Trends in inequality in maternal and child health and health care in Uganda: Analysis of the Uganda demographic and health surveys.

BACKGROUND: Uganda has made great strides in improving maternal and child health. However, little is known about how this improvement has been distributed across different socioeconomic categories, and how the health inequalities have changed over time. This study analyses data from Demographic and Health Surveys (DHS) conducted in 2006, 2011, and 2016 in Uganda, to assess trends in inequality for a variety of mother and child health and health care indicators. METHODS: The indicators studied are acknowledged as critical for monitoring and evaluating maternal and child health status. These include infant and child mortality, underweight status, stunting, and prevalence of diarrhea. Antenatal care, skilled birth attendance, delivery in health facilities, contraception prevalence, full immunization coverage, and medical treatment for child diarrhea and Acute Respiratory tract infections (ARI) are all health care indicators. Two metrics of inequity were used: the quintile ratio, which evaluates discrepancies between the wealthiest and poorest quintiles, and the concentration index, which utilizes data from all five quintiles. RESULTS: The study found extraordinary, universal improvement in population averages in most of the indices, ranging from the poorest to the wealthiest groups, between rural and urban areas. However, significant socioeconomic and rural-urban disparities persist. Under-five mortality, malnutrition in children (Stunting and Underweight), the prevalence of anaemia, mothers with low Body Mass Index (BMI), and the prevalence of ARI were found to have worsening inequities. Healthcare utilization measures such as skilled birth attendants, facility delivery, contraceptive prevalence rate, child immunization, and Insecticide Treated Mosquito Net (ITN) usage were found to be significantly lowering disparity levels towards a perfect equity stance. Three healthcare utilization indicators, namely medical treatment for diarrhea, medical treatment for ARI, and medical treatment for fever, demonstrated a perfect equitable situation. CONCLUSION: Increased use of health services among the poor and rural populations leads to improved health status and, as a result, the elimination of disparities between the poor and the wealthy, rural and urban people. RECOMMENDATION: Intervention initiatives should prioritize the impoverished and rural communities while also considering the wealthier and urban groups.

Feasibility and desirability of scaling up Community-based Health Insurance (CBHI) in rural communities in Uganda: lessons from Kisiizi Hospital CBHI scheme.

BACKGROUND: Community-based Health Insurance (CBHI) schemes have been implemented world over as initial steps for national health insurance schemes. The CBHI concept developed out of a need for financial protection against catastrophic health expenditures to the poor after failure of other health financing mechanisms. CBHI schemes reduce out-of-pocket payments, and improve access to healthcare services in addition to raising additional revenue for the health sector. Kisiizi Hospital CBHI scheme which was incepted in 1996, has 41,500 registered members, organised in 210 community associations known as 'Bataka' or 'Engozi' societies. Members pay annual premiums and a co-payment fee before service utilisation. This study aimed at exploring the feasibility and desirability of scaling up CBHI in Rubabo County, with specific objectives of: exploring community perceptions and determining acceptability of CBHI, identifying barriers, enablers to scaling up CBHI and documenting lessons regarding CBHI expansion in a rural community. METHODS: Explorative study using qualitative methods of Key informant interviews and Focus Group Discussions (FGDs). Seventeen key informant interviews, three focus group discussions for scheme members and three for non-scheme members were conducted using a topic guide. Data was analysed using thematic approach. RESULTS: Scaling up Kisiizi Hospital CBHI is desirable because: it conforms to the government social protection agenda, society values, offers a comprehensive benefits package, and is a better healthcare financing alternative for many households. Scaling up Kisiizi Hospital CBHI is largely feasible because of a strong network of community associations, trusted quality healthcare services at Kisiizi Hospital, affordable insurance fees, trusted leadership and management systems. Scheme expansion faces some obstacles that include: long distances and high transport costs to Kisiizi Hospital, low levels of knowledge about health insurance, overlapping financial priorities at household level and inability of some households to pay premiums. CONCLUSIONS: CBHI implementation requires the following considerations: conformity with society values and government priorities, a comprehensive benefits package, trusted quality of healthcare services, affordable fees, trusted leadership and management systems.

Development of the Kisiizi hospital health insurance scheme: lessons learned and implications for universal health coverage.

BACKGROUND: Kisiizi Hospital Health Insurance scheme started in 1996 to; improve access to health services, and provide a stable source of funding and reduce bad debts to Kisiizi hospital. Objectives of this study were; to describe Kisiizi Hospital Health Insurance scheme and to document lessons learned and implications for universal health coverage. METHODS: This was a descriptive cross-sectional study. Data from different sources were triangulated and thematically analysed. RESULTS: Most households (96%) were organized in Engozi societies (e-Societies), met monthly, and made financial contributions. Cultural solidarity in e-Societies provided a platform for the Kisiizi hospital health insurance scheme establishment, operation and made it compulsory for members. e-Societies disciplinary measures and fear of high out-of-pocket payment for health care enforced enrolment, retention and increased membership. Community sensitisation and community participation in setting premiums and co-payments provided for better understanding of health insurance and rendered them acceptable, affordable and equitable. Membership increased from 330 in 1996 to 38,400 families in 2017. Kisiizi hospital health insurance scheme covered only health services obtained from Kisiizi hospital. Kisiizi hospital health insurance scheme offered no exemption, credit and referral facilities. e-Societies sometimes paid premiums for members from savings and offered them loans to. Kisiizi hospital provided good quality health services, which were easily accessed by insured members. Kisiizi hospital got a stable source of funding and reduced debt burden. CONCLUSIONS: Kisiizi hospital health insurance scheme improved access to health services, provided a stable source of funding and reduced bad debts to the hospital. Internal and external factors to e-Society enforced enrolment and retention of members in Kisiizi hospital health insurance scheme. Good quality health services at Kisiizi hospital demonstrated value for money and offered incentives for enrolment and retention, and coverage expansion. Community sensitization and participation in setting premiums and co-payments rendered Kisiizi hospital health insurance scheme acceptable, affordable and catered for equity. Insured members enjoyed benefits; protection against catastrophic health spending, impoverishment, and easy access to quality health care.