Economic analysis of a new four-panel rapid screening test in antenatal care in Kenya, Rwanda, and Uganda.

BACKGROUND: We performed an economic analysis of a new technology used in antenatal care (ANC) clinics, the ANC panel. Introduced in 2019-2020 in five Rwandan districts, the ANC panel screens for four infections [hepatitis B virus (HBV), human immunodeficiency virus (HIV), malaria, and syphilis] using blood from a single fingerstick. It increases the scope and sensitivity of screening over conventional testing. METHODS: We developed and applied an Excel-based economic and epidemiologic model to perform cost-effectiveness and cost-benefit analyses of this technology in Kenya, Rwanda, and Uganda. Costs include the ANC panel itself, its administration, and follow-up treatment. Effectiveness models predicted impacts on maternal and infant mortality and other outcomes. Key parameters are the baseline prevalence of each infection and the effectiveness of early treatment using observations from the Rwanda pilot, national and international literature, and expert opinion. For each parameter, we found the best estimate (with 95% confidence bound). RESULTS: The ANC panel averted 92 (69-115) disability-adjusted life years (DALYs) per 1,000 pregnant women in ANC in Kenya, 54 (52-57) in Rwanda, and 258 (156-360) in Uganda. Net healthcare costs per woman ranged from $0.53 ($0.02-$4.21) in Kenya, $1.77 ($1.23-$5.60) in Rwanda, and negative $5.01 (-$6.45 to $0.48) in Uganda. Incremental cost-effectiveness ratios (ICERs) in dollars per DALY averted were $5.76 (-$3.50-$11.13) in Kenya, $32.62 ($17.54-$46.70) in Rwanda, and negative $19.40 (-$24.18 to -$15.42) in Uganda. Benefit-cost ratios were $17.48 ($15.90-$23.71) in Kenya, $6.20 ($5.91-$6.45) in Rwanda, and $25.36 ($16.88-$33.14) in Uganda. All results appear very favorable and cost-saving in Uganda. CONCLUSION: Though subject to uncertainty, even our lowest estimates were still favorable. By combining field data and literature, the ANC model could be applied to other countries.

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.

Evaluating user experiences of a clearing house for health policy and systems.

BACKGROUND: Timely access to evidence increases the prospects for evidence informed decision making. We evaluated user experiences of a Clearing House for Health Policy with the aim of increasing access to evidence about the Uganda health system and interventions. METHODS: We conducted in-depth interviews with 15 potential users including policymakers, health policy advisors, health managers and researchers to provide evidence on their experience with the clearinghouse. On average participants took 20 minutes to first navigate the site and 45 minutes to perform search tasks and complete the interview. RESULTS: Most respondents successfully searched for information with accuracy and completeness in a short time. Participants commended the performance and expressed high regard for the credibility of the clearinghouse. The majority felt that using the resource was worth their effort. The clearinghouse provided appropriate functionalities for information searching. Navigating and finding information from the site was achievable. However, inadequate background information about the site and lack of current information were widely reported. CONCLUSION: Our paper provides insights on the issues that can be addressed to improve online resources for health policy and system information in a limited resource setting. Users' experience of such resources can be improved by regularly appraising and appropriately indexing the contents, and optimising the capacity to customise information.

NATIONAL FRAMEWORK FOR THE SUSTAINABILITY OF HEALTH KNOWLEDGE TRANSLATION INITIATIVES IN UGANDA.

OBJECTIVES: The aim of this study was to provide evidence about the design and implementation of policies for advancing the sustainability of knowledge translation (KT) initiatives and policies in Uganda's health system. METHODS: We searched for and reviewed evidence about KT sustainability issues in Uganda, the impacts of options, barriers to implementing these options, and implementation strategies to address such barriers. In instances where the systematic reviews provided limited evidence, these were supplemented with relevant primary studies. Documents such as the government reports and unpublished literature were also included in the search. Key informant interviews and a policy dialogue were conducted, and an expert working group guided the study. RESULTS: The KT sustainability issues identified were: the absence of a specific unit within the health sector to coordinate and synthesize research; health worker not familiar with KT activities and not often used. Furthermore, Uganda lacks a mechanism to sustain its current national health frameworks or platforms, and does not have a system to ensure the sustained coordination of existing national health KT platforms. The policy options proposed include: (i) the identification of a KT champion; (ii) the establishment of an operational KT framework; (iii) KT capacity building for researchers and research users, as well as policy and decision makers. CONCLUSIONS: The sustainability of KT will be influenced by the prevailing context and concerns within healthcare both in Uganda and internationally. Furthermore, the availability of resources for KT advocacy, communication, and program design will impact on the sustainability of Uganda's KT activities.

