Voir page 620 le resume en francais. En la pagina 621 figura un resumen en espanol.
For over 20 years, calls have been made for communities in developing countries, to plan, finance, organize and operate health care services. The Declaration of Alma-Ata implied that community participation was integral to the achievement of health for all, and it stated that "primary health care requires and promotes maximum community and individual self-reliance and participation ... making fullest use of local, national and other available resources" (1). The Bamako Initiative aimed to make primary health care universally accessible through community financing and management (2), but questions remain as. to whether, how and how much poor people in poor countries can or should be expected to contribute towards health care.
The issue of primary health care and its financing matters most to poor people themselves. Material wealth, health and the ability to cope with adverse health events are intimately related. The World Bank defines poverty as "encompassing not only material deprivation but also low achievements in education and health ... [and] vulnerability and exposure to risk" (3). A person with a low income may be unable to afford preventive care--or curative care in the event of illness--and this may worsen their health. In the event of serious illness, the poor are particularly vulnerable to the financial burden of lost income and out-of-pocket medical expenses, as they have low levels of the assets (for example, access to savings and credit or land and belongings for sale/mortgage) necessary to cope. Disease or illness can force a person, and their household, into a vicious downward spiral in which poor health depletes assets and low levels of assets lead to worsening health and an inability to cope with future illness. In theory, health care provided by governments should cover poor people; in practice, it often does not. Ways to protect the poor from the costs of medical care are needed.
Community-based health insurance
Community-based health insurance schemes allow many people's resources to be pooled to cover the costs of unpredictable health-related events. They protect individuals and households from the risk of catastrophic medical expenses in exchange for regular payments of premiums. Prepayment (even in the absence of pooling) can facilitate access to expensive medical care, because it spreads costs over time and prevents people having to pay at the time of treatment. By pooling resources, health insurance schemes can improve equity of and access to health care and can offer financial protection.
In risk-sharing schemes, the insurance premium is unrelated to the likelihood that the insured will fall ill and benefits are provided on the basis of need--hence, payments go to the People who are most ill. Because people with lower incomes and those who are less educated tend to be in poorer health than those with higher incomes and those who are more educated, the former stand to gain more from insurance schemes (4). In cross-subsidization schemes, premiums are indexed to the member's income, and access to health care for the poor is as good as (or better) than that for the wealthy. In such schemes, wealthy members subsidize health care costs for poorer members.
Policy-makers hope that community-based health insurance will contribute to WHO's recently proposed "final" health system's goals of better health, fair financing and responsiveness (5). Community-based health insurance allows pooling in settings where institutional capacity is too weak to organize nationwide risk-pooling, especially in low-income countries. A basic question is whether community-based health insurance can cover populations large enough to put the pooling functions--risk-pooling and cross-subsidization--to use.
Most evaluations of community-based health insurance schemes have focused on instrumental goals--scheme design and management, percentage coverage of target populations and levels of cost recovery (6, 7). …