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
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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
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10 6 3 0
2423
41
113
64
47
32
68
159
120
0
20
40
60
80
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120
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# 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
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
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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