondents’ options on lessons learned.

The study documented several lessons learned by CBHIS implementers. First, people join and stay in a CBHI if they are sure of getting quality services. Satisfaction of beneficiaries by offering them quality healthcare is very important in minimizing dropout from CBHI. As such, poor quality of health care is a driver for members to drop out. Even those that might fear joining are enticed to be part of the CBHI. Second, even with low premiums, some families (the poorest of the poor) may still fail to register with the scheme despite their willingness. Third, long distances and high costs of transport to healthcare providers undermine enrolment. Some people were not joining CBHIS whose service providers were perceived to be far especially if they had alternatives. Fourth, some families fail to pay the premiums when they have conflicting interests, especially in school fees payments and festival seasons coinciding with the premium payments period. Whenever CBHI renewal overlaps with school fees paying periods, it affects retention in CBHIS. Normally CBHIS have a grace period of 1 week to 1 month after opening a new year to ensure that such families also pay. Also, fluctuations in incomes and unstable incomes affect renewal because most of the beneficiaries depend on farming. So, whenever there is a poor harvest, they cannot afford the premium and end up dropping out. Fifth, the low insurance literate level of members makes it nearly impossible for them to run the schemes themselves. This is very common in community-managed CBHIS. This implies community members alone may not fully manage the technical aspects of the entire CBHIS.