27 questions about the eQuality Health Bwindi scheme

1. 27 questions about the eQuality Health Bwindi scheme Bwindi Community Hospital December 2009

2. Introduction • Bwindi Community Hospital is about to start working together with International Medical Foundation (IMF) to start a health scheme for the people of Kayonza, Mpungu and Kanyantorogo sub-counties of Kanungu District, Uganda • The scheme will benefit an estimated 60,000 people

3. Bwindi Community Hospital • Located in Kanungu District, Uganda • Church of Uganda Hospital. Private-not-for-profit • Highly donor-dependent (largely small donations, with a few larger partners) • 120 staff, including 5 doctors • 200 village health promoters working with the Hospital – one in each village • Annual Report and more information is online at www.BwindiHospital.com

4. Bwindi Community Hospital Vision: • “A healthy and productive community, free from preventable disease and with excellent health services accessible to all”

5. Bwindi Community Hospital Services: • Outpatients, dental and eyes • Adult inpatients and diagnostics • Surgery • Child Health • Community Health & Batwa • HIV/AIDS & TB • Sexual and Reproductive Health

6. Kanungu District • South West Uganda • 95% of households are subsistence farmers • 10 hours from Kampala • Hilly terrain with lots of rain and muddy roads

7. 1. What is the eQuality scheme? • At the moment patients pay a fee for service at Bwindi Community Hospital. So if someone is admitted with pneumonia they pay an admission charge and a charge for drugs • With a health scheme people pay in advance for care. And they pay a flat fee – the same amount for everyone. When they need to come to Hospital they don’t have to pay for drugs or care. They have already paid in advance.

8. 2. What are the advantages of a Health Scheme?

9. 2. What are the advantages of a Health Scheme?(2) • It provides a sustainable source of income to the Hospital from the community

10. 3. Who are IMF? • International Medical Foundation is part of International Medical Group, which also runs International Hospital, Kampala • IMG have experience of delivering quality health care, and also own the health insurance organisations IAA and Microcare • This scheme has been given the name eQuality Health Bwindi

11. eQuality, the Hospital and the Community International Medical Foundation Financial support and performance management eQuality Health Bwindi Pay annual subscription for all Bataka members to… Contract with and pay monthly payments to… Bwindi Community Hospital Community Provide services to…

12. 4. eQuality? Why? • ‘Quality’ because Bwindi Community Hospital and IMF have entered into a partnership to ensure quality health services • ‘Equality’ because all people are given an equal opportunity to join the scheme at a price that is affordable to all • The ‘e’ in eQuality shows that we are using modern electronic technology to collect information and measure the impact of the scheme

13. 5. Who pays who? • The community make payments to eQuality Health Bwindi • Bwindi Community Hospital (BCH) provides services to patients • eQuality Health Bwindi pays BCH according to the delivery of quality standards. Payment is per capita – the Hospital gets a fixed amount per person per year (estimated at UGX 12,000)

14. 6. How much will membership cost families to buy? • Everyone aged 5 or over will pay UGX 6,000 ($3) a year to join the scheme • They will make these payments through their Bataka groups (burial societies) who are used to collecting and saving money • The Bataka has collect money from families and will make the payment to eQuality Health Bwindi for all members at the same time • Children under 5 years will have their premium paid as part of the Child Health Access Project (CHAP), so will not be included in this at the moment

15. 7. CHAP? • This is the project being funded by the Eurochange Charity. • This project was initially for one year, but we are negotiating extending it to three years, and possibly even beyond • It pays the costs of care for about 8000 children under the age of 5 in Kayonza and Mpungu

16. 8. What will membership of the scheme entitle a person to? • Members can able to access most emergency and routine outpatient and inpatient health care at Bwindi Community Hospital including admission to the Hospital, investigations, drugs, eye care, dental services and specialist clinics • Care provided on outreach and at Byumba Health Centre II is covered • Some operations that can be performed in Bwindi (like hernia repair) will be covered

17. 9. Will there be any other charges • Yes, there will be a small charge each time someone uses the service of UGX 1000 (UGX 500 for Batwa and children under 5). 10. Why? • To encourage people to only use the service when they are sick

18. 11. So – antibiotics, multivitamins, x-rays and blood tests for all? • No, it will be very important that the Hospital only gives people medicines that they absolutely need, and keeps investigations to a minimum. • The scheme will fail if over-prescribing and over-investigation happen. • One of the quality standards of the scheme is to reduce unnecessary prescribing • Sometimes people will come to the Hospital and will leave with no medicines, if medicines are not deemed necessary

