Community Based Health Insurance

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User Fees or Community Based
Health Insurance

 

Research project No.: 91.92.001
Program: Basic Needs
Carried out by: Wouter Rijneveld

Date: July 2006

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1. Introduction

Health projects are part of the Basic Needs program of Woord en Daad. The majority of these projects
have a focus on primary health care, but about ten projects involve curative health care. Especially
about the latter, Woord en Daad has been discussing the sustainability of financing mechanisms with
her partners. In some contexts, notably Colombia, the objective was to have the hospitals
incorporated in the Social Health Insurance system of the government, so that costs could be paid
from this insurance system. In other contexts, Woord en Daad discussed with partner organisations to
start asking user fees (also know as Out Of Pocket money, OOP) in order to cover at least part of the
running costs in this way. An average of 50% of the running costs for curative health care was set as
a target to be covered by OOP. The vision of asking user fees is not without objections and actual
realisation of cost covering differs between countries and partner organisations. One of the points
raised in these discussions is that asking user fees may result in declining attendance to hospitals.
The same discussion is going on at the macro level. Some months ago, Worldbank published a more
than 300 pages report on Health Financing (Gottret and Schieber, 2006), discussing various models of
public health finance.
Social Health Insurance and Community Based Health Insurance are two models that receive much
attention as alternative mechanisms for government or donor spending and for user fees.
This study is a brief literature survey of the experiences with Community Based Health Insurance
(CBHI). A brief Terms of Reference for this brief research is attached as appendix 1.
The research question defined in this ToR is:
Could CBHI be a possible model for financing health projects of Woord en Daad?

What are experiences with CBHI thus far?

What are advantages and disadvantages of CBHI?

What is the effect of CBHI on the impact, outreach and quality of health programs?

What is the effect of CBHI on the sustainability of health programs?
This means that, since Woord en Daad’s health projects are all private health providers, the focus of
this survey will be on private health providers and not public health providers, although the role of
private health care in relation to the public health system always needs to be considered.
This survey should lead to a recommendation whether or not it seems wise to start a pilot project of
CBHI and if yes, under which conditions.

2. Different Health financing mechanisms

Models for health financing can also be seen as risk pooling mechanisms. All have in common that
money needs to be raised, needs to be managed in order to pool the risks and needs to be allotted
through provider systems. This holds true both at micro and at macro level.

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The above figure from Schieber et al. (2006) shows the interactions between the three stages:
collection, pooling and allocation.
The main models for health finance are summarized below (mainly taken from Gottret and Schieber,
2006). These models are not exclusive; in most countries a mixture of various models is used.

National Health Service systems

This is the model where the government raises income from taxes (or other sources, such as
revenues, external grants), and spends this through a network of public health providers, usually
directed by a Ministry of Health. If this model is used with full coverage, citizens are entitled to health
care at no further cost. This is the model used in the United Kingdom. Several variations are possible,
such as subcontracting of private health providers.
Many developing countries have such a system with only partial coverage (usually only urban areas)
and partial access (usually formal workers).
Strengths
Weaknesses

Comprehensive coverage

High equity

Huge pooling of risk, because of large
numbers

Large scope of raising resources: all income
sources of the government can be used

Uniform system  potential efficiency

Unstable funding (depending on national
budget discussions)

Often favours the rich, because of unequal
access (urban  rural, informal payments)
(richest 20% use 24-48%, poorest 20% use
4-17%).

Potential inefficiency: bureaucracy and
monopoly
It is not likely that this type of system will fully succeed in countries where the informal sector is big,
governance poor or corruption and bureaucracy high.