Willingness to pay for National Health Insurance Fund among public servants in Juba City, South Sudan: a contingent evaluation.

BACKGROUND: This study assessed willingness to pay for National Health Insurance Fund (NHIF) among public servants in Juba City. NHIF is the proposed health insurance scheme for South Sudan and aims at achieving universal health coverage for the entire nation's population. One compounding issue is that over the years, governments' spending on healthcare has been decreasing from 8.4% of national budget in 2007 to only 2.2% in 2012. METHODS: A cross-sectional study design using contingent evaluation was employed; data on willingness to pay was collected from 381 randomly selected respondents and 13 purposively selected key informants working for the national, state and Juba County in September 2015. Qualitative data were analysed using conceptual content analysis. T-tests and linear regressions were performed to determine association between WTP for NHIF and independent variables. RESULTS: Up to 381 public servants were interviewed, of which 68% indicated willingness to pay varying percentages of total monthly individual income for NHIF. Over two-thirds (67.8%) of those willing to pay could pay up to 5% of their total monthly income, 22.9% could pay up to 10% and the rest could pay 25%. Over 80% were willing to pay up to 50 SSP (1 USD = 10 SSP) premiums for medical consultation, laboratory services and drugs. The main factors influencing the respondents' decisions were awareness, alternative sources of income, household size, insurance cover and religion. CONCLUSIONS: Willingness to pay is mainly influenced by awareness, alternative sources of individual income, household size, insurance cover and religion. Most of the public servants were aware of and willing to pay for NHIF and prefer a premium of up to 5% of total monthly income. There is need to create awareness and reach out to those who do not know about the scheme in addition to a detailed analysis of other stakeholders. Consideration could be made by the Government of South Sudan to start the scheme at the earliest opportunity since the majority of the respondents were willing to contribute towards it.

Factors influencing cigarette smoking among soldiers and costs of soldier smoking in the work place at Kakiri Barracks, Uganda.

BACKGROUND: Although Uganda has a relatively low prevalence of smoking, no data exists on cigarette use among military personnel. Studies in other countries suggests military service is a risk factor for tobacco use. OBJECTIVES: To assess prevalence and risk factors for and costs of smoking among military personnel assigned to a large military facility in Uganda. DESIGN: A mixed methods study including focus groups, interviews and a cross-sectional survey of military personnel. SETTING: Kakiri Barracks, Uganda. SUBJECTS: Key informants and focus group participants were purposively selected based on the objectives of the study, military rank and job categories. A multistage sample design was used to survey individuals serving in Uganda People's Defense Forces (UPDF) from June to November 2014 for the survey (n=310). RESULTS: Participants in the qualitative portion of the study reported that smoking was harmful to health and the national economy and that its use was increasing among UPDF personnel. Survey results suggested that smoking rates in the military were substantially higher than in the general public (ie, 34.8% vs 5.3%). Significant predictors of smoking included lower education, younger age, having close friends who smoked and a history of military deployment. Estimated costs of smoking due to lost productivity was US$576 229 and US$212 400 for excess healthcare costs. CONCLUSIONS: Smoking rates are substantially higher in the UPDF compared to the general public and results in significant productivity costs. Interventions designed to reduce smoking among UPDF personnel should be included in the country's national tobacco control plan.

Identifying and characterising health policy and system-relevant documents in Uganda: a scoping review to develop a framework for the development of a one-stop shop.

