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There is increasing advocacy for community-based health insurance (CBHI) schemes as part of a broader
solution to health care financing problems in low-income countries, but to date there is very limited under-
standing of how CBHI schemes interact with other elements of a health care financing system. This paper
aims to set out a preliminary conceptual framework for understanding such interactions, and highlights the
The purpose of this paper is to provide a conceptual frame- Africa (Atim et al. 1998). The diversity of CBHI schemes
work for analyzing how CBHI schemes interact with other means that different schemes will contribute to the overall
components of the health care financing system in terms of financing system in different ways.
financial flows (revenue collection, pooling, purchasing) and
the related issues of population coverage and benefit It is only recently that governments in developing countries
packages. The focus is upon what are frequently incidental, have begun to articulate the role they see CBHI schemes
unplanned interactions between CBHI and other financing playing within the bigger health-financing picture. Of the
schemes; other papers have addressed how governments may schemes listed in Table 1, the Community Health Fund in
explicitly attempt to influence the behaviour of CBHI Tanzania and the Health Card Scheme in Thailand are both
schemes through a variety of mechanisms (Ranson and schemes that their governments helped to develop and shape.
Bennett 2002). Given the fact that, to date, virtually no Yet even in these cases, there has not always been an attempt
studies have discussed CBHI schemes from a system-wide to explore thoroughly the nature of interaction between
perspective, this paper is not designed to present lessons, but various forms of risk pooling. For example, in Tanzania it has
rather to highlight the types of questions that need to be simply been stated that the Community Health Fund will
addressed, and begin to illustrate an organizing framework cover rural communities while complementary employer-
Table 1. Background and context on CBHI schemes used to illustrate alternative modes of interaction between schemes and government
Scheme and location Nature of ownership Providers and Benefit package Sources
relationship with
providers
SEWA, Ahmedabad, India Women-owned Private for-profit, private Predominantly primary Ranson (2002)
micro-credit agency non-profit or public care. Some hospital ILO (2002b)
providers. Bills paid benefits with cap on
by member who then total benefits.
seeks reimbursement
from the scheme.
Nkoranza, Ghana Initially the mission St Theresa’s mission Hospital services Atim and Madjiguene
hospital in Nkoranza hospital (that initiated (2000)
district, more recently the scheme). Hospital
ownership and bills scheme directly
Equity – Poorer members of society join schemes – Equitable access to (a basic package
– Equitable access to benefits by members of) services throughout the population
under the scheme – Progressive distribution of government
– Premiums are progressive subsidies
Financial sustainability/revenue raising – Scheme revenues outweigh expenditures – Adequate total resources mobilized
– Adequate enrollment levels to ensure an acceptable level of care
and social ones. For example, reasonable administrative costs There is also tension between the different objectives
at the scheme level may be achieved, but administrative costs identified in Table 2. Government and individual schemes
at the system level may be exacerbated by the challenges may place different emphasis on different objectives. For
inherent to regulating multiple insurers. Similarly, while individual schemes, ensuring sustainability is likely to be a
promoting sustainability is an obvious objective at the dominant objective: without sustained operations no other
scheme level, it is not clear that, in and of itself, this should objectives can be achieved. Yet mechanisms to promote indi-
be a government policy objective. For example, individual vidual scheme sustainability can conflict substantively with
scheme sustainability may be achieved through dumping equity concerns. Exclusion of high-risk individuals from
severe or chronic cases into the public health care system, or scheme membership will affect the sickest and probably most
through reliance upon government subsidies – both of which vulnerable members of the population. Increasing premium
may potentially detract from the overall sustainability of the levels will discourage the poor from joining. Placing limi-
broader health care system. tations on a benefit package will most likely reduce the level
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of effective protection provided against financial risk. While risk protection may be limited. Furthermore, many CBHI
this will affect all income groups, it may have the most severe schemes involve some form of co-payment for services within
consequences for the poorest. the benefit package, and this will also affect the extent of risk
protection.
Health policy analysts have been significantly more opti-
mistic about the potential for CBHI schemes in low-income Even for those services covered entirely within the benefit
countries compared with for-profit private insurers (Carrin package, there are multiple questions about how individual
1987). The non-profit nature of CBHI schemes appears to CBHI schemes for these services interact with the broader
have led to the assumption that the objectives of CBHI health care financing system:
schemes are more closely aligned with government objec-
tives. While there may be some truth to this, CBHI schemes (1) What happens to people who are not members of the
must be driven by similar imperatives to for-profit schemes scheme? Do they pay user fees? Are they excluded from
in order to ensure their sustainability. So while in principle it care?
