Problems and Purpose

Community Based Health Insurance (CBHI) schemes have become a primary way of financing healthcare in several developing countries today, most often financed through general tax revenues or contributions from social insurance groups.[1] In Ethiopia, the CBHI initiative was set up as a community-based health project that gathers payments made by members into a fund, which covers basic health care costs; thus, members are enabled access at local health care centers whenever they are sick.[2] CBHI stems from the Ethiopian Federal Ministry of Health’s (FMOH) effort to reach universal health coverage by improving overall financial protection for healthcare.[3]

Again, CBHI in Ethiopia targets the government's aim of improving healthcare in the country by implementing a policy that adequately mobilizes domestic resources and improves access to quality healthcare.[4] Although this is not the first health reform adopted by the FMOH, findings from a USAID report reveal that previous reforms did not significantly affect health service utilization as, “rates remained as low as 0.36 contacts per person per year.”[5] This was primarily due to high cost of services, especially for families who could not afford to pay these rates at once.[6] Thus, the CBHI initiative was adopted as a means for families to have better financial protection for healthcare and increase the willingness of members of the community to seek modern health facilities more frequently.[7] Additionally, this approach was also implemented with the objective of increasing access to sustainable healthcare.[8]

Background History and Context

The Community Based Healthcare Insurance (CBHI) strategy in Ethiopia could be considered to originate from an ancient Ethiopian traditional practice known as the Idir.[9] The Idir was a long-term traditional financial institution set up by community members to help sustain local finances and raise funds that help during emergencies such as deaths within groups and families.[10] Over the years, this traditional financial institution has translated into a healthcare insurance scheme that requires the contribution of funds amongst community members to help cater to health care needs whenever a member is sick.[11]

While the Idir practice caters to unforeseen emergencies such as deaths, CBHI in Ethiopia attempts to prevent these unexpected emergencies by converting these same finances to a life saver rather than funeral fund.[12] Accordingly, the initiative was launched as the first of its kind in 2011 across 13 Woredas (districts) within the four main regions of the country.[13] Prior to this, the Federal Ministry of Health (FMOH) tried to pursue a rather vigorous policy on health since 1993, which included the construction of primary health facilities, as well as the development of the human and technical resources required to run them; these human resources involved providing adequate training for personnel.[14] The popular Community Health Workers initiative (CHW), also known as the Health Extension Program (HEP) is an example of these policy efforts.[15] These initiatives were introduced to improve healthcare quality at community levels, so they involved training several voluntary community health workers who would be dispatched to various communities across the country to provide basic healthcare services for households.[16]

These previous (albeit still ongoing) strategies have positively influenced overall health care services in the country, but have not addressed the financial constraints that local community members faced.[17] As a result, the CBHI scheme is the first of its kind to take these considerations into account and put into motion a concise healthcare financing approach.

Though there is no substantial proof that CBHI was born out of citizen and community demands, it can be alleged that the initiative developed out of a lack of equal access to healthcare due to financial constraint.[18] Thus, because it addresses a communal need, it is an initiative which every member of the community is able to engage in, thereby participating with health-care services significantly more than they would have been able to in the past.

Organizing, Supporting, and Funding Entities 

With the aid of the Ethiopian Health Insurance Agency (EHIA) the Community Based Health Insurance (CBHI) initiative was launched in 2011.[19] Both EHIA and the Federal Ministry of Health’s (FMOH) act as supervising and executive units of the project and have set up smaller national coordinating units to supervise operations.[20] Health Insurance Steering Committees have been launched at both the regional (woredas) and local administrative/village (kebele*) levels.[21] These committees are in charge of setting up and running CBHI schemes.[22] The United States Agency for International Development (USAID), CARE Ethiopia and Abt Associates (a global leader in research and program implementation on issues pertaining to health, social, and environmental policies) also play a major supporting role, in terms of designing, piloting and scaling up of the scheme.[23]

Financing comes through premiums gathered by community members that cover all health and curative services for families[24] as well as through a 25% subsidy provided by the government.[25] Once these premiums are collected, the funds go straight to the kebele representatives (usually selected by community members), who then make payments to the woreda** head offices.[26] These offices then reimburse hospitals and health centres.[27] 

