Micro insurance: saving lives one premium at a time in rural Uganda

A community member approaches the Insurance window at the Kisiizi Community Health Insurance Scheme offices in Rukungiri.

A community member approaches the Insurance window at the Kisiizi Community Health Insurance Scheme offices in Rukungiri (PHOTO/Courtesy)

Clad in a brilliant red scarf, which elegantly drapes around her neck and flows in the gentle breeze, a striped t-shirt clings to her wrinkled frame.

Anosiata Kahara, a sprightly 80-year-old, deftly navigates her compound with the aid of a gnarled walking stick, each step taken with purpose.

Her smooth bare feet seem to have trodden the earth for many decades, each callous ridge a testament to a life lived fully. She wears a black skirt, which billows gracefully in the wind, adorned with a delicate floral pattern, lending a soft femininity to her sturdy frame.

As she strides forward, she carries with her the weight of a rich history and a life filled with tough experiences. “Mwebare kwija,” or “thank you for coming”, she says to welcome her visitors with a gentle smile as we arrive at her home in Kichwamba village in Rukungiri district, South Western Uganda.

She is a beneficiary of the Kisiizi community-based health insurance scheme, one of several micro-insurance schemes in Uganda which cater for low income earners, mostly in rural Uganda.

The Kisiizi scheme was founded by the Kisiizi Hospital, a church of Uganda-founded facility that was established with the aim of improving the health and well-being of the community.

Anosiata’s story is just one of many, each woven together to form a tapestry of hope, resilience and determination in the face of adversity. For Anosiata, enrollment in the Kisiizi community-based health insurance scheme proved to be a life-altering decision.

For just an annual premium of sh41,000 or about 11 US dollars and 13 cents, she was granted access to top-notch medical care. About a year ago, Anosiata was diagnosed with uterus cancer and underwent a total abdominal hysterectomy, a complex procedure involving the removal of her uterus and cervix.

Despite the severity of her illness and the invasive nature of the procedure, Anosiata exudes a sense of resilience and optimism.

She reports feeling much better, with only minor chest and muscle pains as residual symptoms. Her recovery is a testament to the care she received through the micro health insurance scheme and serves as a shining example of its effectiveness. With a beaming smile and a twinkle in her eye, Anosiata confidently states, “I am fine now. I have some back pain but the rest is fine.”

Dr. Henry Lukabwe, an obstetrician at Kisiizi Hospital, explains that without the life-saving surgery, Kahara’s fate would have been dire. The illness would have rapidly spread throughout her abdomen, infecting other vital organs and ultimately claiming her life.

Kahara was required to make a co-payment of sh500,000 ($135.75) to access the procedure; a fee set in place to prevent abuse of the hospital’s insurance scheme.

Despite the cost, Kahara credits the hospital for saving her life and acknowledges that without their assistance, the expenses would have been too overwhelming for her to bear.

The Kisiizi Hospital Health Insurance Scheme, with its 40,000 members, has been successful in reducing catastrophic health expenditure, high mortality rates, and malnutrition. Although the scheme does not cover every illness, its impact on the lives of its members has been substantial.

Dr. Ian Spillman, the Medical Superintendent at Kisiizi Hospital, attributes the positive outcomes of the health insurance scheme to early treatment.

According to him, members of the scheme tend to seek medical attention earlier in the course of their illness, before it becomes severe.

On the other hand, non-members often try alternative methods, leading to delayed presentation and more critical conditions that often require hospital admission.

Moses Mugume, a Senior Administrator at Kisiizi Hospital, recounts the history of the micro health insurance scheme. According to him, the idea originated in the 1990s when the hospital recognized the need for a more comprehensive healthcare solution.

At the time, there were burial groups known as “ëngoozi,” named after the improvised stretchers used to carry deceased individuals. This inspired the hospital to launch the micro health insurance scheme, which has since provided affordable and accessible healthcare to thousands of people.

“So we sold the idea instead of waiting for the person to die, why not pay money upfront to the hospital and comfortably walk into the hospital and get treatment,”Mugume said.

Members of the Kisiizi Community Health Insurance Scheme attend a meeting.

Members of the Kisiizi Community Health Insurance Scheme attend a meeting (PHOTO/Courtesy)

Currently, there are over 213 Community Health Insurance Schemes in Uganda, serving a total of 2,418 families. In Rukungiri and its five neighboring districts, the scheme boasts 38,353 beneficiaries.

The smooth functioning of each group is ensured by a designated member responsible for collecting premiums. The group leaders also form part of a 16-member executive committee, serving as a liaison between the members and the hospital management.

