It has now widely been accepted that community-based initiatives have an important role to play in improving poor people’s risk-sharing arrangements. However, whether or not these new emerging institutions are able to address the problem of social exclusion in local communities is far from being clear.
A paper for the Organisation of Economic Cooperation and Development (OECD) examines this issue looking at experiences of community based health insurance schemes in rural Senegal. The study identifies the factors explaining participation in these schemes. The state in most low-income countries has not been able to fulfill the health care needs of the poor, and especially of the rural population. In the last decade, the “health care crisis” led to the emergence of many community-based health insurance schemes or community financing schemes particularly in sub-Saharan Africa. The benefits of these schemes are well known, but little research has been done on their downsides. The study looks at how social axes of difference affect utilisation of community health insurance in four rural Senegalese communities.
The research found that although these schemes reached the poor in general, the very poor found were financially excluded because they could not pay the premium.
In addition:
- Very poor people were in some cases excluded on religious and ethnic grounds.
- Time as well as money was a significant factor for participation.
- Most people in these communities, poor or otherwise, are largely excluded from formal social security. These schemes are therefore important cushions against health shocks for those who can afford them.
A strategic implication of the study for DFID is that the public policy bias of government and donors overlooks the potential of households as policy actors rather than merely beneficiaries.
Other important policy pointers include:
- Social services provided by local organisations are a first step to better social protection for the poor, but are incomplete. Policies need to address deficiencies and adjust to local conditions.
- Well-targeted subsidies to the very poor are necessary.
- Local institutions and organisations need better management. Training could be linked to more formal public services.
- Research needs to be done on how subsidies for the poorest can be designed so as to retain incentive mechanisms.
- Further research is also needed on how to remove barriers to very poor people’s participation in community health schemes.
