آیا طرح های بیمه درمانی مبتنی بر جامعه باعث بهبود دسترسی مردم فقیر به مراقبت های بهداشتی می شود؟ مدارک و شواهد از سنگال روستایی

Community-based health insurance is an emerging and promising concept, which addresses health care challenges faced in particular by the rural poor. The aim of this paper is to analyse whether rural Senegal members of a health insurance scheme are actually better-off than nonmembers. The results show that in poor environments, insurance programs can work: Members of les mutuelles de sant (mutual health organizations) have a higher probability of using hospitalization services than nonmembers and pay substantially less when they need care. Furthermore, the analysis revealed that while the schemes achieved to attract poor people, the poorest of the poor remained excluded.

Health security is increasingly being recognized as integral to any poverty reduction strategy. While the objective of poverty reduction remains of central concern, there has been a shift of focus away from poverty reduction per se to social risk management. Such is the case because of the growing appreciation of the role that risk plays in the lives of the poor ( Holzmann & Jorgensen, 2000). Of all the risks facing poor households, health risks probably pose the greatest threat to their lives and livelihoods. A health shock leads to direct expenditures for medicine, transport and treatment but also to indirect costs related to a reduction in labor supply and productivity ( Asfaw, 2003). Given the strong link between health and income at low income levels, a health shock usually affects the poor the most ( CMH, 2001; Morrisson, 2002). The states in most developing countries have not been able to fulfill health care needs of their poor population. Shrinking budgetary support for health care services, inefficiency in public health provision, an unacceptable low quality of public health services, and the resultant imposition of user charges are reflective of the state’s inability to meet health care needs of the poor (World Bank, 1993).1 In the last decade, the “health care crisis” led to the emergence of many community-based health insurance schemes (CBHI) in different regions of developing countries, particularly in sub-Saharan Africa (Preker, 2004; Wiesmann & Jütting, 2001). The decentralization process unleashed in these countries to empower lower layers of government and the local community further fueled their emergence (Atim, 1998; Musau, 1999). The success of community-based microcredit schemes may have also contributed to the emergence of community-based health initiatives designed to improve the access through risk and resource sharing (Dror & Jacquier, 1999). Elsewhere, particularly in regions of Asia and Latin America, community-based health initiatives have come about independently and as part of income protection measures or to fill the void created by missing institutions.2 Neither the state nor the market is effective in providing health insurance to low-income people in rural and informal sectors. The formal providers are often at an informational disadvantage and face high transaction costs. On both these counts health insurance schemes rooted in local organizations potentially score better than alternate health insurance arrangements.3 In rural and informal sectors where supply of health services is expected to be weak, both financing and provision aspects need to be tackled simultaneously.4 Indeed, most of the CBHI schemes have either been initiated by the health providers i.e., missionary hospitals, or tend to be set around the providers themselves (Atim, 1998; Musau, 1999). Thus, the potential benefit of these schemes is seen not just in terms of mobilization of resources but also in the improvement and organization of health care services. Whereas the CBHI concept is theoretically appealing, its merits still have to be proven in practice. In the literature, this question is controversially debated: Proponents argue that CBHI schemes are a potential instrument of protection from the impoverishing effects of health expenditures for low-income populations. It is argued that CBHI schemes are effective in reaching a large number of poor people who would otherwise have no financial protection against the cost of illness (Dror & Jacquier, 1999). Other available studies however, are less optimistic. Community structures may not necessarily reflect the views of the wider population, critical decisions may not take into account the interest of the poorest, and they may be excluded from decision-making (Gilson et al., 2000). It is furthermore argued that the risk pool is often too small, that adverse selection problems arise, that the schemes are heavily dependent on subsidies, that financial and managerial difficulties arise, and that the overall sustainability seems not to be assured (Atim, 1998; Bennett, Creese, & Monash, 1998; Criel, 1998). The existing studies on CBHI schemes face the important limitation that most of them are not based on household data and/or rely solely on qualitative methods of investigation. In addition, they mainly look at the impact of the schemes on the provider or the insurance scheme, largely neglecting the effects on the members.

Formal health insurance schemes cover only a marginal proportion of the population in low-income countries. Due to economic constraints, lack of good governance and institutional weaknesses, formal social protection for the vulnerable segments of the population is widely absent. This study has analyzed the impact of community-based health insurance on the access to health care of the rural poor taking les les mutuelles de sants in the Thiès region of Senegal as an example. It was shown that in an area where most people are deprived of access to health care of good quality, the introduction of CBHI schemes can make a substantial difference. While low-cost, high-frequency events are covered within the extended family, the risk of hospitalization is shared by the larger community. This has a potential positive effect on the ability of households to smooth their consumption, on labor supply and labor productivity and on the health status of the people insured. Further research should analyze and evaluate these effects, if possible within a panel data set framework. This would give policy makers a clearer idea on the social costs and benefits of introducing health insurance for the poor. Participation in insurance schemes and local organizations is not cost-free and requires a minimum of income which the most disadvantaged often do not have at their disposal. Therefore, donors and policy makers should be aware that it may be very difficult, even impossible, to reach the poorest part of the population when promoting participation in local institutions. In order to reach the poorest members of the community, the cost of participation would have to be reduced by the institutions themselves or the public sector would have to subsidize their premiums. This could be achieved by linking community-financing schemes to social funds, for instance. As one major objective of social funding is to finance investments benefiting the poor and as in most places it is the public sector which administers social funds, such a support scheme would also strengthen linkage to the more formalized health care system. But, public financial support for such schemes should only be considered if the schemes fulfill certain conditions, such as assuring broad-scale access, transparent operational and financial accountability, management experience, etc. An important policy implication of this study is that it is critical to move away from resource mobilization instruments that are based on point-of-service payments. If pre-payment and risk-sharing can be encouraged, they are likely to have an immediate direct and indirect impact on poverty. The direct impact would be, by preventing impoverishment due to catastrophic health expenditures. The indirect impact would be by ensuring access to health and thereby improving health, thus allowing the individual to take advantage of economic and social opportunities. To enlarge poor and rural population access to health care, community-based health insurance schemes can be an important element and a valuable first step. In order to overcome the existing limitations of the schemes, broader risk pools are required. In particular, the role of external financial support––such as government subsidies, donor funding, and re-insurance––in encouraging social inclusion needs to be further explored. An interesting option to be further tested would be to integrate health insurance into microfinance schemes. In this respect, the cases of Self-Employed Women Association (SEWA) in India and the Grameen Bank in Bangladesh are promising examples. Further research is needed on how to scale-up and replicate these schemes, and on how to link them to other social risk management instruments such as social funds.