Community Insurance Bridges Health Care Gap

ISHAKA, UGANDA — Tumuhairwe Ponsiano was down to one cow and two goats.

It was 2007, and he didn’t have cash for medical bills, including his diabetes treatment. So he shed most of his eight cows and eight goats, he says, for prices far below market value. As livestock equates to both income and prestige in Uganda, the sale was wrenching.

“I desperately needed money to access quality treatment,” says Tumuhairwe, 68, who lives on 10 acres in Ryaishe, a remote village in Ishaka district, about 327 kilometers (203 miles) west of Kampala, the nation’s capital.

A year later, he joined a community insurance plan known as Tweragurize. It gave him and his family access to treatment at a local hospital for a fraction of what he paid in 2007.

Such plans, some with thousands of members, are a balm for many Ugandans buckling under medical bills – even in a country that offers free public health care.

The cost of health care threatens to widen Uganda’s inequality gap, as many patients must choose to either pay medical bills or protect their livelihood.

“More than 4% of the [Ugandan] population have been pushed below the poverty line due to health care payments,” says Sarah Byakika, commissioner for planning, financing and policy at the Ministry of Health. “They will sell off their land or animals cheaply to get cash to be able to pay for treatment.”

Nakisanze Segawa, GPJ Uganda

Tumuhairwe Ponsiano sold off some goats and cows to pay medical bills in 2007. Then he joined a community health insurance plan, which he says gives him access to inexpensive, quality care. He uses his coverage to pay for monthly diabetes treatment at a private hospital.

Members of community insurance plans pay an annual fee for health coverage at a network of private hospitals. Some plans cover only routine tests and minor ailments, while others pay for a broader range of treatments, including major surgery.

Those who belong to community plans assail government health centers as inefficient and short-staffed, but they can’t afford private insurance, which can cost up to $80 per month.

A private plan’s monthly premium often dwarfs a community insurance plan’s annual fee. Tumuhairwe, for example, pays 96,000 Ugandan shillings ($25.60) yearly, which covers him and his five family members.

And the coronavirus crisis has heightened the need for affordable, competent care, as Ugandans fend off COVID-19, the disease caused by the virus. As of Sept. 11, Uganda had 4,377 cases and 49 deaths.

Only 1% to 2% of Ugandans use private insurance, according to the National Health Insurance Scheme bill proposed last year, but private care accounts for more than 40% of patients’ total health spending.

Private care can be costly. In a country with a gross domestic product of $777 per capita, a routine gynecological exam may cost $15. A COVID-19 test can run to $60.

Those prices are beyond many rural residents, who often don’t have access to cash. That’s even the case in Ishaka, which boasts large, well-tended matooke (a type of banana) gardens and modern, iron-roofed houses.

Still, some Ugandans avoid public health care, though it’s free.

“I never bothered to go to government health centers because I knew I wouldn’t get the quality of treatment I needed,” Tumuhairwe says. “Accessing doctors and nurses can be a very huge challenge.”

Nuwagaba Ceriano, who also belongs to the Tweragurize plan, shuns public health centers due to long lines and absent staff. Jane Ruth Aceng, Uganda’s health minister, says her agency knows the challenges Ugandans face when they seek government health services.

“We are aware of the long lines, sometimes shortage of drugs, and sometimes absence of staff at the health centers,” she says. “But as a ministry we are working hard to address these challenges.”

A few years ago, Nuwagaba sold four goats to pay for his wife’s surgery at a private hospital. The goats went for a total of 240,000 shillings ($65). Normally they would fetch three times as much.

That drove Nuwagaba to the Tweragurize plan, in which he pays 75,000 shillings ($20) a year for his five family members, including himself.

Like many such plans, the Tweragurize scheme also makes members pay a small fee for every hospital stay.

Moses Friday, programs officer for the Tweragurize plan, says it has 2,607 members. Since its birth in 2007, he says, it has served more than 10,000 people.

Some drop out, Friday says, because they pay premiums but don’t end up using the insurance. Others quit because they can’t afford the annual fee.

Friday says 36% of the plan’s members have sold property to pay health bills.

Uganda has no national health insurance plan, which Byakika says the country needs. Under the National Health Insurance Scheme bill, she says, nearly every Ugandan employed in the formal sector would pay into the plan.

If the law passes, she says, it will slash out-of-pocket medical costs for the poorest Ugandans. “With the proposed health insurance scheme, resources will be pulled together where the rich will help fund treatment of the poor.”

Tumuhairwe says the community insurance plan has freed up funds for other household needs. He also recalls when it rescued him or his relatives.

Eight years ago, he says, a steady, crippling headache left his wife unconscious one morning. He rushed her to a private hospital, where she got treatment, which the plan covered. She recovered.

“Being a member of Tweragurize community has been lifesaving for me and my family,” he says, “because we don’t have to worry about money when we fall sick and don’t have it.”

Alinaitwe Everest translated some interviews from Runyankole.