BACKGROUND: Health policymakers in low- and middle-income countries continue to face difficulties in accessing and using research evidence for decision-making. This study aimed to identify and provide a refined categorisation of the policy documents necessary for building the content of a one-stop shop for documents relevant to health policy and systems in Uganda. The on-line resource is to facilitate timely access to well-packaged evidence for decision-making. METHODS: We conducted a scoping review of Uganda-specific, health policy, and systems-relevant documents produced between 2000 and 2014. Our methods borrowed heavily from the 2005 Arksey and O'Malley approach for scoping reviews and involved five steps, which that include identification of the research question; identification of relevant documents; screening and selection of the documents; charting of the data; and collating, summarising and reporting results. We searched for the documents from websites of relevant government institutions, non-governmental organisations, health professional councils and associations, religious medical bureaus and research networks. We presented the review findings as numerical analyses of the volume and nature of documents and trends over time in the form of tables and charts. RESULTS: We identified a total of 265 documents including policies, strategies, plans, guidelines, rapid response summaries, evidence briefs for policy, and dialogue reports. The top three clusters of national priority areas addressed in the documents were governance, coordination, monitoring and evaluation (28%); disease prevention, mitigation, and control (23%); and health education, promotion, environmental health and nutrition (15%). The least addressed were curative, palliative care, rehabilitative services and health infrastructure, each addressed in three documents (1%), and early childhood development in one document. The volume of documents increased over the past 15 years; however, the distribution of the different document types over time has not been uniform. CONCLUSION: The review findings are necessary for mobilising and packaging the local policy-relevant documents in Uganda in a one-stop shop; where policymakers could easily access them to address pressing questions about the health system and interventions. The different types of available documents and the national priority areas covered provide a good basis for building and organising the content in a meaningful way for the resource.

Players and processes behind the national health insurance scheme: a case study of Uganda.

BACKGROUND: Uganda is the last East African country to adopt a National Health Insurance Scheme (NHIS). To lessen the inequitable burden of healthcare spending, health financing reform has focused on the establishment of national health insurance. The objective of this research is to depict how stakeholders and their power and interests have shaped the process of agenda setting and policy formulation for Uganda's proposed NHIS. The study provides a contextual analysis of the development of NHIS policy within the context of national policies and processes. METHODS: The methodology is a single case study of agenda setting and policy formulation related to the proposed NHIS in Uganda. It involves an analysis of the real-life context, the content of proposals, the process, and a retrospective stakeholder analysis in terms of policy development. Data collection comprised a literature review of published documents, technical reports, policy briefs, and memos obtained from Uganda's Ministry of Health and other unpublished sources. Formal discussions were held with ministry staff involved in the design of the scheme and some members of the task force to obtain clarification, verify events, and gain additional information. RESULTS: The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the three phases of development: from 1995 to 1999; 2000 to 2005; and 2006 to 2011. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Stakeholders, notably the private sector, played an important role in influencing the pace of the development process and the currently proposed design of the scheme. CONCLUSIONS: This study underscores the importance of stakeholder analysis in major health reforms. Early use of stakeholder analysis combined with an ongoing review and revision of NHIS policy proposals during stakeholder discussions would be an effective strategy for avoiding potential pitfalls and obstacles in policy implementation. Given the private sector's influence on negotiations over health insurance design in Uganda, this paper also reviews the experience of two countries with similar stakeholder dynamics.

Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective".

Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a National Health Insurance Scheme (NHIS). This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda's experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up NHISs.

Utilization of health insurance by patients with diabetes or hypertension in urban hospitals in Mbarara, Uganda.

BACKGROUND: Diabetes and hypertension are among the leading contributors to global mortality and require life-long medical care. However, many patients cannot access quality healthcare due to high out-of-pocket expenditures, thus health insurance would help provide relief. This paper examines factors associated with utilization of health insurance by patients with diabetes or hypertension at two urban hospitals in Mbarara, southwestern Uganda. METHODS: We used a cross-sectional survey design to collect data from patients with diabetes or hypertension attending two hospitals located in Mbarara. Logistic regression models were used to examine associations between demographic factors, socio-economic factors and awareness of scheme existence and health insurance utilization. RESULTS: We enrolled 370 participants, 235 (63.5%) females and 135 (36.5%) males, with diabetes or hypertension. Patients who were not members of a microfinance scheme were 76% less likely to enrol in a health insurance scheme (OR = 0.34, 95% CI: 0.15-0.78, p = 0.011). Patients diagnosed with diabetes/hypertension 5-9 years ago were more likely to enrol in a health insurance scheme (OR = 2.99, 95% CI: 1.14-7.87, p = 0.026) compared to those diagnosed 0-4 years ago. Patients who were not aware of the existing schemes in their areas were 99% less likely to take up health insurance (OR = 0.01, 95% CI: 0.0-0.02, p < 0.001) compared to those who knew about health insurance schemes operating in the study area. Majority of respondents expressed willingness to join the proposed national health insurance scheme although concerns were raised about high premiums and misuse of funds which may negatively impact decisions to enrol. CONCLUSION: Belonging to a microfinance scheme positively influences enrolment by patients with diabetes or hypertension in a health insurance program. Although a small proportion is currently enrolled in health insurance, the vast majority expressed willingness to enrol in the proposed national health insurance scheme. Microfinance schemes could be used as an entry point for health insurance programs for patients in these settings.

