Remind me again: why are we here?

Abstract

On pondering the challenges of communi-ty-based health insurance, we are reminded of a scene in a movie. The leader of a war, after losing many battles and wasting the lives of thousands of men, asks his lieuten -ant: “Remind me again: why are we here?” In the midst of all the battles, war itself had become the goal and the ultimate goal of reaching stability and peace had been forgotten. In other words, the means had become the end.Similarly, in many community-based health insurance schemes, the multitude of logistical demands of initiating, managing and maintaining the schemes seem to over -shadow their original purpose – the health and well-being of a specific community and its members. In addition, the implementa -tion of community-based health insurance in low-income countries, especially in sub-Saharan Africa, is too rigid: the designs are often standardized and lack the necessary flexibility to adapt to the local context.The story of community-based health insurance dates back to the Alma-Ata Conference in 1978, when health ministers made a commitment to reform health sys-tems and extend universal primary health care to poor people. They failed to achieve this due to insufficient resources and lack of political will. Subsequently, the Bamako Initiative of 1987 promoted the introduc-tion of user fees and community involve-ment (and management) of primary care in Africa to achieve universal coverage.