Participant Recruitment and Selection

Enrolment in the scheme is determined by government officials on a household basis, rather than individually.[28] To be recognized as a member of the scheme, participants have to be registered through a household to avoid biased and unfair selections of membership. Awareness activities at the pilot stage creates the opportunity for kebeles to choose to join the scheme if a majority of villagers support the idea and show interest.[29] Beyond that, households have the individual choice of being a part of the initiative or not. Once households apply to participate, kebele officials along with the community screen and select the households that they believe to be the poorest to gain access to the extra 10% provided by the government as a subsidy to poorer community members.[30] Each woreda is represented by a general assembly and board members chosen and elected for by the community.[31]

Methods and Tools Used

Community-based health insurance schemes involve a methodology of collective prepayment and pooling of health risks at the level of a self-identified community.[32] Participation in these schemes is voluntary and membership linked to making a contribution, though the rate is poorer households.[33] The community is involved in “the setup, governance, and management” - in fact, the national coordination unit of the CBHI scheme worked on developing financial and administrative management tools.[34] These tools were then used to train and inform the different stakeholders, such as healthcare workers and local government staff. The scheme is overseen in each woreda by an elected general assembly and a board.[35] Based on the “participatory decision-making and management structures”, CBHI can empower communities while also improving transparency and accountability.[36]

This initiative used community-based monitoring. Broadly defined, community-based monitoring involves service providers seeking community oversight and feedback to improve efficiency and quality by responding to the stated needs.[37] Score cards, interviews, and surveys are among some tools utilized with this method.[38] Qualitative information was gathered on three types of target groups in each woreda: members of CBHI schemes, non-members, and the staff, in order to identify how participants perceived “the benefits of CBHI and its perceived positive and negative impacts for members and facility staff.”[39] 

What Went On: Process, Interaction, and Participation

A major feature of the scheme was not only to ensure that decisions were not just made at the governmental level, but to create a structure that required both simultaneous management by community members and the support of the government.[40] Awareness activities are carried on by organizing officials from the ministerial level and after then, decision to join is fully up to kebeles and households involved.[41] Each woreda is represented by a general assembly and a board who have control of day-to-day decision making processes of running the scheme, dealing with registrations, maintenance, and more.[42]

General assemblies consist of 3-5 kebele delegates selected by community members and 8-10 woreda public sector representatives.[43] Under the board is an executive body that operates the day to day aspects of the scheme which includes registering of members and collection of premiums.[44] The government only pays three staff (i.e. coordinator, accountant and information specialist) at the woreda level and uses local government administration staff at the kebele level.[45] There is also a communications specialist, who works with community members to mobilize and help run meetings and activities.[46] 

Each woreda is also paired with a health center that is closest to them, and are thus advised to first access their nearest health center before proceeding to larger hospitals (who might have the necessary resources needed for treatment) upon reference or other collaborating medical centers if need be.[47] Mebratie et al. report a “30 to 41% increase of outpatient care utilization at public facilities” showing that more families are now making access of modern healthcare facilities without having to sell off their property and possessions to afford it; presumably, this has ensured the saving of many lives, due to the fact that improved access can influence early diagnoses and treatments of illnesses.[48] Even though the scheme relies mainly on funds raised by community members, there is free coverage for the poorest 10% through a subsidy provided by the government.[49] Whilst the government subsidizes 25 percent of the fees of the scheme as a whole, contributions are made amongst households per month that range anywhere between 0.56 USD to 0.80 USD per household depending on the region.[50]

Each participating household gets a Community Based Health Insurance (CBHI) health card that permits them to go to the nearest clinic for treatment without having to pay on arrival.[51] Members are only able to access health centres that have signed a contract with the CBHI administrators at the district level.[52] As a result, fees are not reimbursed if members visit a health provider that isn’t in collaboration with the scheme.[53]

Although participants are not limited or denied the opportunity to voice out opinions, the design of the project rarely permits for this to happen. Thus, most participants are given the opportunity to respond and address their opinions and concerns during monitoring phases conducted by the Federal Ministry of Health (FMOH) and the Ethiopian Health Insurance Agency (EHIA); additional research studies on Community Based Health Insurance (CBHI) conducted by other NGOs and research agencies also offered this engagement.[54] Most members have participated through answering questionnaires and interviews that address participant satisfaction, the extent to which participants have increased healthcare utilisation and its effect on household economic welfare.[55] Ergo, participants voice out their opinions mostly during data collecting processes.

