Saving for Health for Informal Workers in Rwenzori region in Uganda

Social protection

Uganda

Background

In Uganda, the burden of family healthcare largely falls on women, many of whom are employed as informal workers. These women face significant challenges in accessing healthcare due to limited financial resources and unstable incomes, often resorting to selling assets or borrowing at high-interest rates to cover health expenses. This results in severe consequences, including loss of life, especially among expectant mothers. In response, Pillar 3 of the Decent Work and Social Protection project has designed an intervention focused on Savings for Health (S4H) to help improve access to health and maternity coverage for informal workers and their families. This is a sustainable strategy to increase access and affordability to health insurance and ensure long-term health security.

The Saving for health initiative is being implemented in 7 districts (Kamwenge, Kabarole, Fort Portal, Kasese, Bundibugyo, Ntoroko and Bunyangabu) of the Rwenzori Region. The initiative aims to promote saving for health among informal workers. The Saving for health initiative is being promoted through existing mature Village Savings and Loan Associations (VSLAs). In July 2023, the project trained and certified 82 Ambassadors who were tasked to roll out the training in Financial Education and Saving for Health to VSLA members. Out of the 82 Ambassadors, 74 are actively using the Financial Education and Health Insurance training manual to conduct training sessions for VSLA members in their respective sub-counties. Currently, 74 Ambassadors are supporting 299 groups (including7,583 members) in saving and borrowing for health related needs. They also gather data on the training sessions delivered and track the financial performance of the VSLAs engaged in Saving for Health. As of March 2024 a total of 194,487,000 had been saved for health by the supported VSLA groups. Overall, the communities are very motivated to save and borrow for health.

Saving for Health Approach

Below is a step by step Approach to the SFH initiative

Development of training curriculum and IEC materials ; the project team, together with a hired consultant developed the financial literacy and saving for health training manual to support the rolling out of trainings to final beneficiaries. The IEC materials included ; poster messages, radio spot messages etc to support in the sensitization in order to reach the 1 million targeted people.

Mapping and selection of areas of operation and potential ambassadors ; The project worked with the district local government to select sub-counties of operation mainly considering the hard to reach areas, areas with limited access to health facilities plus those places with existing VSLAs. During the mapping the district local governement staff supported to identify potential ambassodors.

Training of trainers workshop : using the developed training manual, a team of consultants delivered the training modules to the identified potential ambassadors in a form of a training of trainers workshop.

Certification and allocation of targets to the Ambassodors; The consultants together with the project team assessed the trainee's ability to train and mobilise communities and thereafter selected those that qualified. Targets were allocated to each of the ambassadors.

Community Mobilisation, selection of VSLAs and training ; Ambassodors using the training knowledge rolled out trainings to the selected VSLAs for a period of between 6-8 weeks (one hour per week).

Launch groups to save for health ; after the delivery of trainings, groups are then launched to start saving for health. Groups are provided with counter books to record all financial transactions with respect to saving and borrowing forhealth.

Data collection from the VSLAs ; Ambassodors with support from Enabel Field Officers collect data on the financial performance of the groups. At the end of every quarter, the project is able to know ; how many members are saving , how much has been saved , how much has been borrowed, proportion of savings to women , youth etc. This data is entered in the KOBO tool by the Field Officers and analysed by the monitoring and evaluation team.

It is important to note that the saving for health initiative seeks to motivate communities to save and borrow to meet health related expenses ; with transport being a very huge health related expense. In order to support the groups the huge transportation cost, the project is procuring motorcycles (which is the commonly used form of transport) for the groups on a co-fund basis (80% Enabel contribution & 20% group contribution). Additionally, the project signed a grant with BAMA to support the transportation of expectant mothers and newborns in 2 districts of the Rwenzori region with a lot of synergies. The saving for health initiative is linked to the Community Based Health Insurance intervention that is about to be rolled out. After one year of saving for health, the groups will be introduced to the CBHI approach. Collection of premiums will be easy through the already existing saving for health groups. The project is in the process of signing operational agreements with 2 hospitals to rollout the Community Based Health Insurance Approach to 3,000 people as a pilot. This is a sustainable way of increasing access to health services by the rural population.

