We Should Promote Community Health Insurance

This article, written by Dr. Ronald M. Kasyaba,  appeared in the Monitor on 18 March 2010
(link to the original article)

The Ministry of Health through the national task force is currently conducting county-wide sensitisation tours, considering stakeholder inputs while simultaneously reviewing the proposed National Health Insurance (NHI) Bill to be presented to Parliament. The national health insurance scheme aims at complementing the existing health care financing gaps, and assuring universal coverage and access to quality, equitable and affordable health care. The scheme intends to begin with formal public sector, contributing four per cent of the employees’ gross salary which will be matched by the employer and subsequently roll out to the formal private, and lastly the informal sector.

It is notable that the majority population who suffer catastrophic health expenditure are the informal sector that the proposed scheme is likely to cover in a decade or so. Community health financing schemes whose primary focus is to provide risk pooling to cover part or all health care costs for the mainly informal sector, have existed in some parts of Uganda for over 10 years, and have significantly contributed to improving rural household health status, and economic portfolios.

The household enrollment capacities of these community health insurance schemes have however been decreasing or remained static partly because of the “free health care policy” in public health facilities, and structural and organisational challenges within schemes. The “free health care policy” has not effectively delivered on its intended goals, partly because of challenges which have resulted in frequent drugs and sundries-stock outs, work-force absenteeism and poor work ethics.

The net effect of this has been deplorably low drug dispensing rates–dispensed versus prescribed drugs, of about 30 per cent or less, compared to 90-98 per cent in Private Not-For-Profit (PNFP) health care facilities, and sky-rocketing out-of-pocket payments for health services (In Uganda it is 55-61 per cent of the total health care expenditure).

It is partly in light of the above that community health schemes (CHIs) have voluntarily continued to exist in partnership with mainly PNFP facilities to afford quality health care and manageable out-of-pocket health expenditure. The forthcoming national health insurance plan should draw on the experience and expertise of existing community health care plans in order to appropriately afford access to quality and equitable health care to the informal sector mainly in rural areas.

The proposed bill should seek to provide a legal framework to the existence of community health insurance schemes, and consolidate their relationship with the NHI while at the same time government strengthens the existing community schemes–which are currently operating mainly on the recruitment of households in organised groups.

Just like SACCOS are being boosted for purposes of rural economic empowerment, the government could explore and encourage the possibility of organised rural groups joining community health insurance schemes. Where they exist in Uganda, community health insurance schemes have equitably improved the health status of households and their subsequent economic mileage. The government should consolidate these gains and expand this concept countrywide.

Dr Kasyaba is a member, Uganda community-based health financing association

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3 thoughts on “We Should Promote Community Health Insurance

  1. Yes, this is a good idea but we need experts like you to help us and find ways of how to start such schemes that really help the poor. There is great need of community awareness needed. Instead of people putting much emphasis on funnel services,must first put emphasis on curative measures before they bury themselves. Pulling together resources may help the weak be helped at their level by putting there standards that suit every one in the community.

  2. This is the greatest of investment that any nation can make, if at all it is desirous of poverty eradication. For long many a people have been duped by “free service delivery by government especially” as the engine for development. Experiences the world over has shown that “free lunch” is poor quality.

    Fast forward, it is important to note that regardless of such an insurance policy if the basics are not set right we will still be spending money that could have otherwise been saved and invested productively. Why? More than 75% of health cases presented to our health facilities are preventable.

    But very importantly, the power of the rural poor has not been well thought through. Many policy makers simply brush them off as needy peasants who only deserve handouts. Contrary to these views and perceptions, many interesting studies now show that these very people we call (lazy) poor are reliable good customers for multinational companies. They know the tag and twigs of money management. The only difference is that theirs is irregular and it flows in small batches (unlike the ones who are able be paid for by their employers all at once or those in the conduits of thievery). The miracles of microfinance and the bottom of the pyramid business revolution can no longer be ignored.

    Thus, the main challenge herein is with getting policy makers and service providers encumbered with misty bigger picture/vision to understand that health insurance can be profitable to private service providers and rewarding to the poor besides enabling government to focus on systems and quality controls. The case you show reveals that there is win-win-win proposition for all actors in the health trade. Unless this key huddle is solved the unending consultations and further studies into a biased health insurance system will be the norm while the deserving poor (our engine for future development dividends) continue to die unaided.
    To end this comment, I wish our economist can reflect on the basic contributions of a healthy people into development and not just as an end of development. A household that spends 8 days in a month responding to disease burden is simply unproductive. When a woman has to care for the sick, she withdraws her labour from tilling the land. This withdrawal will affect food production as well as income. This is the simple puzzle behind small acreage common among smallholder farmers. By releasing this underutilized labour you will be amazed at the increasing acreage as well as the diversification in rural areas. This means food and income security. The point I am emphasizing here is that health, agriculture, and economic development are intertwined. Politiking around just one aspect (common with many policy advocates) is simply unhelpful. We need a mix-mode method that puts the poor at the center of our service delivery while professionally and legally we can fence them.

    Finally, as we wait for the crawling popular policy, it would be prudent to sell your methodology and approach to rural NGOs and service providers so that we can energize the arena with such vivid and impacting actions. GBU

  3. there is need for a clear public-private partnership. also emphasis should not be catholic church ownership like in south western uganda. let the schemes be primarily community owned.

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