چارچوب مفهومی برای بیمه درمانی جامعه محور در کشورهای کم درآمد : سرمایه اجتماعی و توسعه اقتصادی

The international policy model linking community-based health insurance (CBHI) and universal coverage for health care in low-income countries is implicitly determined by the development of mutual health insurance in 19th century Europe and Japan. The economic and health system frameworks employed in CBHI policy have not sufficiently taken into account contextual considerations. Social capital theories could contribute to understanding why generally CBHI does not achieve significant and sustainable levels of population coverage. A framework of social capital and economic development is used to organize and interpret existing evidence on CBHI. This suggests that solidarity, trust, extra-community networks, vertical civil society links, and state–society relations affect the success of CBHI. Aligning schemes to “social determinants” of CBHI could result in structures that differ from those proposed by current analytic frameworks.

Community-based health insurance (CBHI) provides financial protection from the cost of seeking health care. It has three main features: prepayment for health services by community members; community control; and voluntary membership (Hsiao, 2001).1 Major international development agencies construe CBHI as a transitional mechanism to achieving universal coverage for health care in low-income countries (Arhin-Tenkorang, 2001, Davies and Carrin, 2001, Gottret and Schieber, 2006, World Health Organization, 2000, World Health Organization, 2005a and World Health Organization, 2005b). The current international policy model linking CBHI and universal coverage is implicitly informed by the history of health service financing in Europe and Japan, where CBHI schemes in the 19th century eventually merged to form various types of national health insurance (Criel & Van Dormael, 1999). However, several studies suggest that while there may be lessons to be learnt, emerging in a different socioeconomic context, under different circumstances, it is not safe to assume that CBHI schemes in their current form will develop into forms of national health financing according to the historical precedent (Barnighausen and Sauerborn, 2002, Carrin and James, 2005, Criel and Van Dormael, 1999 and Ogawa et al., 2003). Although it is estimated that in West Africa there was more than a twofold increase in the number of CBHI schemes in just three years, from 199 schemes in 2000 to 585 in 2003 (Bennett, Kelley, & Silvers, 2004), this is still a small number of schemes when compared to the situation in Europe.2 In the 19th century there were 27,000 friendly societies, which operated much like CBHI schemes, in the United Kingdom alone (Bennett et al., 2004). Also, rather than being locally initiated by farmers, associations of industry workers or employers as in Europe and Japan, today’s CBHI schemes are mostly the result of top-down interventions led by foreign aid agencies or national governments (Criel and Van Dormael, 1999 and Meessen et al., 2002). Reviews have concluded that the evidence base on CBHI is limited in scope and quality (Ekman, 2004) and that it is unclear whether CBHI schemes are actually sustainable in the long term (Bennett et al., 2004). Constraints to increasing CBHI coverage and sustainability have been identified primarily by a body of literature taking an economic or a health system perspective. In agencies such as the World Bank and WHO, analysis of CBHI policy is underpinned by an economic framework, with discussion focusing on features of market transactions such as willingness to pay, information, price, and quality (Dror, 2001, Pauly, 2004, Preker, 2004 and Zweifel, 2004). Another related perspective attempts to set financial transactions into the broader institutional context of the health system, analyzing interactions among insureds, insurance schemes, health service providers, and the state. This is described here as a “health system framework” (see, e.g., Bennett, 2004, Bennett et al., 2004, Criel et al., 2004 and ILO, 2002) and it corresponds with the model of health system analysis laid out in the WHO World Health Report 2000 (World Health Organization, 2000). Underpinning both the economic and health system frameworks is the behavioral model of rational utility maximizing homo economicus. This paper argues that the rational individualist model does not permit the systematic incorporation of social context into policy. New, complementary directions in thinking on CBHI policy are needed; particularly an increased focus on values, goals, and power relations, as has been argued in relation to social policy in general (Flyvbjerg, 2001). Specifically, it is proposed that a critical engagement with social capital theories could contribute to our understanding of why most CBHI schemes do not appear on course to develop according to the 19th century precedent, achieving significant levels of population coverage in a sustainable way. It could also help explain the apparently successful implementation of CBHI in certain countries, most notably Rwanda, where coverage of 25.8% of the total population was achieved during 2000–05 (Musango, Butera, Inyarubuga, & Dujardin, 2006). Social capital has been the subject of spirited academic debate for almost two decades. Since its definition remains under dispute, as a matter of convenience we employ the following as a point of departure for discussion: “the information, trust and norms of reciprocity inhering in one’s social network” (Woolcock, 1998, p. 153). Further categories in the social capital taxonomy are considered later in the paper. For at least 10 years empirical studies have suggested that higher levels of social capital are positively correlated with improved development outcomes in areas such as agriculture, water and