may be anticipated that there is considerable alignment (2) Do health care providers receive additional financial
between government health care financing goals and CBHI support? For example, do they receive government
Fees paid
Non-members
Services
Patients/ Hospitals
provided
scheme members
Primary care
providers
Premiums paid
Provider payment
CBHI scheme
Government
Fees paid
Non-members
Services
Patients/ Hospitals
provided
scheme members
Primary care
providers
Premiums paid
Provider payment
CBHI scheme
Government
Government
subsidies to
scheme
Financial flows (pooling and purchasing) consequences of multiple risk pools in developing country
contexts. Thailand, where in addition to the Health Card
• How does the magnitude of government subsidies to the
Scheme there is a variety of other schemes covering different
scheme compare with government subsidies to providers
parts of the population, is perhaps an exception to this, with
and with revenues from premiums?
growing evidence about equity implications and cost shifting
on the part of the provider. Cost shifting arises due to the fact
Benefit package that different insurance schemes are likely to provide
• Are subsidies to the scheme used to extend and to help different benefits and modes of payment, and therefore there
purchase services that individuals might be unwilling to are incentives for health care providers to play one insurance
pay for (e.g. health education, public health services)? scheme against another in order to increase revenues
(Sullivan 2001). This may simply take the form of subsidiz-
ing care for members of one type of scheme by over-charging
Multiple risk-pooling schemes
another scheme (this is a common practice for public hospi-
The fourth and final extension to the basic model concerns tals in Thailand treating patients under the low income
the situation where there are multiple risk-pooling schemes scheme (Supachutikul 1996)). In some instances, one patient
Fees paid
Non-members
Services
Member Hospitals
provided
households
Primary care
providers
Premiums paid
Provider payment
Government
CBHI schemes
Government
subsidies to
scheme
concerns that schemes can still cream skim through adjust- two key policy areas: how the combination of risk pools
ments in benefit packages, premiums or bureaucratic extends financial risk protection and issues of equity.
requirements that deter higher risk people from enrolling.
The mechanisms listed have been experimented with mainly
Financial risk protection: coordinating risk pools
in the context of high-income countries (and to a limited
degree in middle-income countries). It would seem that in Standard insurance theory suggests that insurance schemes
most low-income country contexts, their implementation is should focus upon unpredictable, low risk, high cost events –
even more problematic due to limited government capacity. in practice however, CBHI schemes cover a bewildering
variety of benefit packages, as evidenced by the benefit
There has also been substantial discussion in the United packages of the schemes referred to in this paper. A system-
States of how multiple, fragmented risk pools limit purchas- wide approach to understanding CBHI would suggest that
ing power and strengthen the relative power of providers vis even if there is no formal coordination between CBHI and
à vis insurers (Reinhardt 1990). There is great diversity in the government financing system, individuals will seek out
developing countries in terms of risk pool size in CBHI and prefer CBHI schemes that offer complementary risk
schemes (ILO 2002a); however, there is limited understand- protection to that provided by government. There are three
Source of funds
Government funded User fee
Essential
package
A B
Outside of
Services
the government risk pool where they are entitled to free based upon the extent to which poor members of the
hospital care (albeit of low quality). community do join. While getting the poor to join CBHI
schemes seems likely to promote their access to basic
This discussion suggests that in any context where govern- services, it is not clear that this is the best strategy through
ment-financed services are an important source of care, which to promote the progressive distribution of subsidies,
demand for risk protection through CBHI schemes will be and it is also a matter of concern as to what happens to the
significantly influenced by government’s own funding poor who do not join.
patterns, and CBHI schemes will need to adjust to reflect
changing government financing policies. For example, one of In order to be able to explore the equity implications of
the stimuli to recent discussions of reinsurance in Ghana has existing CBHI schemes, we need to understand more about
been government plans to devolve teaching hospitals and what happens to non-members and, more broadly, the effec-
require them to become more financially autonomous tiveness of government targeting strategies. For example, the
(reducing the essential package). Conversely, how govern- Thai Health Card scheme explicitly targets the rural middle-
ment develops policy towards CBHI schemes may depend class (Supachutikul 1996). The government operates a
somewhat on what type of risks the schemes are covering. parallel system of programmes to provide free health care
For example, government subsidies to CBHI schemes may services for the elderly, school children and the poorest
better target the poor if they focus upon CBHI schemes that households. In this context, high membership amongst very
risk pool for area B (co-payments) rather than area C poor households in CBHI schemes would be counter to
(services outside the package). equity goals. In most contexts where there are CBHI
schemes however, it is unlikely that there are other social
This discussion of coordinating risk pools also has impli- safety nets that guarantee access for those who do not join
cations for the recent discussion regarding reinsurance of the scheme.
