1. Abt Associates Inc.
In collaboration with:
Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) |
Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)
Catherine Connor
Abt Associates
CORE Group Conference
April 15, 2015
Overcoming financial barriers to
health services
What can communities do?
Community-based Health Insurance

2. 20 years and the way forward in 8 minutes
Emergence of CBHI
Basic model of CBHI – the good and the bad
Current evolution to universal coverage
Role of communities

3. 50-60s Post-
independence
CBHI
late 90s-00s
Restructuring
late 80s/ 90s
Fiscal
crises in
70s/80s
Social health
insurance imported
from European
models
Covers formal
sector only
Excludes rural and
informal sectors
Economic
crises
threaten
welfare state
Collapse or
deterioration
of services
Bamako
Initiative
User fees “cost
recovery”
Growth of
private sector
and civil
society
How did CBHI emerge?
Evolution of health financing in Africa
Protect rural and
informal sector
communities
from user fees
Grass roots
movement
supported by
donors
Adapted from presentation by Chris Atim, Health Insurance Workshop, Health Systems 20/20 Project, Accra 2008

4. Growth of CBHI schemes in West Central
Africa 1997 - 2002
*Ghana data from ‘ 99, ‘ 01, ‘ 02
11
3
10
6 3 0
2423
41
113
64
47
32
68
159
120
0
20
40
60
80
100
120
140
160
180
#MHOs
1997
2000
2002
Source: USAID’S PHRplus Project 2000-2006

5.  Challenged conventional wisdom that people in the informal
and rural sectors of the economy are not insurable
 Built community confidence in risk pooling mechanisms
 Strong evidence that CBHI reduced out-of-pocket payments
for members (financial protection)*
Basic CBHI model: Positive
features and effects
*Source: Ekman, B. 2004. CBHI in low-income countries: a systematic review of the evidence. Health Policy and Planning; 19(5): 249-270. Photo: C. Mbengue
 Local community organized and
managed CBHI members in Benin

6. Evidence of Increased Access to Health Care:
Curative care in Rwanda
0
10
20
30
40
50
Poorest 25% Quartile 2 Quartile 3 Richest 25%
Members Non-Members
% of the sick who
sought care
Source: Household Survey, 2000 (Byumba, Kabgayi and Kabutare); Francois Diop PHRplus Project

7.  Voluntary enrolment – adverse selection
 Small risk pools of near poor populations
 Limited benefits
 Pay providers fee-for-service – cost
escalation
 Often not recognized by government
 Weak management
 Too small to survive
Basic CBHI model: shortfalls in equity,
efficiency, and sustainability
CBHI member in Rwanda
PhotoP.Georges

8. Basic CBHI
model
Enhanced Model
Government endorsement
Subsidy for poor
CBHI Network for
management and service
delivery
National Model
Government stewardship
and funding*
Professional
management
Community mobilization
Burkina, Cameroon,
Cape Verde, Guinea
Benin, Mali, Senegal
Ghana, Ethiopia,
Rwanda
Current Evolution of CBHI in Africa –
Towards Universal Coverage
*legislation, cross-subsidy of populations and regions
Source: Wang, H and Pielemeier, N. 2012. CBHI: An Evolutionary Approach to Achieving Universal Coverage in Low-Income Countries. Journal of Life Sciences 2012.

9. Still a need for community-based solutions
to financial barriers
In Africa, informal sector
represents:
50-80% of GDP
Up to 90% of jobs
Rural - farmers
Urban
 Street vendors
 Construction
Source: Benjamin, Nancy and Mbaye. 2012. The Informal Sector in Francophone Africa. Washington DC. World Bank. Photo: Maria Miralles, Angola
Majority of people in LMICs are
self-employed or employed in the
informal sector

10. Will the Universal Health Coverage
movement leave the poor and informal
sectors behind?

11. Role of communities in CBHI
Advocate to prioritize coverage of marginalized
communities
Organize into groups to facilitate coverage
Implement targeting methods to identify who should get
subsidies (Ebudehe in Rwanda)
Hold CBHI managers accountable, guard against fraud
Hold providers accountable for quality and access
What else?

12. Abt Associates Inc.
In collaboration with:
Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) |
Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)
Thank you
www.hfgproject.org

13. Marginalized communities need advocacy to
influence national policies towards UHC
45
55
62
0
10
20
30
40
50
60
70
Tanzania Ghana South Africa
Percent Willing to Tolerate Cross-Subsidies for Poor
2008 data. Source: Jane Goudge et.al, 2012, Health Policy & Planning, Vol 27, pp. i55-i63. SHIELD Project