By Namiganda Jael
Vicent Mugerwa lost his wife Susan Nanfuma 30, at Luwero hospital on Saturday, February 26th, 2022. Mugerwa checked in his wife who was in labor on Friday 25th. However, doctors pronounced her dead around 10 pm on Saturday night after delivery through a c-section.
Mugerwa painfully recalls the sad incident, he says when his wife checked in the hospital, a doctor asked for UGX 300,000 to conduct a cesarean section on her. “Although I was against paying the money because we were at a government hospital, I gave in to desperation” he explains.
He adds, in addition to rising the amount he was asked for, doctors asked him to look around for the blood because his patient needed it after the operation, he rushed to Bishop Ceaser Asiiri hospital, where he received a phone call informing him that his wife had died. Nanfuma was laid to rest at Wakyato sub-county in Nakaseke district. Mugerwa blames her death on extortion and shortage of medical supplies at Luwero hospital.
Mugerwa’s case is not any different from that of many Ugandans who still languish in public hospitals with little or no assistance at all. The major public complaint about Uganda’s health system is that there are always no medicines in government run hospitals. Uganda suffers a chronic shortage of trained health workers and the few trained doctors keep grumbling over their pay cheque. Brain drain is high in the health sector.
Only 38% of healthcare posts are filled in Uganda. Those health workers within the country, have little incentive to work in poor rural areas. Some 70% of Ugandan doctors and 40% of nurses and midwives are based in urban areas, serving only 12% of the population.
The case is not any different in urban centres where government-run hospitals do not offer better health services. Instead, the rich and those who can afford opt for privately run hospitals which provide better health services. The very rich especially political leaders seek treatment abroad.
Despite record investment over the past five years, Uganda’s healthcare performance is still ranked as one of the worst in the world by the World Health Organisation (WHO). The country is ranked 186th out of 191 nations. Maternal and infant mortality in Uganda are still unacceptably high whereby every day 16 mothers die as they give birth and 131 per 1000 children die before the age of five.
In January 2022, Specioza Nabasinga, 36, also died after delivering at Luwero hospital due to protracted labor, because of the failure of her family to pay UGX 200,000 for medical supplies.
Her husband Laban Otuuka says that Nabasinga checked in for normal delivery but doctors advised her to undergo a cesarean operation on Saturday.According to Otuuka, the doctor asked him to pay UGX 200,000 so as to operate on her wife in vain.
He only managed to raise UGX 100,000 later in the evening. According to Otuuka, although he later paid the money to the doctor to attend to his wife, she passed on due to prolonged labor without attention.
Dr. Steven Magera, the Medical Superintendent of Luwero hospital explained that the hospital faced drug shortages resulting from the delayed supply by the National Medical Stores, adding the money was needed to buy them from a private pharmacy so as to operate on her.
There are so many cases that end tragically like that of Nabasinga and Nanfuma, for those who can afford any alternative, a public hospital in Uganda is not an option. It is in fact considered a death trap.
Hillary Ssempa, for instance, has nothing good to say about government healthcare facilities. For him, their promise of free, quality medical care is hollow. He no longer goes to government health facilities but recalls that whenever he was sick and visited them, he would count himself lucky to find medical workers.
Even then, lab tests could not be done and he would often be referred to buy drugs from private pharmacies, sometimes costing as much as UGX 100, 000. Private healthcare, however, was never an option for him. It was too expensive for him as a low earning small holder farmer in Kihumbagazo village in the western Uganda district of Bushenyi.
The situation worsened when his aging mother started falling sick and her medical care bill mounted. He knew he had to look beyond the usual. He had to look for cheap and effective alternatives. Enrollment on available commercial private health insurance schemes required up to UGX 500, 000 per year for the cheapest bare bones package. Better packages cost millions of shillings.
That is when he was introduced to community health insurance schemes. These are voluntary self-help medical insurance schemes operated by community members for community members. Usually, members must join as a family, pay an agreed sum for a year’s coverage, and get a card that guarantees them service in selected contracted private medical facilities.
Ssempa says the first scheme he joined required only Shs15, 000 per year payable in installments of UGX 5, 000 every four months. But he soon got disillusioned. “The scheme could only cater for simple illnesses like headaches and coughs,” he says.
He later joined Tweragurize Community Health Insurance Scheme. ‘Tweragurize’ literally means ‘Let’s treat ourselves’ and is promoted by Save for Health Uganda, a local Non-Governmental Organization [NGO] .
