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. The CBHI concept developed out of a need for financial protection against catastrophic health expenditure 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 health sector. Kisiizi hospital CBHI scheme has 41,500 registered members since 1996, organised in 210 community associations known as ‘Bataka’ or ‘Engozi’ societies. Members pay annual premium fees 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 objectives of; exploring community perceptions and determining acceptability of CBHI, identifying barriers and enablers to scaling up CBHI and documenting lessons regarding CBHI expansion in a rural community. Method: Explorative study using qualitative methods. Key informant interviews and Focus Group Discussions (FGD) were used in data collection. Twenty two key informant interviews were conducted using semi-structured questionnaires. Three FGD for scheme members and three for non-scheme members were conducted. Data was analysed using thematic approach. Results : Conformity with society values and government priorities, a comprehensive package, trusted


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has been staggering at about 30,000 or so people, estimated at about 2% of the catchment population [8].
Sustainability and expansion of these schemes has been hampered by numerous operational challenges including: small budgets, rising healthcare costs, small risk pools, irregular contributions, and overutilization of services [9]. The other limitations relate to scheme enrolment. These include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes [10].
On the other hand, the registered success has been attributed to: community awareness and understanding of CBHI concept, perceived quality of healthcare services and trust in scheme management [9].
The Kisiizi Hospital CBHI scheme was established in 1996. By the end of 2018, the scheme had 41,500 active members registered through 210 community mutual groups called 'Bataka' or 'Engozi' societies in and around Rubabo County. This was an estimate of 30% of the total catchment population.
The scheme was a strategy of reducing the unpaid hospital debts which had risen to about 2.5% of the total annual recurrent hospital costs [11]. The scheme members pay annual premiums and a small co-payment fee before service utilisation.
The primary purpose of this study was to identify and borrow lessons from Kisiizi hospital CBHI which can be applied in similar communities to implement CBHI.
The article is structured in four parts. First part introduces the CBHI concept and the Kisiizi Hospital CBHI scheme. The second section presents research methodology highlighting the study area, process of data collection, and data management and analysis. Results are presented in the third section. The paper is concluded in the fourth part with a short discussion and points out study implications for Kisiizi hospital and policy 5 makers.

Problem statement
The abolition of user-fees in all government health facilities has not promoted equitable access to healthcare services in Uganda [12]. The poor and vulnerable still have limited access to healthcare services, and cost of services is still a key barrier to access to healthcare services [13]. CBHI is being fronted as a mechanism to address these inequities as well as facilitate introduction of a National Health Insurance scheme.

Main objective
To explore whether scaling up CBHI in Rubabo County, Rukungiri District is feasible and desirable considering local community dynamics including funding constraints and society values.

Specific objectives of the study
i. To explore perceptions and determine acceptability of CBHI by community members and leaders.
ii. To identify major barriers and enablers to scaling up CBHI across Rubabo county in Rukungiri district.
iii. To document lessons learnt regarding CBHI expansion in rural communities in Rubabo county, Rukungiri district.

Summary of existing Literature
Scholars suggest a number of frameworks that can be applied to study feasibility and desirability of scaling up a CBHI. One framework emphasize assessment of the conditions in the community, providing critical considerations for making decisions to introduce health insurance ( Figure 1) [14]. The other suggests that scaling up health insurance requires an assessment of social-economic and political situation of the country such as; the size of the informal sector, administrative and management capacities of the health 6 sector, social capital and the existing health infrastructure [15]. In another study, it was suggested that assessment of feasibility and desirability of health insurance requires generating answers to the following questions; (i) How well does the current financing strategy meet the country's overall goals? (ii) Will health insurance help improve achievement of the overall goals, including improving risk pooling and financial protection, and improving citizen's satisfaction? (iii) Will health insurance improve efficiency and equity in financing and service delivery? (iv) What other options exist for improving healthcare financing, and how do they compare with the introduction of health insurance? [16] In another perspective, some scholars have proposed general areas of focus that should be addressed in feasibility studies, including; Acceptability, Practicality and Expansion [17].
This paper adapts a framework developed by Normand and Weber (1994) and applies the considerations highlighted in the decision making phase, in conjunction with the Bowen's key areas of focus to assess the feasibility and desirability of scaling up a CBHI in Rubabo County, Rukungiri district.

