Community Based Health Insurance: Kisiizi hospital health society KHHS

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Community Based Health Insurance Kisiizi
hospital health society (KHHS)

• Sebastian Olikira Baine
• Institute of Public Health, Makerere University
• Uganda

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Presentation outline

• Background to KHHS
• Implementation of the KHHS
• Management of the KHHS
• Performance of the KHHS
• Lessons learned
• Future research

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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)

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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.

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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.

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Membership to KHHS

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

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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.

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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.

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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.

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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)

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Managementof 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.

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Management of KHHS contd

• 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.

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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).

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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

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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.

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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).

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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

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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.

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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.