The feasibility analysis of integrating community-based health insurance schemes into the national health insurance scheme in Uganda.

BACKGROUND: Uganda has a draft National Health Insurance Bill for the establishment of a National Health Insurance Scheme (NHIS). The proposed health insurance scheme is to pool resources, where the rich will subsidize the treatment of the poor, the healthy will subsidize the treatment of the sick, and the young will subsidize the treatment of the elderly. However, there is still a lack of evidence on how the existing community-based health insurance schemes (CBHIS) can fit within the proposed national scheme. Thus, this study aimed at determining the feasibility of integrating the existing community-based health financing schemes into the proposed National Health Insurance Scheme. METHODS: In this study, we utilized a multiple-case study design involving mixed methods. The cases (i.e., units of analysis) were defined as the operations, functionality, and sustainability of the three typologies of community-based insurance schemes: provider-managed, community-managed, and third party-managed. The study combined various data collection methods, including interviews, survey desk review of documents, observation, and archives. FINDINGS: The CBHIS in Uganda are fragmented with limited coverage. Only 28 schemes existed, which covered a total of 155,057 beneficiaries with an average of 5,538 per scheme. The CBHIS existed in 33 out of 146 districts in Uganda. The average contribution per capita was estimated at Uganda Shillings (UGX) 75,215 = equivalent to United States Dollar (USD) 20.3, accounting for 37% of the national total health expenditure per capita UGX 51.00 = at 2016 prices. Membership was open to everyone irrespective of socio-demographic status. The schemes had inadequate capacity for management, strategic planning, and finances and lacked reserves and reinsurance. The CBHIS structures included promoters, the scheme core, and the community grass-root structures. CONCLUSION: The results demonstrate the possibility and provide a pathway to integrating CBHIS into the proposed NHIS. We however recommend implementation in a phased manner including first providing technical assistance to the existing CBHIS at the district level to address the critical capacity gaps. This would be followed by integrating all three elements of CBHIS structures. The last phase would then involve establishing a single fund for both the formal and informal sectors managed at the national level.

Community health insurance amidst abolition of user fees in Uganda: the view from policy makers and health service managers.

BACKGROUND: This paper investigates knowledge of Community Health Insurance (CHI) and the perception of its relevance by key policy makers and health service managers in Uganda. Community Health Insurance schemes currently operate in the private-not-for-profit sector, in settings where church-based facilities function. They operate in a wider policy environment where user fees in the public sector have been abolished. METHODS: Semi-structured interviews were conducted during the second half of 2007 with District Health Officers (DHOs) and senior staff of the Ministry of Health (MOH). The qualitative data collected were analyzed using the framework method, facilitated by EZ-Text software. RESULTS: There is poor knowledge and understanding of CHI activities by staff of the MOH headquarters and DHOs. However, a comparison of responses reveals a relatively high level of awareness of CHI principles among DHOs compared to that of MOH staff. All the DHOs in the districts with schemes had a good understanding of CHI principles compared to DHOs in districts without schemes. Out-of-pocket expenditure remains an important feature of health care financing in Uganda despite blanket abolition of user fees in government facilities. CONCLUSION: CHI is perceived as a relevant policy option and potential source of funds for health care. It is also considered a means of raising the quality of health care in both public and private health units. To assess whether it is also feasible to introduce CHI in the public sector, there is an urgent need to investigate the willingness and readiness of stakeholders, in particular high level political authorities, to follow this new path. The current ambiguity and contradictions in the health financing policy of the Uganda MOH need to be addressed and clarified.