Significance for the study
First, the study is expected to contribute to the body of knowledge that other researchers might find helpful in designing their studies. Secondly, the information generated could be valuable to policy makers and technocrats in designing and implementing successful CBHI.
Thirdly, the information generated could be used in development of appropriate health financing policies that promote universal health access. Communities in Uganda could benefit because the subsequent policies and interventions that would be developed could be more responsive to their needs and aligned to their circumstances and contexts.

Methods 7
The study was descriptive in nature, exploring the possibility and attractiveness of CBHI in a rural community, employing qualitative research methods. The explorative approach allowed for gathering in-depth information since health insurance is fairly a new concept in Uganda.
The study was carried out in Rubabo county, Rukungiri district, South Western Uganda.
The county forms the primary catchment area of Kisiizi hospital. The area has an estimated population of 136,200 people, served by one private-not-for -profit hospital and thirty three lower health facilities [18].
The study population included: members and non-members of the scheme, local leaders/ opinion leaders, staff and managers of the scheme, and managers of the District Health department.
Participants were selected from three villages with different levels of insurance coverage, classified as: 'Very low coverage' (up to 19% insurance coverage), 'low coverage' (20 -39 % insurance coverage) and 'moderate coverage' (40 -50 % insurance coverage). None of the villages had an insurance coverage of above 50% [19]. The inclusion of participants from a variety of settings aimed at increasing the validity and credibility of the findings [20]. Data analysis was based on the individual participant opinions and perceptions of the scheme.
Participants were further selected purposively, using criterion sampling technique. The criteria for selection of Focus Group Discussions (FGD) participants was that; one must have lived in the selected village for at least two years. Selection of key informants was based on leadership positions in the target office or in the community and availability and willingness to give detailed interviews.
Face -to -face key informant interviews (KI) were conducted, using semi-structured questionnaires. Participants included; officers from the District Health department, local leaders /community opinion leaders and staff and managers of the scheme.
Mixed gender FGD were conducted. One FGD for scheme members and another for nonscheme members were conducted in each of the villages. Each FGD was composed of sixeight participants.

Ethical considerations
First, the Kisiizi Hospital research and Ethics committee approved the study. Secondly, prior to the interviews, an explanation was given in verbal form to each of the study participants and an informed consent was attained. The participants were informed that the information provided would be used by Kisiizi hospital CBHI leadership to design appropriate strategies to scale up CBHI in the local community. The participants were informed of their right to walk out of the interview if they wished to withdraw. The participants were also informed of the likelihood of publishing the results of this study in international journals. Finally, both the researcher and the participant appended their signatures on the consent form.

Process of data collection
Seventeen (17) face -to -face key informant interviews and six Focus group discussions were conducted. Each FGD had six-eight participants (n = 47) and discussions were held at community centres. The key informant interviews were held at the offices of the respective participants. The researcher used a grounded theory in coming up with research tools. This study focussed on appropriate key areas for conducting feasibility studies, especially; acceptability, practicality and expansion [17]. The grounded theory approach helped the researcher in exploring the participants' perceptions and understanding of the scheme processes, motivations and systems.
Research tools were pre-tested in Rugarama sub-county, Ntungamo district. This village was chosen because; (a) it is close to Kisiizi hospital and falls outside the study area, (b) it represents both scheme members and non-scheme members.