Social Health Insurance (SHI)

SHI is also a centralised system for health care. Difference with national health care system is that
sources for income are earmarked taxes or contributions and not the general government budget.
This usually takes place through payroll taxes for either employee or employer or both. The (former)
Dutch Ziekenfonds system is an example of SHI. Sometimes there is one single fund, which provides
the highest risk pooling, sometimes there are several funds, usually non-profit, with basic features set
by the government. Germany was the first country with the system. 27 of the 60 countries using SHI
have reached full coverage, which indicates the difficulty of this. Many donors stimulate countries to
set up SHI, but there is no consensus on whether it works fully well in all contexts. Among the
countries where Woord en Daad is active, Colombia is implementing the systems since 1993 and the
Philippines have recently started setting up SHI. In Colombia, coverage increase from 23 to 62%
(48% among the poorest quintile, Escobar, 2005). Income is raised through payroll taxes and from an
equity fund (from the general budget). Payment is partly to the demand side (where people can
choose to be registered with different insurance schemes), and partly to the supply side: public
hospitals, but supply side subsidies will be phased out. Child mortality among insured population fell
from 44 to 14 / 1000 births. Universal coverage and financial sustainability remain challenges, and, as
Woord en Daad’s partner CDA’s experience testifies: corruption in the system.
Strengths
Weaknesses

More income for health care: easy to deduct
from payrolls, and more willingness to pay
earmarked taxes

Less dependent on budget negotiations

High redistributive dimension (from rich to
poor, esp if no income ceilings are used;
from young to old; from single to family;
from low-risk to high risk)

Usually strong support from population

Difficult to achieve general coverage, esp. if
those to be covered are more than those
who contribute (those outside formal system,
unemployed, elderly, children)
 often exclusion of the poor

Needs strong tax management system

Negative economic impact as labour costs
increase

Complex to manage because of many actors

Escalation of costs. If supply side subsidies:

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excessive use; if fee-for-service subsidies:
excessive provision.

Weak on preventive care provision
For many countries, it is not likely that SHI will become an instrument for universal coverage and
universal access to health care (e.g. Kenya, since 1966, only 7% coverage). Carrin and James (2003)
showed that the following factors determine the success of SHI systems: income per capita, well
educated work force, low income inequalities and high level of political rights. Not many (if any) of the
countries where Woord en Daad is active would seem to qualify for high potential success.

Voluntary or private health insurance

These insurance systems are not based on income from tax and are not income related. Some
countries have mandatory private health insurance (e.g. Swiss and Uruguay), in other cases private
health insurance is also voluntary health insurance. Often, these systems exist alongside either NHS or
SHI. They can function as primary source of coverage of health costs (as in the new system in The
Netherlands), as duplicate source (e.g. for elite target groups offering higher quality care), as
complementary (when costs are only partially covered by SHI or NHS), or as supplementary source
(for services not covered by NHS or SHI).
Strengths
Weaknesses

Good replacement for OOP payments

May enhance access to advanced services

Often reach wealthier people only

Risk of selection (c.f. the Dutch regulation of
‘compulsory acceptance’)
This model seems hardly interesting for the target groups of Woord en Daad in developing countries.
Rather for middle or higher income groups.

Community Based Health Insurance (CBHI)

Other names for CBHI are: health insurance for the informal sector, mutual health insurance
organizations or micro health insurance schemes. A wide definition would be: not-for-profit
prepayment plans for health care, with community control and voluntary membership. CBHI has
existed for centuries in many different countries. Often they were a precursor for SHI systems as in
Germany. There is a wide variety of forms of CBHI, but further discussion of CBHI is done in the
remainder of this report.
The box below defines a number of terms related to CBHI (from Bennett et al., 2004)

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User fees / OOP

User fees or Out-Of-Pocket payments refers to the money people have to pay for medical services or
drugs they obtain. In lower income countries, 85% of the costs for health care is OOP.
Strengths
Weaknesses

High impetus for quality care

Additional source of funding for health care

Judicious use of health care

Little equity

No risk pooling – no protection  limiting
access to health care for the poor

May lead to poverty
The debate on macro level for or against user fees is going on. Policy makers and organisations as
Gordon Brown, Jeffrey Sachs, DfID and Save the Children are against any use of OOP and argue for
abolishing. In view of an increasing volume of external aid for health care, various countries have
abolished OOP, e.g. South Africa in 1997, Uganda in 2001, Madagascar in 2002 and Zambia January
2006. However, various other scholars (e.g. Leon Bijlmakers, ETC; Alex Preker, Worldbank; David
Dror; all during seminar ‘Equity in Health’, 27-06-06) are very sceptical about abolishing user fees and
point to the fact that practice shows that this does not lead to a transfer of resources to the poor
(unevenness in access remains, quality and ownership go down, informal fees go up; Drorr: in South
Africa, still 85% of the people have to pay for their health care). The question asked by them is: “can
the poor afford free health care?”
Most likely, a combination of financing mechanisms will often be needed and no universal overall best
solution can be given.

