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.

Understanding the limitations of "quasi-mandatory" approaches to enrolment in community-based health insurance: Empirical evidence from Tanzania.

In recent decades, a growing number of low-income countries (LICs) have experimented with voluntary community-based health insurance (CBHI), as an instrument to extend social health protection to the rural poor and the informal sector. While modest successes have been achieved, important challenges remain with regard to the recruitment and retention of members, and the regular collection of membership fees. In this context, there is a growing consensus among policymakers that there is a need to experiment with mandatory approaches towards CBHI. In some localities in Tanzania, local actors in charge of community health funds (CHFs) are now relying on what is best described as quasi-mandatory enrolment strategies, such as increasing user fees for non-members, automatically enrolling beneficiaries of cash transfer programmes and enrolling the exempted groups (people who are entitled to free healthcare). We find that, while these quasi-mandatory enrolment strategies may temporarily increase enrolment rates, dropout and the non-payment of contributions remain important problems. These problems are at least partly related to supply side issues, notably to inadequate benefit packages. Overall, these findings indicate the limitations of any strategy to increase enrolment into CBHI, which is not coupled to clear improvements in the supply and quality of healthcare.