sanitation, and microcredit in low-income countries (Anderson et al., 2002, Brown and Ashman, 1996, Grootaert and Narayan, 2004, Krishna, 2001, Lyon, 2000, Narayan and Pritchett, 1997, Uphoff and Wijayaratna, 2000, van Bastelaer and Leathers, 2006 and Weijland, 1999). The World Bank’s “Social Capital Initiative” even suggested that social capital could be the “missing link” between natural, physical, and human capital and economic growth and development (Grootaert & van Bastelaer, 2001). Theories of social capital have also been applied widely in public health policy (see Moore et al., 2006 and Shortt, 2004 for a literature review). However, although an important component of social capital, trust, is occasionally discussed in the CBHI literature, CBHI has not, for the most part, engaged with social capital theories. In the few cases where social capital theory is considered, it is either mentioned only cursorily or the richness and complexity of the theory is overlooked. The specific framework of social capital adopted in this paper was developed by Woolcock (Woolcock, 1998, Woolcock, 2001 and Woolcock and Narayan, 2006). It brings together several theories of social capital and draws on quantitative and qualitative evidence from field studies. Its particular advantage for our analysis is its focus on community level economic development projects in low-income countries, similar to CBHI.3 It offers CBHI policy a framework that incorporates both economic and social theory by attempting to reconcile debates over whether humans are rational agents or governed by norms and culture. In doing so, the social capital framework can be viewed as an attempt to pragmatically address the need for an alternative, or complement, to income-based and purely economic approaches to development (Bebbington, 2004). By applying this framework to CBHI analysis, this paper aims to develop a methodology for grounding CBHI in context-dependent considerations such as values, community goals, and local power relations. Woolcock’s social capital framework is briefly outlined below. Next, the social capital framework is used to organize and interpret evidence and information on CBHI. Since an empirical study identifying the causal links between social capital and CBHI is beyond the scope of this paper, we draw on existing studies of CBHI. Finally, there is a discussion on the possible importance of social capital to the implementation of CBHI and gaps in current knowledge on this subject.

CBHI has been proposed by international development agencies as a transitional mechanism to achieving universal coverage for health care in low-income countries (Arhin-Tenkorang, 2001, Davies and Carrin, 2001, Gottret and Schieber, 2006, World Health Organization, 2000, World Health Organization, 2005a and World Health Organization, 2005b). This policy model linking CBHI and universal coverage is implicitly informed by the historical experience of mutual health insurance in countries such as Germany and Japan in the 19th century, where the social context was dramatically different to that of today’s schemes (Criel & Van Dormael, 1999). This paper argues that the analysis of CBHI in agencies such as the World Bank and WHO, broadly based on economic theory, has taken insufficient account of context-dependent policy considerations. These include values of scheme members and people in their communities, community goals, and local and regional power relations. There is a need to develop an alternative framework to complement the economic and health system approaches to analyzing CBHI. An analysis of the CBHI literature suggests that a critical engagement with social capital theories could enhance our understanding of CBHI and help explain why in most low-income countries (with notable exceptions such as Rwanda) schemes do not appear on course to develop according to the 19th century precedent, achieving significant levels of population coverage in a sustainable way. Features of social capital such as solidarity, trust, extra-community networks, vertical civil society links, and state–society relations at the local level appear to affect outcomes in CBHI. To this extent, it may be possible to talk of “social determinants of CBHI.” However, these social determinants have been insufficiently considered in CBHI policy analysis and development, possibly limiting understandings of failures and successes of CBHI. Our conclusions are not based on the findings of primary research, which was beyond the scope of this paper. The limitation of this is that many of the studies employed do not necessarily aim to identify the importance of social capital. We have therefore been compelled to draw additional conclusions beyond the objectives of the researchers, by linking their work to a new framework. With this caveat in place, possible social determinants of CBHI and their impact on CBHI are tentatively proposed here. We firstly argue that applying Woolcock’s social capital framework (Woolcock, 1998, Woolcock, 2001 and Woolcock and Narayan, 2006) to the CBHI data puts into question the idea, proposed in the CBHI literature, that schemes characterized by strong intra-community ties are more likely to experience success in CBHI than those without these ties, because of increased solidarity which may reduce adverse selection and moral hazard. The framework complicates the picture by proposing that communities characterized by only strong intra-community ties may actually be disadvantaged in CBHI development due to increased levels of corruption and clientism, or a preference for more informal financial networks. A broader understanding of the factors determining the effect of bonding social capital on CBHI is therefore needed. Bridging social capital in the form of more extensive professional links with NGOs, umbrella organizations, or local government (within