Determining the willingness to enroll into the proposed contributory National Health Insurance Scheme among public servants working in Gulu City, Northern Uganda

Abstract

Introduction: Uganda is committed to achieving Universal Health Coverage (SDG 3.8) by 2030. While health insurance is key to achieving universal health coverage, it is not yet well developed in Uganda contributing less than 2% of the healthcare financing. Uganda's spending on health is only USD 43 (Ugx 158833.44), and this is far below (WHO) recommended minimum of USD 84 (Ugx 310,279.28) per capita thus creating a USD 41 gap. Out-of-pocket health expenditures remained the major source of health financing at 28% thus limiting access to healthcare.However, only private commercial and community health insurance schemes operate in Uganda with a very minimal population enrolled. Uganda has proposed the establishment of a National Health Insurance Scheme where individuals are expected to contribute premiums to be covered by the scheme. As of 2024, the proposed scheme is yet to be fully approved into law. Objective: The objective of this research was to determine the willingness to enroll into the proposed contributory National Health Insurance Scheme among public servants working in Gulu City, Northern Uganda. Methodology: A cross-sectional study design was conducted among the public servants working in Gulu City. Data was collected on factors influencing willingness to enroll, level of knowledge, perception, and institutional factors. A probability simple random sampling method was used to select 396 public servants and were interviewed using semi-structured questionnaires. Quantitative data was analysed using SPSS statistical software, version 26.0 (IBM). Descriptive statistics and multivariable logistic regression was used to determine the willingness to enroll into the proposed contributory National Health Insurance Scheme and its associated factors among public servants working in Gulu City, Northern Uganda. Additionally, 12 heads of department were purposively selected and interviewed using key informant guide; qualitative data was analysed using thematic content analysis to generate themes. Results: The proportion of the public servants who were willing to enroll for the proposed contributory NHIS was 47.2%. Out of 187/396(47.2%) who expressed WTE, 351/396(88.7%) were willing to pay a maximum of Ugx 29,000 (equivalent to USD 7.90) as the monthly premium. The Willingness to Enroll (WTE) was associated with having chronic illness (AOR 7.114, 95% CI: 2.575-19.656, p-0.001), preferring a monthly premium deductible payment model (AOR, 0.059, 95% CI: 0.010-0.330, p-0.001), quality of diagnostic facilities (AOR 0.399, 95% CI: 0.169-0.945, p-0.037), staff friendliness (AOR 2.690, 95% CI: 0.967-7.487, p-0.058), level of awareness of NHIS (AOR 0.218, 95% CI: 0.108-0.439, p-0.001), and the necessity for stakeholder consultation (AOR 5.437, 95% CI: 1.024-28.876, p-0.047). Conclusion and Recommendations: The predictors that influenced WTE were; having a chronic illness, owning a refrigerator, preferring a monthly premium-deductible payment model, the quality of diagnostic facilities, staff friendliness, awareness of the NHIS, and the necessity for stakeholder consultation. Consequently, the research recommends raising awareness about the proposed contributory NHIS and organizing broader stakeholder consultation meetings to gather their opinions and approval of the NHIS before its legislative enactment.