Success story from Kyotuha Village Saving and Loan Association

Kyotuha Village Savings and Loans Association (VSLA) in Bweramule Sub-County, Ntoroko district started in 2021 to among other reasons, create opportunities to access capital for investment into development projects such as business and cattle keeping, and address the costs of transport to Bweramule Health Center III and other health facilities accessed by the residents due to the poor road infrastructure in the area. So far, the group has through their savings profits bought materials and fixed a simple makeshift bridge that can only be used by pedestrians and motorcycle riders to access the village.

In September 2023, the group started getting training on financial literacy and saving for health by Kasangaki Edward, an ambassador trained by Enabel to promote saving for health in village savings and loans associations. In the same month, all 33 members of the group comprising 17 females and 16 males had started saving for health. The group now has a total of 8,000,000 UGX saved for health in their account. The group chairperson said that 1,000,000 UGX has been borrowed by 5 group members to meet a health need, 3 of whom have already returned 700,000 UGX in the previous month.

According to the chairperson of the group, Mukume Robert, until the end of last year, they had set the weekly saving for health amount per member to between 2,000 – 5,000 UGX. “With time, we realized that this limited some of the members, so we left it open. Members can now save any amount from 2,000 UGX and above”, said Mukume Robert. The strategy has greatly boosted the group’s health savings among members. “The amount of money people get in a week keeps changing. Someone can save 2,000 UGX today and decide to bring 7,000 UGX the following week. This flexibility is very important for the group and the members”, added the chairperson.

According to the group members, Kyotuha village has for a long time had challenges with access to health services due to the long distance to the nearest health facility. “Transport alone will require at least 40,000 UGX. It even gets worse when you get a referral to either Karugutu Health Center IV or the regional referral hospital in Fort Portal”, said Basemera Teddy, one of the group members. The community remembers a series of cases, some of which ended up being fatal due to delays in accessing health services.

The group chairperson painfully recalls a time when a mother lost her child because a traditional birth attendant did not properly manage the delivery process. “The woman went into labour and the only reliable services were those of a traditional birth attendant”. Said the chairperson. Similarly, another expectant mother ended up giving birth to twins in the hands of unqualified community members after failing to reach the health facility in time. Despite the children being alive, they continue getting frequent health complications which were attributed to the mismanagement at birth.

Currently, Kyotuha Village Savings and Loans Association has 4 expectant mothers who are saving for health. They have saved 734,000 UGX in total for health. With their savings, they are hoping to have access to quality and timely maternity services at Bweramule Health Center III, the only closest facility to their community. “With my savings, I will be able to afford transport to the health center and buy clothes for my baby”, said Kajumba Joselyne, an expectant mother in the group.

Among their plans, the group plans to engage in goat rearing as an income-generating activity to boost their savings and achieve their plans of acquiring motorcycles to transport community members to access medical attention during health emergencies. “Given the current nature of our roads, the only means of transport that can quickly maneuver is a motorcycle, and that is why we want to make these available to our group members”, said Mukume Robert, the group chairperson.

Lessons Learnt with respect to decent work

When women have access to quality healthcare and health innovation, they are better able to access economic power.
Healthy women inevitably participate in the labor force.
Healthy women can be financially independent.
Investing in women’s health is a guaranteed return on investment
Women and girls are expected to predominantly undertake the care and reproductive roles of society – unpaid work.
Engaging in Income Generating Activities such as small businesses and agriculture allows VSLA members to earn additional income beyond their primary sources. This extra income can be allocated towards saving for health.
Diversifying income sources reduces dependency on a single income stream, providing a buffer against income fluctuation and unexpected expenses including health care costs.

Next Step

Roll out community-based health insurance to the groups saving for health.
Scaleup saving for health intervention to Albertine region.
Support (using the co-fund approach) the saving for health groups motorcycle transportation to enhance quick access to health facilities.
Through a grant with BAMA Foundation, a total of 25,000 expectant mothers will be transported from their homes to a health facility to deliver their babies with a skilled mid-wife.