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3. The story of CBHI so far

CBHI has existed for centuries in many countries. In many countries with NHS, SHI or universal
private coverage, smaller scale CBHI schemes were used as building blocks (e.g. “onderlinge
verzekeringsorganisaties” and “friendly societies”, 27.000 of these in the UK end of C19. Workers’
unions in the time of the industrial revolution often started these.) This also indicates, as Preker et al.
(2002) show that low income countries may not be able to leap-frog the developmental process
toward general public funding for health. In many countries, there are traditional risk pooling and
saving mechanisms that function as a natural setting for CBHI. This is especially the case in Sub
Saharan Africa and Asia. In 1997, a survey found 81 documented CBHI schemes, mainly in West
Africa and Asia (Bennet et al., 2004). The number of schemes is rapidly growing, among others
because a 2001 WHO report from the commission on Macroeconomics and Health advised positively
on the use of CBHI. In Ghana they grew from 4 to 159 in two years; in the whole of West Africa from
199 in 2000 to 585 in 2003 (covering 1.5 million people, Bennett et al., 2004), in India: 7.5 million
people are covered by 40 schemes, mainly in rural or semi-urban areas and among lower castes,
Bangladesh 2.5 million people, Philippines 1.2 million (ILO, 2005, in: Cohen, 2006). In the Philippines,
the government is currently (since 2003) involving CBHI schemes to develop the national insurance
system, through the PhilHealth Organized Groups Interface.
Three common features of CBHI schemes are (Gottret and Schieber, 2006)

Affiliation is based on community membership and the community is involved in management of
the system. Community is taken in a wide sense: geographic, workers, religious, ethnic, etc. Legal
ownership is sometimes with the community (9%), or with central / local government (44%) or
with an NGO (25%) or an hospital (11%).

Beneficiaries are often excluded from other forms of health financing: government systems are
inaccessible, SHI is for formal workers, private health care is too expensive.

Members share common values; often based on traditional methods of solidarity.
Yet there is a wide variety of types. Devadasan et al. (2004) give the following typology:
In the first type, the hospital is also the insurer: provider based insurance. The third type has the
biggest potential for risk pooling and scaling up, since the insurance company (in India mainly ICICI
Lombard) may be involved with several schemes; however, reimbursement is done after expenses are
claimed and lag time for reimbursement is sometimes several months (Ranson, 2002).
Gottret and Schieber (2006: 98ff) give three other typologies of CBHI schemes (such as: based on
type of risk covered, based on ownership, or based on sources for income), but the above scheme
seems most practical to use.
In Rwanda, people pay user fees to public providers since 1976. In 1999, the government started 54
Micro Health Insurance schemes in three rural districts. People pay RWF 2,500 per year and get free
care at health centres, transport to district health centres and some services at district level.