Data management, analysis and interpretation
Data analysis followed the process of transcribing and checking, open coding, identification of patterns/themes and finally summarising the data [22]. The audiorecorded data was converted into written text to facilitate analysis. Coding was done manually. The researcher read through the texts several times so as to make meaning of the entire story before breaking it into parts. The researcher made memos in the margins which helped to identify common words/phrases, and the differences which helped to generate common themes, patterns within the responses. The generated themes were then linked to the study objectives, researcher's views and also in comparison with findings of previous studies.
The researcher chose to present empirical data with both quotes from individual participants as well as with excerpts of the discussions between the participants. This was aimed at making the results a more valid reflection of the empirical data. The researcher decided to mark the excerpts from the discussions 'Member FGD' or 'Non-Member FGD' to represent Focus Group Discussions for insurance members or Non -insurance members respectively. In addition, pseudo names of participants were used, in order to maintain the anonymity of the participants.

Quality control methods
First, the strategy of member checking was applied, where the researcher would recite back the responses in order to seek participant's clarification before the end of the interview. The second strategy was participant review, where, transcribed information was sent back to some of the participants to seek for their approval if that was a true copy of what was discussed. Thirdly, the researcher adopted a strategy of bracketing, where the researcher's experiences, beliefs, values and feelings were deliberately put aside in order to accurately describe participants' opinions and perceptions.

Ethical approval and consent to participate
The study was submitted to and was approved by the Kisiizi Hospital research committee.
Prior to the interviews, an explanation was given in verbal form to each of the study participants and an informed consent was attained. The participants were informed that the information provided would be used by Kisiizi hospital CBHI leadership to design appropriate strategies to scale up CBHI in the local community. The participants were informed of their right to walk out of the interview if they wished to withdraw. Both the researcher and the participant appended their signatures on the consent form.

Consent for Publication
Participants were informed of the likelihood of publishing the results of this study in international journals.

Background characteristics of participants
A total of 64 participants took part in this study. Up to 26.6% (17) were key informants and 73.4% (47) participated in the focus group discussions. Up to 29.7% (19) were males and 70.3% (45) were females. Key informants ranged in age from 27 to 69 (mean = 48).

Conformity with national health policies/guidelines
Participants stated that the scheme's objective of promoting access to quality healthcare services at low cost, is in line with local and national government priority of promoting universal health coverage.

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For instance, Key informants 2, 3, and 5 mentioned that; "The government priority is to promote universal health coverage. The people should be able to access quality healthcare service at low cost".
In addition, Key informant 7 mentioned that; "The Kisiizi hospital CBHI provides an opportunity to all people especially the very poor to get quality services at Kisiizi hospital, at a very low cost"

Conformity with society values and culture
Participants uniformly stated that the scheme's ideology and methods of work are very similar to the methods, practices and objectives of the local community associations which offer financial and material support to grieving families in times of death of loved ones or even in times of illness.
In support of the scheme, key informant 11 (Opinion leader) mentioned that, "The scheme works more like our engozi groups, where we support each other with finances and food items during funerals".

Acceptability of the benefits package
Most of the participants mentioned that the scheme offers insurance cover for common acute illness, accidents/ trauma and maternity services. It was also mentioned that the scheme does not offer cover for high blood pressure and diabetes services. For instance, Anna in FGD2 stated that "Members with hypertension and diabetes should also be given a significant subsidy". Most participants described that, the benefits package meets healthcare needs of most of the people in local communities.

Assessing feasibility of scaling up the Kisiizi Hospital CBHI scheme.
This section presents findings on the practicability of CBHI implementation amidst existing constraints. Feasibility considerations were categorised as either enablers or barriers.

Existing community associations or groups
Participants mentioned that the scheme worked through and with the existing Bataka /Engozi groups to promote the health insurance agenda and to enrol members. For instance, Key informant 2 mentioned that; "It was easy to penetrate the community through the "Engozi" groups, which had to add health insurance into their development agenda"

Affordable premium fees and co-payment fees
It was established that the scheme members pay annual premium fees and the copayment fees. Premium fees range from 11,000 ugx -17,000 ugx (USD 3 -4.7) per year for each member. In addition, the members were required to contribute a co-payment fee It was also established that the scheme office operates an electronic data management system which facilitates member registration, member verification, report processing and control of fraud.
For instance, "We use an electronic system to register and identify valid members whenever they come to the hospital for healthcare services. We are also able to monitor prescription patterns which is key in controlling unnecessary use of services through this electronic system" (Key informant 4).

