The most significant finding from this study was the low prevalence of health insurance coverage among the study population, 57/723(7.9%), with 42 of 57(73.7%) insured having accepted the COVID-19 vaccine with a mean age of 33.81 years SD+8.863 at 95% CI:31.46-36.16 (Table 1, Table 2). The insured but rejected the COVID-19 vaccine were 15 of 57 (26.3%). On the other hand, the uninsured but accepted the COVID-19 vaccine were 538/723(74.4%) and were younger, with a mean age of 31.15 years SD+10.149 at 95% CI:30.38-31.92 and a median age of 29 years (Figure 1 and Table 1). The insured participants and those without had ages ranging between 18-52 years and 18-75 years, respectively. The Likelihood ratio for COVID-19 vaccine acceptance among the insured was in the age group 9.813; df=4; p=0.044 (Table 1). The most vulnerable participants were widows, divorcees, and marriage separate participants who had no one with insurance coverage. In addition, participants from remote districts of northern Uganda and those without formal education had no insurance coverage too (Table 2). This finding has implications that during the COVID-19 pandemic, these vulnerable groups were adversely affected by the lack of access to health information and services because they had no health insurance coverage.

According to the WHO, Universal health coverage means that everyone has access to the health services they need, when and where they need them, without financial hardships [2]. It includes a full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care [1,2]. In addition, Universal health coverage (UHC) ensures that people have access to the healthcare they need without suffering financial hardships [1,2,4]. UHC is also critical for achieving the World Bank Group’s (WBG) twin goals of ending extreme poverty and increasing equity and shared prosperity [1]. Ending extreme poverty and increasing equity are the driving forces behind the WBG’s health and nutrition investments [1].

Currently, at least half of the world’s population does not receive the health services they need [1,4,11,12]. About 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on health [1,4]. To make health a reality for all, individuals, and communities with access to high-quality health services for taking care of their health and the health of their families are necessary. Skilled health workers provide quality, people-centered care, and policymakers are committed to investing in universal health coverage [1,2,12]. Universal health coverage must be strong, people-centered primary health care with sound health systems rooted in the communities they serve [1,11,12]. They focus not only on preventing and treating diseases and illnesses but on helping to improve the general well-being and quality of life [1,2].

Our study found that the most vulnerable participants, such as widows, divorcees, and married separate, had no health insurance coverage (Table 2). In addition, participants from remote districts of northern Uganda and those without formal education were not insured (Table 2). The lack of health insurance coverage among most of the study participants has implications. During the COVID-19 pandemic, the population was adversely affected by a lack of access to health information and services, usually available to those with health insurance coverage.

Interestingly, discussions on the national health insurance scheme in Uganda started in the late 1980s and evolved slowly over the years [3]. In 2017, discussions on the plan accelerated when Advance Family Planning’s local partner, PPD ARO, stakeholders, Population Action International (PAI), and The William and Flora Hewlett Foundation worked to ensure that the draft scheme had family planning programs [3]. The coalition steered advocacy efforts to provide family planning commodities and services that the stakeholders formed throughout the scheme’s development processes [3]. Between 2016 and 2020, Parliamentary champions asked PPD ARO to organize a series of meetings with members of Parliament, the Ministry of Health, the Ministry of Finance, and the Uganda Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH+N) civil society platform to continue this momentum [3]. For three consecutive years, Uganda’s representatives in the Network of African Parliamentary Committees of health, a regional entity, committed to passing the national health insurance scheme but struggled to get the Ugandan Ministry of Health to draft and introduce the bill to Parliament [3]. However, in June 2019, Parliamentary champions sensed a stalling of the draft bill in the Ministry of Health [3]. They asked PPD ARO for technical support to inform a private member’s account for Hon. Dr. Michael Bukenya, the chairperson of the parliamentary health committee [3]. The introduction of the private member’s bill put pressure on the government to revive, update, and present their bill to Parliament in August 2019. Eventually, the Ugandan Ministry of Health’s revised bill incorporated elements from the private member’s bill in its final form [3].

Therefore, in February 2020, PPD ARO published an issue brief on the draft scheme and organized a series of media engagement activities to share details and benefits of the plan with the public, including its coverage of family planning [3]. The advocacy kept the issue central to parliamentarians all over the country as the COVID-19 pandemic unfolded and challenged national health financing [3]. The media were instrumental in keeping the pressure on Parliament to pass the bill, which finally happened on March 31, 2021 [3]. However, this bill has not been assented to and has effectively prevented the population from accessing services as required by the UHC declarations and SDGs [3].