and beyond the health sector) is likely to be important. Such links can foster more professional relations, strategic alliances, administrative capacity, and enlarged risk pools in CBHI schemes. However, vertical links with NGOs, while bringing many benefits, may also foster dependency and may reinforce social structures that endorse and privilege the work of technical experts. This does little to augment the accumulation of capital (social, economic, human, or otherwise) of intended beneficiaries of technical assistance—the scheme staff and scheme members. The role of bridging social capital in CBHI therefore ought to be explored. A related question is whether and how the advantages of bonding social capital could be sustained alongside increased horizontal and vertical bridging links. Alongside links with NGOs and civil society, the concept of “embeddedness,” also constituent of bridging social capital, suggests that local government structures can foster productive informal social relations between communities and local government officials (Evans, 1996). In CBHI, structures that facilitate the personal engagement of local bureaucrats may also increase the possibility of corruption. The effect of embeddedness also needs to be weighed up against more conventional “complementarity” (public/private division of labor) and laissez faire approaches, although it is worth noting that the latter may not be viable in cases where CBHI is to be scaled up and integrated into a government program for universal coverage (such as social health insurance) as proposed by World Health Organization, 2000 and World Health Organization, 2005b. The process of working through the social capital framework has led us to the conclusion that certain types of social capital are probably a determinant of successful CBHI, but it has also led us to think beyond this. It may become apparent that numbers of CBHI schemes need to actively develop bridging relations to foster the types of social capital required to ensure that the schemes are aligned to local communities’ goals, power relations, and values. Bridging ties are “constructible” since they constitute social relations that are facilitated by institutional arrangements rather than affective bonds ( Bebbington and Carroll, 2000, Evans, 1996, Fox, 1996, Krishna, 2004 and Putzel, 1997). For example, CBHI schemes could link into federations of community-based organizations with diverse political and economic interests, situating themselves in the broader regional or even national development agenda and increasing their inclusiveness locally. Or schemes may find that they need to pursue diverse activities to complement insurance, such as income generation. In egalitarian societies, if institutional structures that foster norms and loyalties at the intersection between civil society and government are in place, CBHI schemes could systematically forge links with decentralized government structures (such as District Health Management Teams) or develop into quasi-non-governmental organizations. Social capital theory has been critiqued as a rationale for social engineering by development agencies. It is accused of broadening the scope of justifiable intervention from the economic to the social, to rectify market imperfections in order, in turn, to ensure that market-oriented policies are successful, while obscuring a critique of those policies (Fine, 2001). CBHI, as a form of private, voluntary health insurance, is a market-oriented policy, but this paper does not aim to build a case for, or against, social interventions to ensure it is successful. Rather, we hope to demonstrate the potential utility of social capital research in unpacking complex social relationships in CBHI and making their importance to policy and programming intelligible. Evidence from future studies may support social interventions to develop CBHI. Or, echoing critical analyses of other market-oriented health sector reforms (Bennett et al., 1997), future evidence may indicate that social interventions require local institutions to develop new capacities such that the market-oriented reforms become more demanding on these local institutions than alternative, public sector policies. So far, this discussion has not considered methodologies for primary research into the effects of social capital on CBHI. Indicators of social capital have already been developed and these could be adapted for quantitative studies investigating the relationship between social capital and CBHI. Such a task would be no small undertaking. An in-depth literature review of research on social capital suggests that a number of serious conceptual and statistical problems exist with the current use of social capital by social scientists, particularly in attributing causality to social capital in empirical studies (Durlauf & Fafchamps, 2004). We suggest that while applying the social capital framework to CBHI could indeed entail statistically testing a theory of the social conditions under which CBHI is successful, this is not the only possible research methodology. An alternative approach would be to employ the framework qualitatively, for example, by using it to guide semi-structured interviews and anthropological fieldwork to advance CBHI policy analysis and to understand its social context. This would involve situating technical analyses (which have already been undertaken within existing economic and health system frameworks for CBHI) in praxis and taking account of context-dependent considerations, such as values, goals, and power relations (Flyvbjerg, 2001). Such a process could result in the evolution of schemes that are structured and operate quite differently than those proposed under the economic and health system frameworks and that have quite different long term trajectories than the schemes emerging in the 19th century.