“Remind me again why we are here?”

21 March 2013

An article by Amal Shafik , PhD from Cairo, Egypt, doing research on Health systems in developing countries

As I ponder the story of Community-based Health Insurance (CBHI) I am reminded of a telling scene in a movie I watched three years ago, where the leader of a war, after losing many battles and wasting the lives of thousands of men, asks his lieutenant: “Remind me again why we are here?” In the midst of all the battles, war itself became the goal . After engaging in battle after battle, the ultimate goal of reaching stability and peace was forgotten. In other words the means became the end.


Similarly, in many CBHI schemes, the multitude of logistical exigencies of initiating the scheme  as well as managing and maintaining its operations,  seem to almost inevitably overshadow the purpose for which the scheme was originally conceived—the health and well being of a  specific community and its members. Moreover, there is a lot of rigidity in the ways how CBHI is currently being implemented in low-income countries, especially in sub-Saharan Africa: the designs are all too often standardized and lack the necessary flexibility to adapt to the specificities of the local context.


The story can be traced back to the promise of the Alma Ata Conference of 1978, in which health officials of the world made a commitment to reforming health systems and extending universal primary health care to poor people. They failed due to insufficient resources and to lack of political willingness.  Subsequently, the Bamako Initiative (BI) turned up and promoted the introduction of user fees and community involvement (and management) within the framework of primary care in Africa, as means to accelerating and strengthening the large-scale implementation of primary health care, and thus to achieving universal accessibility  [1]. BI policies, however, were progressively abandoned because of the exclusion effects of user fees.


CBHI, described comprehensively as a voluntary, non-profit insurance scheme, formed on the basis of an ethic of mutual aid [2], emerged as an alternative to user fees. CBHI includes a variety of community insurance arrangements primarily intended to bridge the gap in access and social protection between people covered by formal schemes and those who have to pay for care out of their own pocket. Depending on the context of their implementation, CBHI schemes are referred to in the literature with a variety of terms  [3].


The raison d’être of any CBHI scheme is to serve the members of the community, particularly the most vulnerable. The World Bank underlines that community based health financing is effective in reaching a large number of low-income populations who would otherwise have no financial protection against the cost of illness.


After two decades of CBHI experience through several implementation models, one question that surfaces frequently is whether CBHI schemes remain faithful or not to the initial goal of serving their communities. The answer to this question will depend on who is assessing the performance of CBHI schemes—decision makers of the CBHI operation or beneficiaries of the schemes? However, should they not be one and the same ? Particularly if we are discussing a community initiated and managed system intended to serve the very same community. Unfortunately, this does not seem to be the case in many schemes.


Performance criteria of the private (and for-profit) insurance business are at times applied to asses CBHI schemes, more often than not ignoring the crucial differences between the two. Such differences are not confined to purpose only, but also extend to the logic underlying the management of the insurance scheme and the value frame of reference for decisions about the effectiveness and efficiency of the system. Assessment of CBHI success or failure should be made, at least partially, on different grounds using different tools and assessing different outcomes. It is in this light that one could re-examine the concept of adverse selection within the context of CBHI.


Within the context of for-profit insurance, the term “adverse selection” is commonly used to describe cases of asymmetric information between insurance providers and their clients, where prospective clients know more about their own health status and risk levels than the insurers.


Several case studies of CBHI schemes have argued that adverse selection exists in many of them. One example is the prepayment scheme offered to women in a community in Zaire, where mainly

women in the reproductive age bracket who needed hospital admission for their future deliveries subscribed to the scheme [4, 5] .


However, extending the concept of adverse selection to CBHI may be dangerously problematic, particularly if it is used beyond strictly explanatory purposes to inform operational decision making. As a descriptive construct, adverse selection is useful to consider in the context of CBHI to encourage creative thinking about mechanisms to ensure financial sustainability of the CBHI scheme. Using it as an operational concept guiding decision-making about how to manage the CBHI schemes may in essence divert CBHI schemes off their intended course of serving the community in a spirit of solidarity.


To elaborate, let us consider how the for-profit insurance business deals with adverse selection. Within the context of for-profit insurance, adverse selection is treated as an important liability that needs to be minimized if not eliminated all together. Accordingly, several strategies are employed, The common thread among all such strategies is to exclude or discourage those with higher health care risks –and consequently costs—from coverage.


Applying such strategies in the context of CBHI would deprive CBHI schemes of their very reason of existence, which is to include and attract members of the community who are most in need for health care. Many CBHI schemes have employed some of the for-profit insurance strategies to deal with adverse selection. Waiting periods and stipulation of household insurance are commonly used strategies in many CBHI schemes. While such strategies may have lessened the financing burden to keep some CBHI schemes barely afloat, they have contributed to extending the suffering of the sick and destitute, and/or to effectively excluding extended and large households—common in many developing contexts—from affording coverage.


Using strategies to deter the most in need from enrolling in CBHI seems to be completely inconsistent with the very purpose and value frame of CBHI, fundamentally rooted in inclusion and financial protection. Scheme must be economically viable and sustainable, but focusing on curbing adverse selection deals with the wrong end of the equation. It is on coming up with innovative financing mechanisms for CBHI schemes that the emphasis should be. One of the relevant tracks in that respect is to consider subsidizing with public money the CBHI premiums for the poorest (who are also the sickest), as is currently done in Ghana and Rwanda (6). This needs to be done in a cautious way so as not to disrupt local solidarity dynamics.


Health economist should focus more effort on developing a different business model for CBHI to allow such schemes to remain true to their purpose of ensuring coverage to the most in need and least able to pay while remaining financially viable and sustainable. Addressing such a challenge remains a necessity if we are to realise the promise of universal health coverage. It is however necessary for all involved in advancing the cause of CBHI to be always reminded that community welfare and involvement will always be the litmus-test for any suggested interventions.


Let us never forget ―Why we are here ...!



1. Gilson L, Kalyalya D, Kuchler F, Lake S, Oranga H, Ouendo M: The Equity Impacts of Community Financing Activities in three African Countries. International Journal of Health Planning and Management, 2000, 15::291-317.

2. Atim C: Contribution of mutual health to financing, delivery, and access to health care. In Synthesis of research in nine West and Central African countries:Technical Report Volume 18. Edited by Partnerships for Health Reform Project. Bethesda (MD): Abt Associates; 1998.

3. Criel B, Atim C, Basaza R, Blaise P, Waelkens MP: Editorial: Community health insurance (CHI) in sub-Saharan Africa: researching the context. Trop Med Int Health 2004, 9(10):1041-1043.

4. Noterman J-P, Criel B, Kegels G, Isu K: A prepayment scheme for hospital care in the Masisi district in Zaire: A critical evaluation. Social Science & Medicine 1995, 40(7):919-930.

5. Cutler DM, and Zeckhauser, R. J. (Ed.): The anatomy of health insurance. 2000 edition. Amsterdam, The Netherlands: Elsevier Inc. ; 2000.

6.  Soors W, Devadasan N, Durairaj V  & Criel B (2010). Community Health Insurance and Universal Coverage: Multiple paths, many rivers to cross. World Health Report (2010). Background Paper, 48.