19. 12. Is there anything not included? • Yes, there are some exemptions: • Maternity care and HIV care are provided for under other schemes within the Hospital, so are not covered under this one • Operations not provided in Bwindi and referral costs are not covered • Expensive drugs like rabies vaccination are not covered • Cosmetic dental work is not covered

20. 13. How do I join? • Individuals and families cannot join – you can only join as part of a group. • More than 95% of people in the area are members of Bataka groups. When the Bataka pays the annual payment for all of its members they can all join • The Bataka head will bring payment to the eQuality office in Bwindi • We should already have your details including your fingerprint. We will just stamp your green book to confirm that you are a member

21. 14. Can someone pay in instalments? • Groups can decide for themselves how to collect payments

22. 15. If a person is not covered will they still get care? • They will still get health care, but their bill is likely to be very large. Our bills will be for the actual cost of care • For example, the average admission to adult ward including drugs and the cost of staff actually costs the Hospital about UGX 150,000 We will charge all of this to uninsured people • Except in the case of life-threatening emergencies, payment will be before seeing a doctor or clinical officer for un-covered people

23. 16. Will staff of BCH have to buy membership for their families? • Staff and their family members who are not part of a Bataka group will have to form a group for payment, as will other people who work in the Bwindi area • We think that staff who are already part of a Bataka group should show leadership and make payments through their Bataka, otherwise it may seem unfair. • Staff will be able to get a refund from the Hospital for the payments that they make for themselves and their immediate families

24. 17. If I pay and don’t use the Hospital, will I get a refund? • No. Some people will incur costs of more than UGX 200,000 and some people will not incur any costs. • This is known as ‘pooling risk’ – the risk of payment is shared among the whole community

25. 18. Will UGX 10,000 per person per year cover all of the costs? • No. Even if 30,000 people join the scheme then they will contribute 30,000 x 6,000 = 180 million per year • The OPD, Surgery and Adult wards in the Hospital will cost more than UGX 500 million to run this year, and we expect them to cost more next year

26. 19. So where will the rest of the money come from? • Grants • Government • Donations

27. 20. Who will run eQuality in Bwindi? • There will be an eQuality office at the Hospital with one employee • This person will collect money on behalf of the scheme, and will make payments to the Hospital. • This person will also monitor the quality of the Hospital

28. 21. Quality of the Hospital? • Availability of doctors and clinical officers • Availability of drugs • Patient satisfaction • Access to care for the poorest • Waiting times for operations All of these things and others will be measured, and the Hospital will only be paid if it is providing high quality care

29. 22. How will the data be captured? • Bwindi Community Hospital already has a population database containing demographic and health information about every person and family in the area • When people join the scheme their membership will be reflected on this system • Fingerprint recognition will be used to confirm identity

30. 22. How will the data be captured? (2) • Every someone uses the Hospital their disease and their treatment will be recorded • GPS coordinates will be used to monitor uptake of the scheme and use of the Hospital • Poverty measurements including income, water and sanitation and food security have already been made • Household data will be updated through an annual household survey

31. 23. Will International Hospital be making a lot of profit from this? • No, this will cost them money at the start (they will make a loss that they will have to raise money for). • The aim is that in the long-term this scheme breaks even (neither make a profit or a loss)

32. 24. So why are International Medical Foundation making an effort to work with Bwindi? • Because they share our vision of: A healthy and productive community, free from preventable disease, and with excellent health services accessible to all • Because they want to learn from this scheme and try to replicate it elsewhere

33. 25. When does all this start? • By the end of December all people in 4 parishes of Kayonza will be registered onto the population database • Children under 5 are already using the scheme • Bataka groups can start paying premiums in January 2010 and using the scheme in February 2010

34. 26. What else needs to happen? • The Hospital needs to continue the computerisation project in OPD and other areas to record usage of the services • James Twebaze is leading a sensitisation programme, starting with local leaders • The Hospital will change its billing system – and increase prices for people who choose not to join the scheme • Prices will remain low for Parishes that we have not yet registered onto the database and until one month after they have registered

35. 27. And the community? • Bataka leaders need to learn all about this scheme and share information • The CAO, LC V and LC III leaders are supporters of this scheme • Groups, not individuals, will make payments to the eQuality scheme. And the groups will be responsible for collection of money • We will begin marketing with posters and leaflets in December

36. Any more questions?