Long distance and high transport costs to Kisiizi hospital
It was established that Kisiizi hospital is located over 30 Km away from the main road and over 50 Km from the urban centre. Participants uniformly mentioned that it is difficult to travel to and from Kisiizi hospital due to unreliable public transport means. For instance Shallon in non-member FGD 2 mentioned that "It is difficult to travel to and from Kisiizi in the afternoon and night hours". In non-member FGD 3, Timothy mentioned that; "Public transport costs to Kisiizi Hospital for a patient and one care taker are higher than costs of medical care in a nearby clinic"

Low levels of knowledge, negative attitude and beliefs about health insurance
Some participants questioned the motive of pooling funds annually and expressed fears in the accountability of these funds. For instance, Miriam and Tina in Non-member FGD 1, asked that "Where does the money go if one does not get sick throughout the year?" In addition, a few participants claimed to have witnessed segregation of insurance patients from cash -paying patients at Kisiizi hospital. For instance, in Non-member FGD 1, George mentioned that "The health workers at Kisiizi hospital offer better services to patients who pay cash than those in health insurance".

Inability to pay Premium and co-payment fees.
Participants stated that a few families in the local communities have failed to enrol into the scheme due to failure to raise premium fees. Key informant 6 mentioned that "The very poor families especially those that do not belong to community associations cannot afford to pay premium fees".
Secondly, overlapping of school fees periods with membership renewal period was mentioned as another factor for failure to renew scheme membership. Key informant 3, 5, 7 and 11, mentioned that "Some families have dropped out of the scheme due to failure to pay premium fees, especially during periods when children are returning to school".

Desirability of scaling up the Kisiizi Hospital CBHI scheme
First, the participants revealed acceptability and support for the scheme, linked to the scheme's ability to offer financial support to clear hospital bills. Participants testified of 18 having benefited from the financial support from the scheme. It was revealed that the scheme has created an opportunity for the poor to access quality hospital care, which they could not have managed to pay for out -of -pocket. Participants further revealed that scheme members no longer sell family land or borrow funds at high interests in order to settle hospital bills. The study findings agree with previous studies that 53% of the patients getting surgery in Ugandan hospitals borrow money to finance their care and 21% sell family property [23].
Secondly, participants stated that the scheme objectives and processes are in conformity care. The findings of this study agree with previous research that community social capital enables better access to care [25].
Concerning the benefits package, participants largely agreed that the scheme meets healthcare needs of the majority. It offers cover for common illnesses/health conditions.
However, participants recommended for introduction of a subsidy for hypertension and diabetes care. The findings of this study agree with the findings of previous studies that people in rural areas preferred a benefit package which is comprehensive in nature, offering inpatient, outpatient and emergencies services [26].
Regarding the available health financing alternatives, participants revealed that free basic healthcare services are readily available at lower health facilities. However, hospital level services can easily be accessed at Kisiizi hospital which charges user fees. The participants further revealed that, most families raise the required hospital finances through sell of land or property. These findings agree with existing literature that user fees deter utilisation of services, whereas prepayment or insurance schemes offer potential for improving access [27].

