- Open Access
Community-based health insurance and social capital: a review
© Donfouet and Mahieu; licensee Springer. 2012
- Received: 18 October 2011
- Accepted: 4 April 2012
- Published: 4 April 2012
Community-Based Health Insurance (CBHI) is an emerging concept for providing financial protection against the cost of illness and improving access to quality health services for low-income rural households who are excluded from formal insurance. CBHI is currently being provided in some rural areas in developing countries and there is ongoing research about its impact on the well-being of the poor in these areas. However, the success of CBHI revolves around the existence of social capital in the community. This has led researchers to explore the impact of CBHI on the well-being of the poor in rural areas, especially as it relates to social capital. The overall objective of this paper is to review recent developments that address the link between CBHI and social capital. Policy implications are also discussed.
- Community-based health insurance
- Social capital
- Rural areas
Financing quality health care is a major challenge in developing countries. Health plays a key role in the economic development of a country. For this reason, policy-makers in developing countries have increased their efforts towards providing quality health care both in urban and rural areas [1, 2]. Despite these efforts, many countries still have low geographical coverage quality health care. For Example, in Sub-Saharan African countries, inhabitants are facing precarious health conditions. About 26 per cent of children under five years old are underweight . According to Morrisson et al. , the percentage of children suffering from acute malnutrition (and whose families are classified below the absolute poverty threshold) ranged from approximately 15 to 20 per cent in intermediate revenue countries (Cameroon, Ivory Coast, Zimbabwe), to more than 50 per cent in very poor countries such as Madagascar and Niger. About 42 million children below five years old suffered from acute malnutrition in Sub -Saharan Africa in 1996. The most recent estimates released by the United Nations Food and Agriculture Organization (UNFAO)  shows that the majority of the world's undernourished people live in developing countries. In the world, 925 million people are undernourished, of which 239 million live in Sub-Saharan Africa countries. This malnutrition will continue to cause poor health and affect the well-being of the households in this region of the World if adequate measures are not taken.
Over the last years, demographic growth coupled with unequal growth in these regions has increased the number of people who are living in extreme poverty. Nowadays, about 50 per cent of the people in Sub-Saharan Africa are living below the poverty threshold. Furthermore, more than 100 million people do not have a balanced diet . Such a situation increasingly affects rural areas in developing countries which have very low standards of well-being  and quality health care . Most households in these rural areas are characterised by a high prevalence rate of sanitation-related diseases, which undermines their health, in turn weakening their ability work and invest.
The disappearance of free health care (mostly primary health care) has resulted in the loss of a form of social protection for a large portion of the population especially rural households and those working in the informal sector. As a result, many policy-makers, international institutions, NGOs and the civil society have set out to seek effective alternatives in order to provide rural households a permanent solution to the problem of accessing health care. Development actors are increasingly considering community-based health insurance (CBHI)1 as an instrument that can enable not only easy access to quality health care, but also reduce absolute poverty among low-income populations. CBHI is a form of micro health insurance which is mainly used in rural areas in developing countries [9–11]. Over the last decades, insurance was recognized as a financial instrument which could enable low-income households to manage their financial risks . The role of CBHI therefore is to help low-income households manage risks and reduce their vulnerability in the face of financial shocks. CBHI is usually based on the following characteristics: voluntary membership, non-profit objective, linked to a health care provider (often a hospital in the area), risk pooling and relying on an ethic of mutual aid/solidarity , p.5. According to Churchill , p.12, CBHI: " refers to the protection of low-income people against specific perils in exchange for regular premium payments proportionate to the likelihood and cost of the risk involved". Several studies show that low-income households are willing to pay for CBHI [9, 14, 15]. In most cases, the payment of the premiums are in cash (monthly, quarterly, yearly) or in kind  such as agricultural commodities. However, the success of CBHI relies on the existence of social capital in the community. As declared by Woolcock and Narayan , p.3: "social capital refers to the norms and networks that enable individuals to act collectively". Fukuyama , p.4 asserted that "social capital can be defined simply as the existence of a certain set of informal values or norms shared among the members of a group that permit cooperation among them". Sobel  describes social capital as circumstances in which individuals can benefit from group membership. Thus, social capital refers to social life-networks, norms, and trust that enables households to act together more effectively to pursue shared objectives [20, 21]. This social capital in the community can be an asset for the breakthrough of CBHI, thus contributing to the demand for CBHI at the community level. As outlined by the BIT , one of the key principles of a good functioning of CBHI is the solidarity and trust between members. This solidarity and trust stirs up members who are susceptible to risk to put together their resources for common use. Hence, the overall objective of the paper is to review the link between CBHI and social capital. The remainder of the paper is organized as follows; section 2 focuses on recent developments that address the link between CBHI and social capital, section 3 presents a theoretical framework that shows the link between CBHI and social capital, and section 4 concludes with some policy implications.