The organization introduced the Community Health Insurance Scheme in the late 2000s to help poor people access quality health care and protect families against incurring catastrophic medical expenses.
The NGO’s executive director, Fredrick Makaire, says the idea of affordable self-help healthcare schemes was born out of the realization that “many people were dying at home” without care because public health care is almost useless while those who ventured to private hospitals often had to sell family assets to pay up the bills.
According to Makaire, up to 35,000 people are currently enrolled under his organization in eight districts in central and western Uganda. They include Luwero, Nakaseke, Nakasongola, Mubende, Mityana, Sheema, Bushenyi, Mitooma and Masaka.
“We chose to focus on areas where there’s need and the population is interested. We also look at areas where people are able to contribute some bit of money because we only consider private facilities who offer a bit of quality healthcare,” he said.
Tweragurize Community Health Insurance Scheme has 29 families and is part of a bigger scheme in Bushenyi which has 350 members.
Under the plan, each member pays UGX 15, 000 per year. So Ssempa,who has a family of five, pays UGX 75, 000 every year. The scheme has contracts with six private health facilities including Bitooma Missionary Hospital, Ishaka Adventist Hospital, and Mushanga, Kitagata, Bugonji and Nyakashuro health facilities. They treat members without further cost and all the member has to do is show their insurance card.
Those enrolled on the scheme pay their premium through Community Health Schemes at their parish level, which are under the supervision of Save for Health Uganda.
Subscribers to the scheme access health services from 12 health facilities under the Community Health scheme. The facilities include among others Bishop CeaserAsili Memorial Hospital in Luweero district, Kiwoko and Nakaseke Hospitals in Nakaseke district.
Those charged with the responsibility of enrolling new clients and collecting the premiums from old clients mainly use Bodaboda motorcycles and sometimes walk from one client to another for those who can not afford to move especially the elderly but for the rest who can access the community centres, they put up a camp there and announce on local radios or loud speakers calling on those who would wish to join to register as well as the old ones to renew.
This method is conventional because those in villages can hardly access mobile money services or even a simple mobile phone however, for those in urban centers, there are various options including mobile money services or banking.
This is usually done on a quarterly basis. Those visited will be identified prior to the exercise, this allows for easy monitoring, interaction and feed back from members.
He says the organization is one of the over 40 promoters of community health insurance schemes, others include, Health Partners Uganda, the catholic medical bureau and the protestant Medical bureau.
According to Makaire, there are three types of community health schemes namely the member management scheme where community members run it themselves, mobilize themselves, collect and bank the premiums and do the day to day management of the scheme.
The other one is the service provider management scheme, where the health care provider initiates a community health insurance scheme and actually manages it. Also, there is the third party managed scheme where a community asks a third party partner to help with management of the scheme, here, a community owns the scheme but the day to day management function is transferred to a third party under some terms.
He explains that community health insurance schemes were introduced about 20 years ago and currently spread across 40 districts. People covered in those schemes are now about 170, 000 across the country covered under 68 service providers majority of which are private not for profit under the Catholic medical bureau and protestant medical bureau. Only government facilities with a private wing can enroll but these are very few.
“How it works is that under the community based scheme, the community organizes themselves, or with a partner who helps them with administrative work and organizational structures, they sensitize them with health insurance education support, form groups and leadership structures like chairperson, treasurer, and mobilizers who are then trained by the third party partners,” he says
“Once structures are in place they are left to run it on their own and put it in a pool. They mobilize service providers with quality service and close to their location, sign service contracts and then members who contributed to the pool with their family members are given membership cards to just walk to the health facility to get the service.”
Members pay different premiums depending on the social economic status of the community once the pool is formed. Premiums range between UGX10, 000shs to UGX100,000 per year and with this premium, a member accesses services that a facility that has been contracted can offer, the challenge however, is that these facilities do not cover referral. If it is a case they cannot manage, that is where the insurance scheme stops then the patient is on their own wherever they are referred and have to pay out of pocket.
Members have to renew subscription every 12 months. For those who pay very low premium however, there’s a ceiling on services they can get. Those who pay less get a lower amount for treatment every time they seek treatment as compared to those who pay a higher premium.
There are however quite a number of limitations faced according to Makaire, the biggest being, that the policy environment is not favorable because these Community Health Insurance Schemes are not well regulated limiting service provision.
“People trust their local leaders and each time they want to pay, they tend to consult with their leaders but these authorities hesitate to promote these schemes simply because they are not regulated,” Makaire explains.
