Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso

Using community wealth ranking to identify the poor for subsidies: a case study of community-based health insurance in Nouna, Burkina Faso

Access to health-care is low in developing countries. Poor people are less likely to seek care than those who are better off. Community-based health insurance (CBI) aims to improve healthcare utilisation by removing financial barriers, unfortunately CBI has been less effective in securing equity than expected. Poor people, who probably require greater protection from catastrophic health expenses, are less likely to enrol in such schemes. Therefore, it is important to implement targeted interventions so that the most in need are not left out. CBI has been offered to a district in Burkina Faso, comprising 7762 households in 41 villages and the district capital of Nouna since 2004. Community wealth ranking (CWR) was used in 2007 to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. The CWR is easy to implement and requires minimal resources such as interviews with local informants. As used in this study, the agreement between the key informants was more (37.5%) in the villages than in Nouna town (27.3%). CBI management unit only received nine complaints from villagers who considered that some households had been wrongly identified. Among the poorest, the annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 after subsidies. CWR is an alternative methodology to identify poor households and was found to be more cost and time efficient compared to other methods. It could be successfully replicated in low-income countries with similar contexts. Moreover, targeted subsidies had a positive impact on enrolment.

Exploratory study of the impacts of Mutual Health Organizations on social dynamics in Benin

The primary aim of Mutual Health Organizations (MHOs) is the financial protection of their members. However, given their community-based, participative and voluntary nature, it is conceivable that MHOs, as social organizations, would affect social dynamics. In an exploratory study in Benin, we studied social dynamics related to mutual aid, relationships of trust, and empowerment. Four MHOs, as contrasted cases, were selected from among the 11 in the region. Focus groups (n = 20) and individual interviews (n = 29) were conducted with members, non-members, and elected leaders of the four MHOs, and with professionals from the health facilities concerned. We carried out a qualitative thematic analysis of the content. Mutual aid practices, which pre-date MHOs, can be mobilized to promote MHO membership. Mutual aid practices are based on relationships of trust. The primary reason for joining an MHO is to improve financial accessibility to health services. Non-members see that members have a strong sense of empowerment in this regard, based on a high level of trust in MHOs and their elected leaders, even if their trust in health professionals is not as strong. Non-members share these feelings of confidence in MHOs and their leadership, although they trust health professionals somewhat less than do the members. The MHOs' low penetration rate therefore cannot be explained by lack of trust, as this study shows that, even with some distrust of the professionals, the overall level of trust in MHOs is high and MHOs and their leaders function as intermediaries with health professionals. Other explanatory factors are the lack of information available to villagers and, most especially, the problems they face in being able to pay the MHO premiums.