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

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

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

Growth of CBHI schemes in West Central Africa 1997 - 2002

*Ghana data from ‘ 99, ‘ 01, ‘ 02

113

10 6 3 0

2423

41

113

64

47

32

68

159

120

0

20

40

60

80

100

120

140

160

180

# MHO

s

199720002002

Source: USAID’S PHRplus Project 2000-2006

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

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

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

Photo

P. G

eorg

es

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.

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

Will the Universal Health Coverage movement leave the poor and informal

sectors behind?

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?

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

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