Factors influencing cigarette smoking among police and costs of an officer smoking in the workplace at Nsambya Barracks, Uganda.

INTRODUCTION: Studies in several countries indicate that being a police officer is a risk factor for tobacco use. Currently, no such studies have been performed among police officers in Uganda, or in Africa generally. The aim of this study is to assess prevalence and costs of smoking among Ugandan police officers. METHODS: A multistage survey model was employed to sample police officers (n=349) that included an observational cross-sectional survey and an annual cost-analysis approach. The study setting was confined to Nsambya Police Barracks, in Kampala city. RESULTS: Police officers smoke 4.8 times higher than the general public (25.5% vs 5.3%). Risk factors included lower age, higher education and working in guard and general duties units. The findings show that the annual cost of smoking due to productivity loss could be up to US$5.521 million and US$57.316 million for excess healthcare costs. These costs represent 45.1% of the UGX514.7 billion (in Ugandan Shillings, or about US$139.1 million) national police budget in the fiscal year 2018-19 and is equivalent to 0.24% of Uganda's annual gross domestic product (GDP). CONCLUSIONS: Considering these data, prevalence of smoking among police officers are dramatically higher than in the general population. Consequently, smoking in police officers exerts a large burden on healthcare and productivity costs. This calls for comprehensive tobacco control measures designed to reduce smoking in the workplace so as to fit the specific needs of the Ugandan Police Force.

Delays in diagnosis and treatment of pulmonary tuberculosis in patients seeking care at a regional referral hospital, Uganda: a cross sectional study.

OBJECTIVE: A cross-sectional survey involving 134 pulmonary TB patients started on TB treatment at the TB Treatment Unit of the regional referral hospital was conducted to ascertain the prevalence of individual and health facility delays and associated factors. Prolonged health facility delay was taken as delay of more than 1 week and prolonged patient delay as delay of more than 3 weeks. A logistic regression model was done using STATA version 12 to determine the delays. RESULTS: There was a median total delay of 13 weeks and 110 (82.1%) of the respondents had delay of more than 4 weeks. Patient delay was the most frequent and greatest contributor of total delay and exceeded 3 weeks in 95 (71.6%) respondents. At multivariate analysis, factors that influenced delay included poor patient knowledge on TB (adjOR 6.904, 95% CI 1.648-28.921; p = 0.04) and being unemployed (adjOR 3.947, 95% CI 1.382-11.274; p = 0.010) while being female was found protective of delay; adjOR 0.231, 95% CI 0.08-0.67; p = 0.007). Patient delay was the most significant, frequent and greatest contributor to total delay, and factors associated with delay included being unemployed, low knowledge on TB while being female was found protective of delay.

Willingness to pay for Community Health Insurance among taxi drivers in Kampala City, Uganda: a contingent evaluation.

BACKGROUND: Community Health Insurance (CHI) schemes have improved the utilization of health services by reducing out-of-pocket payments (OOP). This study assessed income quintiles for taxi drivers and the minimum amount of premium a driver would be willing to pay for a CHI scheme in Kampala City, Uganda. METHODS: A cross-sectional study design using contingent evaluation was employed to gather primary data on willingness to pay (WTP). The respondents were 312 randomly and 9 purposively selected key informants. Qualitative data were analyzed using conceptual content analysis while quantitative data were analyzed using MS Excel 2016 to generate the relationship of socio-demographic variables and WTP. RESULTS: Close to a half (47.9%) of the respondents earn above UGX 500,000 per month (fifth quintile), followed by 24.5% earning a monthly average of UGX 300,001-500,000 and the rest (27.5%) earn less. Households in the fourth and fifth quintiles (38.4% and 20%, respectively) are more willing to join and pay for CHI. A majority of the respondents (29.9%) are willing to pay UGX, 6,001-10,000 while 22.3% are willing to pay between UGX 11,001 and UGX 20,000 and 23.2% reported willing to pay between UGX 20,001 and UGX 50,000 per person per month. Only 18.8% of the respondents recorded WTP at least UGX 5,000 and 5.8% reported being able to pay above UGX 50,000 per month (1 USD=UGX 3,500). Reasons expressed for WTP included perceived benefits such as development of health care infrastructure, risk protection, and reduced household expenditures. Reasons for not willing to pay included corruption, mistrust, inadequate information about the scheme, and low involvement of the members. CONCLUSION: There is a possibility of embracing the scheme by the taxi drivers and the rest of the informal sector of Uganda if the health sector creates adequate awareness.