This structure enables effective communication and ensures that the needs and concerns of the members are adequately addressed.

Desusededit Itaazya, an executive member of the Kisiizi Community Health Insurance Scheme, explains the role of the executive committee in relaying information to the members.

He explains that the executive holds meetings with the hospital management, and afterwards, invites the group leaders to attend and share the information with the rest of the community.

“The executive sometimes has meetings with the hospital management. From there the executive invites the group leaders and tell them the same such that group leaders can take the information to the last man in the village,” Itaazya said.

However, promoting a health insurance scheme can be challenging due to regulations that prohibit hospitals from advertising services that require payment. This has left many individuals unaware of the scheme, leading to skepticism among some members of the community.

For those who are unable to pay, the hospital offers a “Good Samaritan Bag” program, equivalent to a clause in the Health Insurance Bill, which caters to indigent individuals who are not required to pay for health services.

In 2010, Bwindi Community Hospital launched a similar scheme, which has since grown to cover 204 groups with 27,022 beneficiaries, making up 34% of the catchment area.

Community health insurance can be replicated through national health insurance policy

The national health insurance bill was passed by parliament on March 31st, 2021 but faced resistance from employers and employees as they were unwilling to make compulsory contributions.

According to the bill formal sector employees (public and private) will contribute 4% of their monthly salary and the Employers will contribute 1% of the employee’s monthly salary. Pensioners will contribute 1% of their monthly pension payment.

This is similar to the National Social Security Fund (NSSF) mandatory national pension plan where employers and employees pay 10% and 5% of gross pay respectively.

The bill was sent back to the Ministry of Health for further review. The former Director General Health Services, at the Ministry of Health, Dr Jack Zaramba, believes that if managed properly, the national health insurance scheme can succeed.

“There was a fear that it would difficult to manage. NSSF is managing. Why is NSSF having the money. All you have to do is place people that will manage it properly. Peg it to NSSF if it requires so,” he said. “If Bwindi can do it, why can’t government do it?”

Organizations like Save for Health Uganda have already rolled out health insurance programs in some parts of the country.

Frederick Makaire, Executive Director of Save for Health Uganda said that one of the most successful micro insurance schemes is the Luwero program which has over 20,000 people.

Makaire thinks that government should change its strategy and create regulations for the community health insurance schemes before rolling out the health insurance scheme.

The success of the community health insurance schemes challenges the government to provide a universal health scheme. However, experts believe that the funding for the sector must be increased significantly for the national health insurance scheme to succeed.

“The community is showing interest in these schemes. The schemes have been here for the last 25 years and they have not stolen anyone’s money. So we could promote those and reach out to the majority of the population, then later on we can harmonize the two groups and achieve the national health scheme,

“If we only think of employers and employees, then we cannot start a national health insurance. We are likely going to wait for another 10-20 years,” Makaire said.

Data from the ministry of health points out that Uganda spends about sh7.5 trillion each year on health. Of this 15% is funded by government, 42% by donors and 41% is contributed by patients out of their pocket. Only 2% is financed through prepayment mechanisms.

Experts say that for the national health insurance scheme to succeed, the sectors funding must be significantly increased to equip the national health facilities which is the possible.

The success of the community health insurance schemes challenges government which has taken long to provide a universal health scheme.

Alhaj Kaddunabbi Lubega, CEO of the industry regulator, the Insurance Regulatory Authority (IRA) said that microinsurance schemes are of particular interest to government as a means of growing coverage.

“This market segment is one of our key focus areas owing to its particular attributes and impact on inclusiveness,” Lubega said, revealing that micro insurance schemes grew 21.6% to sh0.657 billon in 2021.

“This growth is generated mainly from the hitherto an unserved market which is a good indicator of insurance widening,” he explained.

Uganda’s Insurance industry growing

The Insurance Regulatory Authority (IRA) most recent quarterly report indicates that the industry’s total gross written premium for the third quarter of 2022 increased to sh1.08 trillion from sh912 billion, an 18% leap year-on-year.

The story of insurance is incomplete without an account on claims. Claims payment is critical to the insurance value chain as it makes insurance tangible.

“As a regulator, we have instituted measures for zero-tolerance for non payment of legitimate claims. In this regard, it is impressive to note that Gross Claims paid on account of both life and non-life (including Health Mmembership Oorganizations) increased by 27% to sh564.79 billion in 2021,”Kaddunabi said.

He said that total claims paid on the account of agriculture losses alone increased from sh4.116 billion in 2020 to sh7.505billion in 2021. The growth in claims has consistently exceeded the growth in Gross written premiums showing enhanced commitment of players to honour their obligations.

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