Bridging community‐based health insurance and social protection for health care – a step in the direction of universal coverage?

Abstract

keywords health care, community-based health insurance, social protection, universal coverageAccess to affordable and effective health care is a majorproblem in low and middle income countries (LMIC) andout-of-pocket expenditure for health care a major cause ofimpoverishment (Meessen et al. 2003; Frenk et al. 2006;McIntyre et al. 2006; Van Doorslaer et al. 2006). Oneway to facilitate access and overcome catastrophic expen-diture is through a health insurance mechanism, wherebyrisks are shared and financial inputs pooled by way ofcontributions from salaries or taxation (Carrin et al.2005). In European history, social health insurance (SHI)initially covered salaried workers and their families. Theself-employed, unemployed and destitute were onlycovered at a later stage (Ba¨rnighausen & Sauerborn 2002).In LMIC today, the majority of people are either self-employed or work in the informal sector, which makesexpansion of formal health insurance, if any, much moredifficult. Taxation systems are generally insufficientlydeveloped and do not allow for adequate revenue collec-tion to ensure universal coverage (Carrin et al. 2005).One response to the difficulty of providing insurancecoverage for people in the informal sector is the develop-ment of community-based health insurance (CBHI). Suchan arrangement implies that the community plays animportant role in mobilizing, pooling, allocating, manag-ing and/or supervising health-care resources (Jakab K Jakab & Krishnan 2001;van Ginneken 2002; Carrin et al. 2005). CBHI schemesattempt to tap willingness and ability to pay for health careand try to build local risk-sharing arrangements based onsolidarity which requires time to mature. In practice,however, most CBHI schemes are small. A review of 258CBHI schemes found that 50% had less than 500 members[International Labour Organisation (ILO) 2002], whichundermines the CBHI’s potential (Criel & Waelkens 2003;Carrin et al. 2005).Small-scheme federations or networks can be establishedto increase membership and improve financial leverage ofCBHI (Waelkens & Criel 2004). Support organizations canbe set up to provide management assistance at the outset;scheme management can be subcontracted to an umbrellaorganization or schemes may even merge (Carrin et al.2005). Alternatively, a scheme with a larger membershipmay be started (Carrin et al. 2005), although this may onlybe possible if premiums are subsidized. In this respect,Bennett (2004) suggests that government subsidies toschemes should target the poor, more specifically thoseunabletopayapremium,toenableequitableaccesstohealthservices. The situation of CBHI in sub-Saharan Africa leadsto a similar analysis (Ndiaye et al. 2007): CBHI is not anoption for the poorest, and someone else therefore needs topay the insurance premium for them – in full or in part.Hence, the need for subsidies to cover the poorest house-holds–whileatthesametimeexercisinggreatcautionnottoundermine and jeopardize local solidarity dynamics andwillingness to pay by other than the poorest households.Rationale for bridging CBHI and social protectionprogrammes (SPP) for health careThe World Bank defines SPP as public interventions that:(i) assist households and communities to better manage