Health Coverage and Financial Protection in Uganda: A Political Economy Perspective.

BACKGROUND: As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. METHODS: The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector. RESULTS: We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. CONCLUSION: By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

Financial protection and coping strategies in rural Uganda: an impact evaluation of community-based zero-interest healthcare loans.

In low- and middle-income countries, catastrophic health expenditures and economic hardship constitute a common risk for households' welfare. Community health financing (CHF) represents a viable option to improve financial protection, but robust impact evaluations are needed to advance the debate concerning universal health coverage in informal settings. This study aims at assessing the impact of a CHF pilot programme and, specifically, of the initial phase involving zero-interest loans on health expenditures and coping strategies in a rural district of Uganda. The analysis relies on a panel household survey performed before and after the intervention and complemented by qualitative data obtained from structured focus group discussions. Exploiting an instrumental variable approach, we measured the causal effect of the intervention, and the main findings were then integrated with qualitative evidence on the heterogeneity of the programme's impact across different household categories. We found that the intervention of zero-interest healthcare loans is effective in improving financial protection and longer-term welfare. Community perceptions suggested that the population excluded from the scheme is disadvantaged when facing unpredictable health costs. Among the enrolled members, the poorest seem to receive a greater benefit from the intervention. Overall, our study provides support for the positive role of community-based mechanisms to progress towards universal coverage and offers policy-relevant insights to timely design comprehensive health financing reforms.

Community perceptions on demand-side incentives to promote institutional delivery in Oyam district, Uganda: a qualitative study.

OBJECTIVE: To examine the perceptions of community members and other stakeholders on the use of baby kits and transport vouchers to improve the utilisation of childbirth services. DESIGN: A qualitative study. SETTING: Oyam district, Uganda. PARTICIPANTS: We conducted 10 focus group discussions with 59 women and 55 men, and 18 key informant interviews with local leaders, village health team members, health facility staff and district health management team members. We analysed the data using qualitative content analysis. RESULTS: Five broad themes emerged: (1) context, (2) community support for the interventions, (3) health-seeking behaviours postintervention, (4) undesirable effects of the interventions and (5) implementation issues and lessons learnt. Context regarded perceived long distances to health facilities and high transport costs. Regarding community support for the interventions, the schemes were perceived to be acceptable and helpful particularly to the most vulnerable. Transport vouchers were preferred over baby kits, although both interventions were perceived to be necessary. Health-seeking behaviours entailed perceived increased utilisation of maternal health services and 'bypassing', promotion of collaboration between traditional birth attendants and formal health workers, stimulation of men's involvement in maternal health, and increased community awareness of maternal health. Undesirable effects of the interventions included increased workload for health workers, sustainability concerns and perceived encouragement to reproduce and dependency. Implementation issues included information gaps leading to confusion, mistrust and discontent, transport voucher scheme design; implementation; and payment problems, poor attitude of some health workers and poor quality of care, insecurity, and a shortage of baby kits. Community involvement was key to solving the challenges. CONCLUSIONS: The study provides further insights into the implementation of incentive schemes to improve maternal health services utilisation. The findings are relevant for planning and implementing similar schemes in low-income countries.

Effects of demand-side incentives in improving the utilisation of delivery services in Oyam District in northern Uganda: a quasi-experimental study.

BACKGROUND: We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda. METHODS: We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention. RESULTS: Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. 'Bypassing' was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6. CONCLUSION: The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system.