Derseh et al., highlight that although CBHI was first introduced by the government and does receive financial subsidies from the government to cover poorest groups, it is firmly community-based, as the community takes on the collective entitlement and responsibility of maintaining payment of premiums to ensure that the scheme is successful.[56] There has also been full involvement of community leaders (i.e. local chiefs, religious leaders, elders and others) as advocates, which has helped influence the creation of awareness and facilitated acceptance towards the scheme.[57]

Influence, Outcomes, and Effects

Project Outcomes

Citizens involved helped influence knowledge production on the progress of the scheme. Responses provided by citizens gave a comprehensive indication of the success of the scheme so far. In addition to this, Mebratie et al. estimate that there has been empowering outcomes from the scheme on community engagement with healthcare facilities due to better financial security.[58] The authors also conducted a study across 12 different woredas to highlight the increase in access to healthcare services and the role CBHI played in facilitating financial protection.[59] They found that tendencies to be in debt have reduced in communities, as members no longer incur heavy debt from borrowing to treat themselves.[60] Continued participation in the scheme also suggests that enrollment influences the probability of members getting access to drug/healthcare infrastructure. Quality of services provided have also improved, mostly as a result of the increase in cash flow that the scheme encourages, reflecting positively on the availability of drugs and supplies.[61]

Development Outcomes: Women's Empowerment

An important outcome highlighted in the study is the role the scheme played in empowering women and children and serving them better.[62] Academic Naila Kabeer describes women’s empowerment as the “process by which those who have been denied the ability to make strategic life choices acquire the ability to do so.”[63] This, she says, is best illustrated through the ability to exercise choice, acquire agency and lay claim on future resources.[64] Results from the scheme demonstrate that because Community Based Health Insurance (CBHI) members could access healthcare without having to pay any fee at the time of service, many women and children could now go to healthcare centers without requesting for financial support from the male head of the household.[65] Their CBHI card gives them the agency to simply walk into a healthcare center and demand for healthcare assistance. While according to Kabeer this is definitely an indication of empowerment, she also writes that it is difficult to measure empowerment because it often relies heavily on the validity of assumptions made.[66] In regards to CBHI, this might be true, as we are not aware of the previous positions of women and if they could not access healthcare in the past with their own minimum wage finances. Women are often said to be most involved in informal jobs (such as street vending, or service delivery) and therefore often have their own finances. While these assumptions are definitely not proven, they simply serve to pose as a counter argument to the notion that the CBHI has influenced gender empowering outcomes. Additionally, even if empowerment has been achieved in this regard, there are still several categories of everyday life through which women are still struggling to attain agency. 

Analysis and Lessons Learned

A USAID report on the scheme revealed the following lessons:[67]

1. Strong government commitment is essential to the successful pursuit of Universal Health Care.
2. The incorporation of Community Based Health Insurance (CBHI) schemes with government systems can be beneficial.
3. Community wide involvement from community and religious leaders or elders is necessary for the success of the scheme.
4. CBHI enhances the accountability of healthcare centers.
5. The quality of health care service is important for full participation, as some facilities lacked the necessary infrastructure at the beginning of the scheme.
6. Addressing capacity at a local level to support the scheme is important.
7. Sustained technical assistance is important.

Importance of strong prior community ties

The emergence of CBHI was effective due to already existing forms of community engagement which contributed towards a smoother transition of community cash saving schemes into health care financing systems.[68] It could be easier to gain community trust, seeing as the schemes design built on traditional forms of financing.[69] Promises made to the community were easily sold, as it was almost a win-win situation for them (i.e. continue to engage in a formalized form of Idir, while at the same time receive free healthcare and access to services and better facilities). 