Interestingly, every country worldwide has committed to achieving universal health coverage (UHC) by 2030 as part of the United Nations Sustainable Development Goals (SDGs) [4,11,12]. But, some countries are progressing faster than others in delivering equitable access to health services, affordable medicines, and vaccines [11].

Among those leading the pack is Vietnam. Today, 87.7% of Vietnam’s population, or 83.6 million people, are covered by health insurance [11]. According to the latest Global Monitoring Report on UHC, published jointly by the World Health Organization and the World Bank, 97% of Vietnamese children now receive standard immunizations, compared to 95% of children in the United States [11]. Since 1990, the country’s maternal mortality rate has fallen by 75% [11]. Vietnam has reached such impressive milestones ahead of schedule, despite having an average per capita income of just $2,342 as of 2017 [11]. The key to its success is not the scale of investment in healthcare, which amounts to a modest $142 per person annually (including both public funding and out-of-pocket expenses), but rather how the government uses its resources, including the country’s intellectual capital [11].

Vietnam’s strategic approach was in its Ministry of Health’s directing healthcare activities scheme, which required health facilities at the central and provincial levels of government administration to help build up the capacity of district and community facilities [11]. A key objective of this scheme was to shift more of the burden of delivering medical services from higher-level hospitals onto lower-level primary healthcare facilities [11]. Given a long history of deep disparities in health outcomes between urban and rural areas, Vietnamese still often tried to bypass their local healthcare centers in favor of major hospitals in urban centers [11]. This created inefficiencies in the health system and increased out-of-pocket costs for patients and their families without guaranteeing the best care [11].

Thus, going beyond ensuring that community health facilities can offer affordable, quality care, there is a need to change public perceptions [11]. Families need to trust that they can get a dependable diagnosis of malaria, chronic obstructive pulmonary disease, or diabetes locally, as well as the necessary medications and other treatments. Therefore, health facilities must strengthen their relationships with local communities by routinely providing a level of service that satisfies patients [11]. Such connections will help to advance another health-improving, cost-saving imperatives where local health workers should be able to educate their communities to maintain health and avoid illnesses. Success will require good working conditions and access to the ongoing training and management support that are critical to job satisfaction [11].

Vietnam’s government recognized that to implement its healthcare strategy effectively, it needed help from other partners [11]. It then established a Working Group for primary healthcare transformation led by the Vietnamese Ministry of Health and included diverse actors from the public, nonprofit, and private sectors [11]. The group’s founding partners were the World Economic Forum, Harvard Medical School, and Novartis [11]. The working group aimed to strengthen existing primary care demonstration projects in 30 Vietnamese provinces and applied the lessons learned to develop holistic solutions that could be replicated and scaled up in Vietnam [11]. It also prioritized rigorous measurements and evaluation of outputs, from the quality of community-level health services to the cost-effectiveness of primary health care [11]. The government invited each partner to contribute capabilities, resources, and knowledge to this endeavor. For example, Harvard Medical School brought world-class expertise in the organizational management of primary healthcare teams [11]. National partners brought, among others, a deep understanding of the local context, which was essential for developing and implementing sustainable solutions [11]. For its part, Novartis offered insight on how to deploy digital technology at a large scale, engage rural communities in health education, and expand education programs for healthcare practitioners in rural communities [11]. Notably, Novartis made similar contributions through another successful public-private partnership in Vietnam, Cùng Sông Khòe [11].

In partnership with Vietnam’s government, Cùng Sông Khòe (CSK) has been delivering services to underserved rural communities in Vietnam since 2012 [11]. That initiative expanded healthcare for common medical conditions like diabetes, hypertension, and respiratory diseases, patient health education, and continuing medical education for health professionals [11]. Since 2012, CSK has reached out to more than 570,000 people, mainly adults, across the sixteen provinces of Vietnam [11].

It would therefore be naïve to think that all going on in Vietnam are beds of roses because Vietnam is facing significant challenges ahead [11]. It is grappling with behavioral and environmental factors underlying poor health and diseases, especially high rates of smoking among males, high rates of alcohol consumption, air pollution, and the rapidly growing number of aging populations [11]. Governments must conduct critical healthcare reforms to improve healthcare outcomes; for example, the government should incentivize doctors to be more selective in referring patients to higher-level hospitals and sending more patients to local primary-health-care centers [11]. Nonetheless, Vietnam’s progress toward UHC has been remarkable, partly due to the government’s embrace of strategic public-private partnerships (PPP) [11]. For countries that have struggled to move forward, this model and approaches from other high performers in the race for UHC, such as Indonesia, Rwanda, and Thailand, may be worth embracing [11].