CBHI schemes (Dror 2002). Where schemes focus upon co-
payment for the essential package (B), reinsurance is It is possible that non-members might actually be made
unlikely to be necessary, as most services within this package worse off by a CBHI scheme than before. This might occur
face predictable demand and are low cost. Schemes that in a number of ways:
focus upon area C are much more likely to require reinsur-
ance. • Establishment of the scheme may be associated with
an increase in prices for health care for non-members
(as was the case in the Community Health Fund in
Equity implications
Tanzania);
Table 2 hypothesized that core equity objectives for govern- • In a context of restricted supply, access for non-members
ment were (1) to create equitable access to a basic package to providers may be adversely affected as members may
of health care services, and (2) to promote the progressive receive preferential access;
distribution of government subsidies. Some prior studies (e.g. • Faced with differential reimbursement/payment rates,
Jakab and Krishnan 2001) have made an implicit assumption providers may reduce the quality of care provided to non-
that it is desirable for poorer people to join CBHI schemes, members (depending on the incentives inherent in the
and indeed have measured the ‘equity’ of CBHI schemes reimbursement schedule);
2 czh018 (jr/d) 1/4/04 12:23 pm Page 156
• Government may redirect its budget from direct support important not only in contexts where government intends to
to public health care services to support to CBHI schemes, contribute to or in some way interact with CBHI schemes;
leading to lower quality care for non-members at govern- the implications of CBHI and broader health care system
ment providers; interaction need to be better understood in virtually all
• If a large proportion of the middle class join CBHI type contexts. While there is a growing body of evidence about the
schemes then, in the medium term, pressure upon govern- impact of individual schemes, there is virtually no infor-
ment to maintain public funding for health care services mation about the role that CBHI schemes can and do play in
may be reduced. terms of the broader health care financing system. The paper
has tried to illustrate how, even if an individual CBHI scheme
Again, whether or not these effects occur is an empirical appears to be achieving its own goals in terms of equity,
question, which future analyses of CBHI schemes really need efficiency and financial sustainability, it is far from certain
to address. that the scheme is contributing to social objectives across
these dimensions. Given the lack of evidence and under-
The complex flows of government subsidies to CBHI standing about how CBHI schemes contribute to overarch-
schemes described in the previous section further complicate ing health financing/health system goals, recent advocacy for
bring CBHI goals into greater alignment with government six countries. Technical Report No. 19. Bethesda, MD: Partner-
goals, in practice, in many of the contexts where CBHI ships for Health Reform (PHR).
schemes now thrive there is rather limited trust in govern- Bennett S, Creese A, Monasch R. 1998. Health insurance schemes
for people outside formal sector employment. ARA Paper No.
ment and limited government capacity to regulate. In such
16. Geneva: World Health Organization (WHO), Division of
contexts, scheme proponents have an understandable Analysis, Research and Assessment.
concern that government intervention may be a death knell. Busse R. 2002. The role of health insurance subsidies in achieving
Given these tensions it will prove difficult to achieve a proper pro-poor redistributional goals. In: Dror DM, Preker AS (eds).
balance between regulating schemes to achieve government Social reinsurance: a new approach to sustaining community
objectives and stifling scheme growth through heavy-handed health financing. Geneva: ILO, and Washington, DC: World
intervention. Bank.
Carrin G. 1987. Community financing of drugs in Sub-Saharan
Africa. International Journal of Health Planning and Manage-
Endnotes ment 2: 125–45.
Carrin G, De Graeve D, Deville L. 1999. Introduction to
1 The function of insurance is stated to be ‘access to care with
special issue on the economics of health insurance in low and
financial risk protection’ (Kutzin 2001). middle-income countries. Social Science and Medicine 48:
Schneider P, Diop F. 2002. Impact of prepayment pilot on health care this paper and made extremely insightful and helpful comments.
utilization and financing in Rwanda: findings from final Chris Atim, Grace Chee and Kent Ranson also provided useful
household survey. Partners for Health Reformplus (PHRplus) information about particular CBHI schemes. Preparation of this
TE002. Bethesda, MD: Abt Associates. paper was supported by the Partners for Health Reformplus
Shirima RM. 1996. The Community Health Fund in Tanzania. In: (PHRplus) Project. This was made possible through support
Beattie A, Doherty J, Gilson L, Lambo E, Shaw P (eds). Papers provided by the United States Agency for International Develop-
from an EDI Health Policy Seminar held in Johannesburg, ment (USAID) under Prime Contract No. HRN-C-00–00–00019–00
South Africa, June 1996. Washington, DC: World Bank. awarded to Abt Associates, Inc. The opinions expressed herein are
Soderlund N, Khosa S. 1997. The potential role of risk equalization the author’s and do not necessarily reflect the views of Abt Associ-
mechanisms in health insurance: the case of South Africa. ates, Inc. or USAID.
Health Policy and Planning 12: 341–53.
Sullivan K. 2001. On the “efficiency” of managed care plans. Inter-
national Journal of Health Services 31: 55–65.
Supachutikul A. 1996. Situation Analysis on health insurance and Biography
future development Bangkok: Health Systems Research Insti- Sara Bennett, Ph.D., is the Senior Research Advisor for the Partners
tute. for Health Reformplus Project, a USAID-funded project operated
Varophan P. 1992. Reimbursement and appropriateness of treat-