Community members also play a key role in sustaining the project. Their involvement keeps the scheme running as the continued participation of one household encourages the continued participation of another. As a result, participation is very important for the success of the project because every single member of the CBHI scheme per community depends on the contributions made by one another to complete these funds. Thus, if one household fails to make their contribution, members are sometimes left short changed.

Need for increased involvement in vocalizing health needs

Although the scheme was launched by the Federal Ministry of Health (FMOH), outcomes were also affected by the community, and thus in the end all parties were represented. There should perhaps have been an initial meeting in each community to find out what community members were passionate about and looked forward to in terms of healthcare and then based on this, created focus groups that helped to map out this process. Focus groups could then have been initiated more frequently, to track the progress of the project as well as become a symbol pr face for accountability processes both for community members and the government.

Need for more transparency

Although general assembly members are selected at the local level as well, it is hard to tell if members of these committees were selected based on clientelistic features or not. Clientelism is defined by Fox as the “relationship based on political subordination in exchange for material rewards”.[70] In this situation, members chosen could have been selected based on political interests; thus, these politically selected members gain access to cheap health care even if they are from middle class families who could alternatively afford to pay by themselves. Consequently, there is a valid reason for more research to be conducted in questioning the extent towards which power relations and abuse of the service may be influencing the success of the scheme.

Increasing visibility between state-led forms of participation and community-led engagement practices

The participatory level in this scheme is not as high as many citizen participation projects.[71] In light of this, the differences between state-led forms of participation and community-led engagement initiatives should be analysed as a means of identifying the best paths to democratic outcomes – especially with consideration of contextual limitations (i.e. the authoritative nature of the Ethiopian government, in this case). Furthermore, this authoritative nature can also be attributed to the levels at which citizen response on the impact of the scheme is reported as data collection might not be an honest reflection of people’s real views, especially if participants fear the risk of stating too many negative observations.

Sherry Arnstein, in her notable research on the ladder of citizen participation, notes that participation and the interactions involved in most cases encompass elements of power and control, where there is top-down decision-making control from agencies.[72] Comparatively, those at the bottom barely participate due to the manipulated nature of the position they are in at the bottom.[73] In other words, seeing as the aim of most development projects is to either educate members or fix an issue, these members are manipulated into following the rules of those at the top, leaving little to no room for their participation in decision making.[74] The CBHI scheme, although advertised as a cooperative engagement between the community and the government, features a situation where many decisions are made at the top and rarely any at the level of community members are actually utilizing the service. This consequently challenges the democratic outcomes of the scheme, although this may not be the government objective.

Analysis of Gaventa and Barrett in relation to Citizen engagement and CBHI

Some of the development outcomes mentioned in Gaventa and Barrett's report are on their way to being achieved with the CBHI scheme - if not fully achieved yet. The four development and democratic outcomes highlighted by Gaventa and Barrett and present in the CBHI scheme are as follows:[75]

1. The enhanced construction of citizenship
2. The strengthening of participatory practices
3. The strengthening of responsive and accountable states
4. The development of inclusive and cohesive societies.

The first outcome, enhanced construction of citizenship, can be measured through the involvement and willingness of community members to continue to pay their monthly fees, even if no member of their own individual families has ever needed healthcare services. This can promote citizenship, as a sense of belonging and inclusion begins to be constructed - members begin to realize that being part of a community is not only about self enhancement but the overall improvement of the community at large. The second outcome - strengthening of participatory practices - is also embodied within the project, as the scheme fosters a practice of formalized community engagement through micro-financing.

A developing nation could rely on domestic resources (in this case premiums paid by community members) to enhance a development strategy. As this case demonstrates, traditional practices could also be adopted as a strategy to aid rural dwellers to embrace modern practices. A large portion of the global population still do not engage with the resources that modernization brings along, which is often attributed to the issue of access.The scheme here increases the willingness of community members to use modern healthcare infrastructure, without worries of affordability.[76] Thus, a resounding theme in this initiative is the fortified convergence of the traditional (idir practice) and modern (access to health infrastructure), and how the former can still play a role in ascertaining the latter despite modernization. Accordingly, it would be interesting to look further into the intersections and interrelations between state led forms of participation and community-based practices.