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4. Effects of CBHI

On sustainability of health programs

The sustainability of the scheme and the effect of CBHI schemes on the sustainability of health care
financing need to be distinguished. In the case of provider-based schemes, the two are almost equal.
For the sustainability of the schemes, the design of the schemes, management skills and effective
marketing are among the most important factors, while economies of scale may be even more
important. This is where the need for reinsurance arises, where CBHI schemes reinsure their funds
with bigger scheme-cooperatives, networks or official insurance companies.
5-7% administrative costs is normal for CBHI schemes, but this often involves volunteer labour. This
percentage may be lower for bigger schemes and for schemes that grow out of micro credit
organisations. Sustainability of schemes is increased by excluding or limiting certain costs or by
increasing co-payments. However, this shifts the burden and the risk back to the clients.
In India, provider-based CBHI schemes (mainly with private not-for-profit hospitals) still needed 20-
40% external funds from whatever source (Devadasan et al., 2004). Preker et al. (2002) show from a
literature survey that CBHI schemes recover 12-51% of health costs.
In Rwanda, members contributed twice as much to the costs of health care as non members (Bennett
et al., 2004)
If adverse selection occurs, sustainability decreases. This takes place when people with high risk join
the scheme, increase the costs and make lower risk people to leave or not to join the scheme. This is
the reason that many CBHI schemes exclude e.g. hiv-aids and TB (e.g. none out of 10 schemes in
Senegal included hiv-aids, 6 out of 8 in Ghana did, but only preventive care). However, considerable
research is done about pilot projects where hiv-aids is included in CBHI schemes or where these
schemes are used as a channel to provide access e.g. to external funds for ARV from the Global Fund.
Schemes often apply the 60% rule to avoid adverse selection: 60% of a group or community should
be enrolled in the scheme. On the other hand, this rule may be an obstacle for enrolment. Other
schemes offer discount to groups that have 60% enrolment.

On impact of health programs

Derrienic et al. (2005) did an assessment of twelve CBHI schemes in Uganda. They found that a
significant positive effect of scheme membership on quality of life (actual health situation and ability
to cope with health costs). Marketing strategies with the help of membership incentives (subsidies on
insecticide treated nets) proved effective. The Mutolere hospital based scheme also includes
preventive care in its benefit package, thereby reducing the costs for curative care.
In Rwanda, members of schemes are four times more likely to make use of health care (members:
1.2-1.6 consultations/capita/annum, non-members 0.2-0.3), members consumed fewer drugs per
consultation, indicating that health care is sought in an earlier stage. Use of preventive services for
women and children increased fourfold compared with non members. Prenatal care was 65% more
likely and delivery assistance was twice as likely. Increased social solidarity was another benefit
(Bennett et al., 2004). The research by LSHTM found that some insured members still fall below
poverty line because of OOP spending for uninsured costs, which indicates that the benefit package
may not be sufficiently comprehensive.
In India, officially health care is free for the poor, but in practice people have to pay for drugs and
informally also for treatment. More than 40% of hospitalized people borrow money and 24% of
hospitalized people fall below poverty line because of the costs involved (2002 Worldbank study by
Peters et al., quoted in Devadasan et al, 2004. For Andhra Pradesh, this figure is 22%, Preker et al.,
2002). Experience with CBHI shows that people seek earlier treatment when insured and do not wait
until sickness becomes an emergency.
CBHI schemes mainly reach the rural middle class (who generally belong to the country’s poor). It is
harder to reach the poorest section. Targeted subsidies or solidarity funds from local churches are
sometimes used successfully to increase the outreach. Payments in kind, or scheduled at harvest time,

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or linked to saving schemes are other ways. Preker et al. (2002) also conclude that financial
protection does take place, but that the poorest are sometimes excluded.
CBHI schemes also have a potential impact on the quality of health care itself, by providing additional
resources and by strengthening accountability. However, this effect is hardly documented, as also
Ekman (2004) notes: There is strong evidence that community-based health insurance provides some
financial protection by reducing out-of-pocket spending. There is evidence of moderate strength that
such schemes improve cost-recovery. There is weak or no evidence that schemes have an effect on
the quality of care or the efficiency with which care is produced. In absolute terms, the effects are
small and schemes serve only a limited section of the population. The main policy implication of the
review is that these types of community financing arrangements are, at best, complementary to other
more effective systems of health financing.
However, not everyone agrees about the positive effect of CBHI schemes on health status. A report
by ILO and STEP (2002) did a literature survey and concluded (with a lot of caution because of the
small quantity of reliable data) that there is no evidence for a positive impact on health status, on
utilization of services or on risk protection and that there is no valid evidence either for any other
benefit. The main factor responsible for this lack of impact, according to the study, is the small size of
the schemes, with 70% under 2000 members. The study sees the main use of CBHI’s in its
intermediate function to provide access to SHI or NHS systems.