The second challenge is the contradicting health policy, the free health care policy, technically in the country now, services are supposed to be free and thus people feel like there’s no need to subscribe for an insurance scheme since the services in government hospitals are free yet in reality these services are not available.
The third challenge and reason for the slow progress of the scheme is the low income at house hold level, people who would wish to join the schemes don’t actually have any money to spare and thus stay out. Sometimes the quality of service at those service provider centers is lacking thus discouraging members already enrolled and those who would wish to subscribe.
According to Ssempa, community health insurance is the way to go now to address the dire situation in Uganda’s public health facilities where patients languish with no help and some end tragically. He says many Ugandans ought to embrace the scheme with support from government because this is ideal. “we mustn’t burry our heads in the sun, let us find such workable initiatives for a better health system in this country,” he says.
Mugerwa and Otuuka found out about these schemes way too late after they had lost their loved ones but say it is never too late, they have now subscribed with their community schemes, KibengoAsiikaObulamu Health Scheme in Kikyuusa Sub County in Luweero district and Kikamulo Mukama Akuuma Health Scheme in Kikamulo sub-county respectively.
“It has become easier for me to provide my children with quality health care, my wife left me with five children, I am their primary caretaker and it has been hard getting treatment for all of them yet the government health centers have not been of any help. But now, I can breathe a sigh of relief, this scheme really lifted a weight off my shoulders,” Otuuka exclaims.
According to sister Anestine, the nursing officer at Bishop Ceaser Aisiri hospital in Luwero district which the “Muno mu Bulwadde” community health insurance scheme contracted, the turn up this year has been way higher than last year and the previous years. Families are now enrolling a maximum of five members, every year, an increase from before where one would only enroll themselves or just three members.
She says around 4000 people subscribed this year but since people are now renewing for 2023, the numbers are increasing even more with over 5000 already registered under this scheme although some have dropped out. Sister Anestine says this depends on the economic situation in the community.
“The number has been increasing which prompted the hospital to start up a project to empower our community economically so that the families that enroll in this program not only get some money to enroll on the community health insurance scheme continuously and steadily but also improve in terms of nutrition thus improved health. We provide them with livestock so they get a daily supply of milk and if one’s animal reproduces another female, they are obligated to pass that on to another member and chain continues like that,” she explains.
Sister Anestine says the challenges they face include migration to other places as well as people dropping out of the scheme. She adds that as a health facility, they don’t have any say in how the scheme is managed stressing that “We are contracted because they already have structures as an organization so we just work to ensure that we give quality service and value for money regardless of how poorly the scheme may be managed.”
In regards to payment, the premiums are still low but we have managed to grow because the lowest now pays UGX 35,000 yet we started at UGX 10, 000 and that is for the rural ones, the Semi urban pay between UGX 60, 000 and UGX 80, 000 and those in urban centers pay can pay as much as UGX 100, 000 annually.
“It is little money but we hope that more families will be able to join next year. Our clients are mostly women and children although some families enroll the vulnerable community members like the elderly. We are here to provide a service for all, regardless and that what we continue to do diligently despite the hurdles we meet, a healthy community translates in to economic transformation,” she says.
Makaire calls for introduction of the national health insurance scheme act saying they been waiting for over 20 years, drafting and discussing with many stake holders. “In 2021, March 10th parliament debated this bill and passed it but when it went to the president for assent, he never assented to it and the speaker then, didn’t follow it up, yet president has only 30 stipulated days which elapsed and after that parliament never called back the bill,” he adds.
Makaire explains that when the 11th parliament came, the current speaker Anitah Among ruled that all those bills that were never completed were null and void. The bill is now back to the ministry of health and Makaire is not sure if it is being revised. “We don’t know if our ideas have been incorporated but we have heard that it is being revised to consider all the dissenting voices that had opposed the previous bill,” he says.
Apparently, President Yoweri Museveni hadn’t assented because the manufacturers associations and the employers were not willing to make a contribution for their employees, so they wanted to be exempted from making a contribution for their employees because then the cost of doing business would be higher in addition to their contribution towards the saving scheme NSSF, he notes.
President Museveni reportedly asked the ministry to meet those with dissenting views and harmonize it. The initial suggestion was that both employer and employee make a contribution. Makaire now calls on the ministry to sort these issues out so that the bill is finally passed and assented to.
He also hopes that the role of community health insurance schemes can also be well spelt out and incorporated therein because it has been tried and tested for the past 20 years or so.