The third outcome, strengthening of responsive and accountable states, can be seen through the role of the Federal Ministry of Health (FMOH) and the Ethiopian Health Insurance Agency (EHIA) with their responsibility to keep the CBHI sustainable and continuously improving. Although it is hard to say if this has been achieved yet as it is an ongoing outcome, the fact that the government is accountable to all the community members involved in the scheme challenges both the FMOH and the EHIA to stay transparent and accountable to all the funds they receive. Due to the nature of the scheme, where several communities have their eyes on the quality of services they are receiving, a mismanagement of funds or failure to deliver promises would easily be noticed. While this presents the opportunity for several democratic outcomes, especially if recognition of government shortcomings encourages members to speak up and resist, it is also necessary to consider the fact that the different power relations existing within the scheme could pose as a resistance for community members - who are at the lowest level of this power hierarchy - to voice out any sorts of frustrations. 

Finally, Gaventa and Barrett's fourth outcome, development of inclusive and cohesive societies, can also be classified as an ongoing process, which would be carried on even after the CBHI schemes come to an end - if they do. This initiative promotes the development of more cohesive and inclusive societies because it negates the existence of class or ethnic differences: families are involved into the scheme regardless of their differing social differences. Although it is catered towards the poorest families in the community, these families are only selected based on their social class and no other strata of qualification. 

Overall, this initiative can enhance community engagement and reflect Gaventa and Barrett’s four developmental/ democratic outcomes. Thus, it would be necessary to keep paying attention to the ongoing processes of the initiative – as it is still fairly new – and for the scheme to balance up the roles of actors at the bottom and those at the top. 

See Also

Community Organizing 

Community Development Associations 

Community-Based Participatory Research 

Community-Based Monitoring 

References

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[70] Jonathan Fox, “The difficult transition from clientelism to citizenship: Lessons from Mexico.” World politics, no. 46 (1994): 153, https://www.researchgate.net/publication/247837753_The_difficult_transition_from_clientalism_to_citizenship 

[71] Guy Carrin, “ Community based Health Insurance Schemes in Developing Countries: facts, problems and perspectives,” x.

[72][73] Andrea Cornwall, “Unpacking ‘Participation’: models, meanings and practices.” Community Development Journal, no. 43(3), (2008): 271, https://scinapse.io/papers/2166826583 

[74] Arnstein's Ladder of Citizen Participation, The Citizen’s Handbook, accessed February 16, 2019, http://www.citizenshandbook.org/arnsteinsladder.html

[75] John Gaventa and Gregory Barrett, “So what difference does it make? Mapping the outcomes of citizen engagement”, IDS Working Paper, (2011): 3, http://unpan1.un.org/intradoc/groups/public/documents/un-dpadm/unpan044380.pdf

[76] Solomon Feleke, Hailu Zelelew, and Tesfaye Ashagari, “Ethiopia’s Community-based Health Insurance: A Step on the Road to Universal Health Coverage,” USAID Health Finance and Governance, accessed February 9, 2019, http://pdf.usaid.gov/pdf_docs/PA00KDXT.pdf.

External Links

Gaventa & Barrett IDS Working Paper http://www.ids.ac.uk/files/dmfile/Rs347.pdf

USAID Report: Ethiopia’s Community-based Health Insurance http://pdf.usaid.gov/pdf_docs/PA00KDXT.pdf

World Health Organization Discussion Paper: Community-based Health Insurance Schemes in Developing Countries http://www.who.int/health_financing/documents/cov-dp_03_1_community-base...

Notes

* A kebele is the lowest level of government administration, equivalent to wards

** A woreda is the district level government administration; ie. woredas consist of kebeles

Image: Ethiopian Woman With her CBHI Membership Card/HFG https://goo.gl/5mZ25D