5. Best practices

Cripps et al. (2000) have written a very extensive and practical (222 pp) guide to setting up a CBHI
scheme.

The importance of marketing

Marketing CBHI is much tougher than micro credit, especially when medical services are officially free
or have formerly been offered for free. Making use of existing networks of grass roots groups, like
micro credit groups, self help groups, workers’ unions or a system of social workers who know the
people helps marketing of CBHI. The twelve schemes researched by Devadasan et al. (2004) all make
use of existing community based organisations, or unions, or cooperatives. More comprehensive
benefit packages are the most forceful factor for marketing success.
In India, targeted subsidies for the poorest were advocated for. Experience has shown that it is vitally
important to make good use of marketing first and financial sustainability of the schemes should not
be dependent on subsidized premiums. In Karnataka enrolment went down from 82.000 to 25.000
when people from lower castes were asked to pay the premiums themselves in the fourth year, after
having been subsidized for three year (Cohen, 2006).

Participation and ownership

The definition of CBHI already includes the notion of ownership. Especially in terms of defining the
conditions, the premiums, the packages of benefit, it is important to listen to the participants’ wishes.
Among experts there is disagreement as to what the poor want most: protection for emergency
situations (surgeries, hospitalisations), or protection and payment for primary health care, drugs or
even transportation costs.
Ownership of the schemes also improves efficiency and reduces fraud by increasing social control and
accountability. E.g. in a scheme in Uganda, members decided to raise co-payments in order to protect
the financial viability of the scheme (Derrienic et al., 2005).
Another aspect of it is influence in management of the fund. Especially with provider-based CBHI, this
is an important and more difficult issue.
Also, when there are targeted subsidies, the community should be involved. Criel (seminar 27-06-06)
indicated that in this way targeted subsidies for premiums for the poorest of the poor (the destitute,
homeless) are easily determined, but difficulties arise when it concerns those just above this level.

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Working at understanding insurance concepts

This is related to the point about marketing. In many case studies, lack of understanding is mentioned
as a reason for drop outs for the schemes: people do not understand the use of co-payments or
expect to have their premiums returned if they do not fall sick.
A pre-assessment of willingness to pay seems to increase this willingness (Preker et al., 2002).

6. Actors

In The Netherlands

Following, the 27-06-06 seminar, an initiative is started to form a network for exchange and
cooperation. Cordaid and Ecorys are leading, ICCO is also involved.

InterPolis (now part of Achmea) (Toon Bullens) is active in CBHI. Achmea is also planning to set
up a foundation.

Micro Insurance Association Netherlands, MIAN (www.mian.nl). Rabobank Foundation is partner
of this association. They support some projects in Sri Lanka, Philippines, India (TN)

Rabobank Foundation. Frank Bakx indicated that RF has no specific expertise in the field of CBHI,
but would be willing to think along and use his network to introduce us to experts.

Dutch NGO’s involved in CBHI’s: Cordaid (Mutolere hospital, Uganda), Oxfam Novib (Dhan, India.
I.s.m. Mian / Interpolis), ICCO: nog niet.
Other countries:

Belgium: Masmut (www.masmut.be) is a platform of various actors: research, policy, insurance
companies, NGO’s in the field of micro and social health insurance.

Uganda: Uganda Community Based Health Financing Association (UCBHFA), financed by Ministry
of Health in Uganda: a network of CBHI schemes.

India: network of CBHI: (www.comhealthins.org), CHIN (Community Health Insurance Network).
The network has 67 members from many different states, but not all are involved in CBHI yet
(incl. a hospital from The Leprosy Mission in Uttar Pradesh). Through its website, CHIN offers
many overviews of CBHI, case studies, lessons learned and impact analyses. Dr Devadasan is
coordinator of this network.