Feasibility of scaling up the Kisiizi Hospital CBHI scheme.
First, participants acknowledged that numerous Engozi groups do exist in the local community. The scheme operates through these local associations to promote the Health insurance agenda and enrol members. This was considered as key factor in the success of this scheme. The findings of this study agrees with previous studies that CBHI schemes can build on existing social capital to increase coverage by enrolling households through community associations [25].
Secondly, it was revealed that the local community trusts the quality of services at Kisiizi Hospital. Most participants were comfortable with the level of quality of services at Kisiizi hospital. Previous studies indicate that perceptions, attitudes and beliefs about service providers strongly influence the households' decisions to enrol and remain enrolled into the scheme [26].
Thirdly, participants revealed that insurance fees are affordable to many households in the local community. It was further shown that, the fees were set by members and administrators of the scheme basing on affordability as a key factor. Existing literature indicates that ability to pay premium and co-payment fees is a strong enabling factor to scheme enrolment [8].
In addition, results indicated that the members are actively involved in the management of the scheme through an elected executive committee. The management systems are enhanced with a robust electronic data management system. Previous studies have indicated that; trust in the management of the scheme especially the integrity of the scheme managers strongly influences a household's decision to enrol into the scheme [28], and having robust management or administrative structures is essential to scheme implementation and influences sustainability of the CBHI schemes [9].
Irrespective of the above, expansion of the Kisiizi hospital CBHI scheme continues to face a number of deterrents.
First, most participants mentioned long distances associated with high transport costs to Kisiizi hospital as a key barrier to enrolment especially for distant communities. The high transport costs to and from the hospital masks the visible advantages of scheme membership. This finding is in line with existing literature that large distance to innetwork health facilities constitutes a significant obstacle to enrolment, and even a reason for non-renewal of membership into CBHI schemes [9].
Secondly, a few participants were not very convinced of the reasons for pooling funds in preparation for unforeseen illness, and the subsequent accountability of the funds at the end of a financial year. These statements depict lack of knowledge on the concept of health insurance, especially among non-insured community members. Existing literature indicates that; low levels of knowledge leads to doubt and influences negative attitudes towards CBHI schemes [29], while consumer awareness and understanding of the concept of health insurance are significant determinants of scheme uptake [9].
Lastly, it was revealed that some families are not able to raise premium fees and have failed to enrol into the scheme. It was also discovered that some families drop out of the 21 scheme whenever renewal period overlaps with period when children are returning to school. In the same way, existing literature indicates that families drop out of CBHI schemes due to difficulties to meet subscription fees [30], and the policy to pay annual premiums fees in one payment is a significant obstacle for some families [9].

Strengths and Limitations of the study
The strength of the methodology applied in this research include; involving participants from different communities with different insurance coverage and following the Consolidated criteria for reporting qualitative research -COREQ [31].
This study had several limitations. First, the researcher was new in this field of qualitative research. However the researcher was able to get guidance from existing literature on qualitative studies. Secondly, the researcher never had adequate funds for the study.
This study did not receive any external funding. However, the researcher exercised strict budget control on the available funds. The transcripts were translated into and coded in English language. However, all translations were conducted by a researcher Assistant who is fluent in both local and English languages. The translations were later reviewed by the researcher who is also fluent in both languages.

Implications for policy and practice
CBHI implementation fills the health financing gap in communities with limited free healthcare. However, the following considerations are critical to CBHI implementation and scale up.
First, Policymakers and Scheme implementers should ensure that the scheme objectives and policies are in conformity with culture, society values and government priorities. It also requires a benefits package that observes population preferences and meets the healthcare needs of the majority of the population.
Second, Scheme members must be given opportunities to actively participate in decisions.
This approach enhances trust, accountability, and scheme ownership. Insurance fees should be in ranges affordable to the majority of the community members. Ability to pay insurance fees is a strong enabling factor to scheme enrolment. More to that, communities must be sensitized on CBHI concepts to inform individuals about the scheme and its motivations. Furthermore, the quality of services must be trusted. Perceptions, attitudes and beliefs about services and service providers strongly influence decisions to enrol and remain enrolled into the scheme. This should be enhanced with a large network of service providers/health facilities to allow easy access to care.
Third, strategies to mitigate potential inequities that might result from enrolment or access to services should be put in place. Such strategies might include: Subsidies or fees exemptions especially for the very poor and vulnerable people; and flexible fees payment or renewal policies that are tailored to the context. The study was submitted for approval to the Kisiizi Hospital research committee. Written consent was obtained from all participants before the interview. The participants were informed that the information provided would be used by Kisiizi hospital CBHI leadership to design appropriate strategies to scale up CBHI in the local community. The participants were informed of their right to walk out of the interview if they wished to withdraw.