Community health insurance in Uganda: why does enrolment remain low? A view from beneath.

Community Health Insurance (CHI) in Uganda faces low enrolment despite interest by the Ugandan health sector to have CHI as an elaborate health sector financing mechanism. User fees have been abolished in all government facilities and CHI in Uganda is limited to the private not for profit sub-sector, mainly church-related rural hospitals. In this study, the reasons for the low enrolment are investigated in two different models of CHI. Focus group discussions and in-depth interviews were carried out with members and non-members of CHI schemes in order to acquire more insight and understanding in people's perception of CHI, in their reasons for joining and not joining and in the possibilities they see to increase enrolment. This study, which is unprecedented in East Africa, clearly points to a mixed understanding on the basic principles of CHI and on the routine functioning of the schemes. The lack of good information is mentioned by many. Problems in ability to pay the premium, poor quality of health care, the rigid design in terms of enrolment requirements and problems of trust are other important reasons for people not to join. Our findings are grossly in line with the results of similar studies conducted in West Africa even if a number of context-specific issues have been identified. The study provides relevant elements for the design of a national policy on CHI in Uganda and other sub-Saharan countries.

Low enrollment in Ugandan Community Health Insurance schemes: underlying causes and policy implications.

BACKGROUND: Despite the promotion of Community Health Insurance (CHI) in Uganda in the second half of the 90's, mainly under the impetus of external aid organisations, overall membership has remained low. Today, some 30,000 persons are enrolled in about a dozen different schemes located in Central and Southern Uganda. Moreover, most of these schemes were created some 10 years ago but since then, only one or two new schemes have been launched. The dynamic of CHI has apparently come to a halt. METHODS: A case study evaluation was carried out on two selected CHI schemes: the Ishaka and the Save for Health Uganda (SHU) schemes. The objective of this evaluation was to explore the reasons for the limited success of CHI. The evaluation involved review of the schemes' records, key informant interviews and exit polls with both insured and non-insured patients. RESULTS: Our research points to a series of not mutually exclusive explanations for this under-achievement at both the demand and the supply side of health care delivery. On the demand side, the following elements have been identified: lack of basic information on the scheme's design and operation, limited understanding of the principles underlying CHI, limited community involvement and lack of trust in the management of the schemes, and, last but not least, problems in people's ability to pay the insurance premiums. On the supply-side, we have identified the following explanations: limited interest and knowledge of health care providers and managers of CHI, and the absence of a coherent policy framework for the development of CHI. CONCLUSION: The policy implications of this study refer to the need for the government to provide the necessary legislative, technical and regulative support to CHI development. The main policy challenge however is the need to reconcile the government of Uganda's interest in promoting CHI with the current policy of abolition of user fees in public facilities.

What are the emerging features of community health insurance schemes in East Africa?

BACKGROUND: The three East African countries of Uganda, Tanzania, and Kenya are characterized by high poverty levels, population growth rates, prevalence of HIV/AIDS, under-funding of the health sector, poor access to quality health care, and small health insurance coverage. Tanzania and Kenya have user-fees whereas Uganda abolished user-fees in public-owned health units. OBJECTIVE: To provide comparative description of community health insurance (CHI) schemes in three East African countries of Uganda, Tanzania, and Kenya and thereafter provide a basis for future policy research for development of CHI schemes. METHODS: An analytical grid of 10 distinctive items pertaining to the nature of CHI schemes was developed so as to have a uniform lens of comparing country situations of CHI. RESULTS AND CONCLUSIONS: The majority of the schemes have been in existence for a relatively short time of less than 10 years and their number remains small. There is need for further research to identify what is the mix and weight of factors that cause people to refrain from joining schemes. Specific issues that could also be addressed in subsequent studies are whether the current schemes provide financial protection, increase access to quality of care and impact on the equity of health services financing and delivery. On the basis of this knowledge, rational policy decisions can be taken. The governments thereafter could consider an option of playing more roles in advocacy, paying for the poorest, and developing an enabling policy and legal framework.