India: (www.microhealthinsurance-india.org) Consortium of the Federation of Indian Chambers of
Commerce and Industry (FICCI), the Erasmus University Rotterdam, The Netherlands, and the
University of Cologne, Germany (Dutch profs David Dror and Wijnand van der Ven). Focus on
research and training. With a good database of article (abstracts) on the topic. In case we would
consider a (pilot-) project in India, it should be worthwhile to contact this consortium. Also in case
we would like to do extended research, a student from Erasmus University would seem a good
option.

www.concertation.org. African network for CBHI. French speaking countries. With summaries

about health finance, regulation for health insurance, documents and lists of organisations per
country. (6 CBHI schemes in Burkina Faso, mainly very small).

7. Conclusions and Recommendations

Strengths of CBHI
Weaknesses of CBHI

Better access / use to health care

Protection against high costs

Better cost recovery of health care (but not
fully)

Increased solidarity

Potential for increased efficiency and
effectivity through increased accountability

Useful as intermediate mechanism toward
general insurance systems

May serve as effective mechanism for
targeted subsidies

Limited protection

Sustainability of schemes questionable

Often small scale (related to two points
above; reinsurance needed)

Exclusion of the poorest

Danger of adverse selection (only high risk
members join)

Danger of over-consumption or over-
prescription (depending on model used)

Effect on providers of care often limited

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1. Insurance business is a very technical area that requires very specific expertise, different from
expertise in micro credit.
2. CBHI is not a solution to replace external assistance to health projects. It should rather serve as
an additional resource for health finance or a (partial) replacement for OOP spending, to be
completed by government spending / external funding / OOP co-payments.

Actions for pilot project

Looking at the complexity of CBHI, the absolute need for participation from the communities involved
and the probable need for an extensive feasibility study, the decision to set up a pilot project must be
taken by the partner organisation involved after careful discussion.
1. CSS seems the most natural partner to possibly become involved in CBHI. A hospital, a micro
credit program and a PHC program are all operating in the Khulna area. CBHI could possible be
provider based (the AWM hospital), but could also be linked to the micro credit program. In any
case, a sizeable number of potential members could be reached. At the same time, Bangladesh
does have experience with CBHI. Rabobank Foundation is going to be involved in the micro credit
program of CSS. Frank Bakx indicated that he would be willing to also take CBHI into
consideration, but that specific expertise in this field would need to be attracted from elsewhere,
possibly through the network of Rabobank Foundation.
Recommendation: discuss CBHI with CSS during any next visit. Next steps depend on the
outcome of such a discussion.
2. Other partners: send this brief survey for information and indicate that Woord en Daad is
considering to become active in this area. During working visits to these partners, the topic should
be raised. Possible next steps depend on initiative and enthusiasm of partners.
Partners concerned: AMG India, Word and Deed India, AMG Guatemala, CDA Colombia, AMG
Haiti.

Literature

Bennett, S., A. G. Kelley, and B. Silvers. 2004. 21 Questions on CBHF: An Overview of Community-Based Health
Financing. Bethesda, Md.: Abt Associates, Inc., Partnerships for Health Reform Project.
Carrin, G., and C. James. 2003. Determinants of Achieving Universal Coverage of Health Care: An Empirical
Analysis. In: Martine Audibert, Jacky Mathonnat, and Eric De Roodenbeke, eds., Le financement de la santé
dans les pays d’Afrique et d’Asie à faible revenu. Paris: Karthala. (cited in: Gottret and Schieber, 2006)

Cohen, Margot. 2006. Community-Based Health Insurance shows promise in India. Article on http://www.prb.org
[accessed on 20-07-06].
Cripps, Gilbert, Janet Edmond, Richard Killian, Stephen Musau, Priya Satow, and Madjiguene Sock. 2000. Guide
to Designing and Managing Community-based Health Financing Schemes in East and Southern Africa.
Bethesda, MD: Partnerships for Health Reform, Abt Associates Inc.
Derriennic, Yann, Katherine Wolf, and Paul Kiwanuka-Mukiibi. February 2005. An Assessment of Commmunity-
Based Health Financing Activities in Uganda. Bethesda, MD: The Partners for Health Reformplus Project, Abt
Associates Inc.
Devadasan, N., Kent Ranson, Wim Van Damme and Bart Criel. 2004. Community Health Insurance in India, an
overview. Economic and Political Weekly. Consulted online at http://www.comhealthins.org [20-07-06].
Ekman, B. 2004. Community-Based Health Insurance in Low-Income Countries: A Systematic Review of the
Evidence. Health Policy and Planning 19 (5): 249–70.

