1. Community Based Health Insurance: Kisiizi hospital health society (KHHS) Sebastian Olikira Baine Institute of Public Health, Makerere University Uganda

2. Presentation outline Background to KHHS Implementation of the KHHS Management of the KHHS Performance of the KHHS Lessons learned Future research

3. Background to KHHS KHHS was initiated in 1996 because patients sought health care in advanced stages of their illnesses. Reasons: lack of funds to meet the cost of health services at the hospital seeking cheaper health services (often of poor quality and from untrained health providers)

4. Background to KHHS Some patients escaped from the hospital beds before complete recovery without settling their health care bills. By the end of 1994, unpaid debts by patients accounted for about 2.5% of the total annual recurrent costs of Kisiizi hospital. Pressure of maintaining good quality health services forced the hospital to raise the prices to levels beyond which further increase would retard health service utilisation by the local residents significantly.

5. Implementation & objectives of the KHHS KHHS was launched in September 1996. Community mobilisation/sensitisation on CHI. The overall objectives of KHHS were three fold: to improve access to health services by the local community; to provide a stable source of funding for the hospital; and, to reduce the problem of bad debts.

6. Membership to KHHS KHHS offers the local community registered in Engozi societies the opportunity to join the CBHI scheme. Current enrolment: 18,943

9. Membership Almost all (96%) local residents belong and subscribe to Engozi societies. All members of the Engozi society make regular financial and/or other forms of contributions to the society. Part of the funds accumulated are available for loaning out to members to generate income.

10. Membership Engozi societies are eligible to register with KHHS provided at least 60% of their member families, or 20 families in the case of small Engozi societies are willing to pay premium and co-payments required by KHHS. Engozi societies with less than 20 families on board are not eligible to join KHHS. Families that join KHHS are expected to enroll all family members.

11. Services provided in the KHHS Members can consume all health services offered at the hospital. KHHS does not cover normal deliveries, spectacles, cosmetic dental care, cosmetic surgery, chronic diseases (e.g. DM, HT, Asthma), ambulance services, referral to other providers, private rooms, and self- inflicted health problems.

12. Premiums & co-payments _________________________ F/size Premium ______________________________________ 1-4 UGX 24,000/yr 5-8 UGX 32,000/yr 9-12 UGX 40,000/yr Add. Person: UGX 8,000/yr _________________________ Co-payments: UGX 1,000 (OPD) & 5,000 (Admission)

13. Management of KHHS Each KHHS member family is given an identity card (contains names and photos of all family members). family identity cards and a receipt to show evidence that the family has paid premium are brought to the hospital when a family member is seeking health care,. On arrival at the hospital, the identity cards are checked and members pay the appropriate co-payments.

15. Management of KHHS cont’d KHHS has a computerised administration system which records all members, their premiums and co-payments, service utilisation, and costs of treatment. There are office staffs who manage the day to day running of KHHS, accountable to the overall management of the hospital. The community is involved in the management of KHHS through the chairpersons of Engozi societies who interact with the KHHS office staff on a regular basis.

16. Note: Kisiizi hospital is both the health provider and insurance carrier. Importance: a disincentive for problems associated with insurance (i.e. adverse selection, moral hazards and cost escalation).

17. External assistance Initially, KHHS received technical and financial support from the MOH and DFID. Now it receives support from the Austrian government. Current management by MicroCare

18. Performance of the KHHS The KHHS expenditure was more than the funds generated by the scheme and there is a constant government financial support. Premiums and co-payments are low and cannot generate enough funds to sustain KHHS on its own. Equity is indirectly addressed by keeping the premiums within affordable ranges while the government underwrites the scheme.

19. Lessons learned Continuous mass mobilisation or sensitisation promoted community participation in KHHS Easy access to health services that were once far away from the community Not all community members have understood explicitly the concept of CHI (not all families were enrolled) Cultural or traditional organisations or social organisations that bind their members together can be used as a base for developing sustainable support for CHI (as is the case of KHHS and Engozi societies).

20. Conclusions Given the present (and future) resource constraints upon public expenditure, it is highly unlikely that Uganda can afford to ignore a financing strategy based on multiple sources of funding (including CHI). Need to establish a comprehensive and explicit CHI policy that indicates precisely the strategic intent, process, monitoring and evaluation indicators of the outcomes intended; and also flexible to allow new developments

21. Conclusions Continuous social mobilisation of households about CHI (and health insurance in general) is of paramount importance to overcome the constraint paused by lack of knowledge to community participation which impacts negatively on the viability and sustainability of CHI schemes. Mobilisation of the community promotes sustained use of the health services and support for CHI.

22. Suggestions for future research Price elasticity studies establish the optimum premiums and co-payments in CHI in the informal sector. Qualitative investigations into community perceptions of CHI and their behaviour.