Escobar,M-L. 2005. The Columbia Health Sector and the Poor. World Bank, Washington: the World Bank

Gottret, Pablo and George Schieber, 2006. Health financing revisited; a practitioner’s guide. Washington: the
World Bank.
ILO and STEP (International Labour Organization and Strategies and Tools against Exclusion and Poverty). 2002.
Extending Social Protection in Health through Community Based Health Organizations. Discussion paper, ILO
and STEP, Geneva.
Preker, Alexander S., Carrin, Guy, Dror, David et al. 2002. Effectiveness of community health financing in
meeting the cost of illness. Bull World Health Organ, vol.80, no.2, p.143-150. [consulted at

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Ranson, M.K. 2002. Reduction of catastrophic health care expenditures by a community-based health insurance
scheme in Gujarat, India: current experiences and challenges’. Bulletin of the World Health Organization 80
(8): 613-621.
Schieber, George, Cristian Baeza, Daniel Kress, and Margaret Maier, Financing Health Systems in the 21st
Century. 2006. Disease Control Priorities in Developing Countries (2nd Edition),ed. , 225-242. New York:
Oxford University Press. DOI: 10.1596/978-0-821-36179-5/Chpt-12
Seminar: Equity in Health: challenges for social and community insurance schemes. Held 27-06-06, at Den Haag.
Organised by Dutch Ministry of Foreign Affairs and Cordaid Speakers: Leon Bijlmakers, ETC; Alex Preker,
Worldbank; Bart Criel, Institute Tropical Medicins Antwerp; Grant Rhodes, Ecorys; Pontius Mayunga, Mutolere
Hospital Uganda.

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Appendix 1 – Terms of Reference Research

This is the Terms of Reference (TOR) for the following Research
Name of research study
Research on Community Based Health Insurance
W&D Projectnumber
91.92.001
Contact person/programme
Wouter Rijneveld
Partner organization(s) involved
n.v.t.
Contact person(s)
n.v.t.
Other agencies involved
n.v.t.
Contact person/programme
n.v.t.
Leading organization
Woord en Daad
Research carried out by
Wouter Rijneveld
Date of application
01-07-2006
This TOR has been discussed and agreed upon by the parties involved.
1. Introduction and Context
-
See Introduction of the report
2. Objectives and expected results of the research
-
Objectives:

Get an overview of experiences with community based health insurance (CBHI) as a
mechanism for financing health care.

Determine whether it is worthwhile to start up a pilot project with CBHI.
-
Research question: Could CBHI be a possible model for financing health projects of Woord en
Daad?

What are experiences with CBHI thus far?

What are advantages and disadvantages of CBHI?

What is the effect of CBHI on the impact, outreach and quality of health programs?

What is the effect of CBHI on the sustainability of health programs?
-
The conclusion of the brief report (max 10 pp) should be whether and how to set up a pilot
project of CBHI.
3. Methodology and Approach
-
Literature survey
-
Seminar on Social and Community Health Insurances, 27-06-2006
4. Required expertise
-
Internal research
5. Roles and responsibilities
-
Internal research
6. Follow up
-
This introductory research will determine whether or not a pilot project will be started. If this
will be recommended, this will be further discussed with potential partners.
7. Planning and budget
-
Research: July – September 2006, so that costs for a pilot project can be included in the
yearplan 2007
-
Time involvement: 4 days at 9 hours = 45 hours
-
Costs: none, except travelling costs to seminar
8. Approved by:
Gorinchem, date
Place, date
On behalf of Woord en Daad
On behalf of organisation

9192001.Community Based Health Insurance.060720.wr.doc13/14

Jan Lock, managing director
Name, function

9192001.Community Based Health Insurance.060720.wr.doc14/14

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