Popularized by Putnam , the concept of social capital has been the subject of several studies that have attempted to measure it. Some of these studies treat social capital as a dependent variable (a phenomenon which has to be explained), and this is the institutional view of social capital that argues that the vitality of community networks and civic society is largely the product of the political and institutional environment [17, 36]. An alternative method, developed in recent years is to study the role or function, or better still, the contribution of social capital to health. Therefore, social capital is studied as an independent variable (this is a communitarian view of social capital). The issue is thus to bring out its contribution to access to basic health care for rural households. Its scope is basically social networks, trust or associations which can improve the health situation of households. Therefore, a positive relationship between CBHI and social capital is expected.
In equation (1), one of the explanatory variables, say X1, refers to social capital and the others are related to socio-demographic characteristics such as age, gender, income, marital status, number of children in the households, profession etc.
Depending on how Y is measured, a specific estimation model can be used. For instance, if Y is a continuous variable, the ordinary least squared (OLS) model is used. If Y is a binary variable, the probit or logit model is used. If Y lies in interval, the interval regression is used .
If β 1 is positive and statistically significant at conventional levels, there is a positive relationship between the WTP for CBHI and social capital. Theoretically and empirically, β 1 must be positive since it is always expected that solidarity, norms, trust and participation at the community level to have a positive effect on the demand for CBHI.
Access to health services is a main concern in poor countries. Most policy debates are around how to keep the poor from falling into a poverty trap that is often caused by medical expenses. Delaying medical treatment or choosing self-treatment can generate serious health consequences. Hence tackling this issue is of utmost importance. Many policymakers in developing countries are trying to develop health care programs that would cater to the poor and be sustainable at the same time.
Lack of health insurance coverage of the poor in developing countries impedes access to adequate health care. Consequently, CBHI has been considered as an effective means to reach the poor with health care services. Since there has been an increased attention to such a health insurance scheme, the analysis of the demand for CBHI is extremely important for formulating policies and strategies for the health sector. Adequate knowledge of the determinants of healthcare demand is essential for devising strategies to increase allocative efficiency of resources. Nevertheless, for CBHI to have a long-term effect, there must be a social capital in the community. Thus, the overall objective of the study was to review recent developments that address the link between CBHI and social capital. A thorough review reveals that a higher level of social capital at the community level will positively and significantly impact households' decision for health insurance, which will in return increase the demand for CBHI. One important policy implication is to strengthen social ties at the community level. An open question for further studies is what type of social capital to develop in priority. Both inter and extra community social capital has pros and cons, and it is unclear which one ought to be reinforced.
a It is also called community health funds, mutual health organizations, rural health insurance, etc.
b Contingent valuation is a survey-based method used to assess the value participants attach to public goods which are not provided by the market. It is commonly used in the health, marketing, education and environment sectors.
c The hypothetical bias is the difference between the hypothetical WTP and the real WTP.
This work was carried out with financial and scientific support from the International Labor Organization (40052113/0) under the Microinsurance Innovation Facility and the expertise of the European Development Research Network (EUDN). We will also like to thank the African Doctoral Dissertation Research Fellowship offered by the African Population and Health Research Center (APHRC) in partnership with the International Development Research Centre (IDRC) for financial assistance. The authors are grateful to Dr. Pongou Roland (University of Montreal), Dr. Marleen Dekker (University of Leiden) and two anonymous referees for useful comments. We are also grateful to Dr. Eric Tangumonkem for editing the English of the paper. The usual disclaimer applies.
- Carrin G, Waelkens M, Criel B: Community-Based health insurance in developing countries: a study of its contribution to the performance of health financing systems. Tropical Medicine and International Health 2005,10(8):799–811. 10.1111/j.1365-3156.2005.01455.xPubMedView ArticleGoogle Scholar
- Jütting JP: Do community-based health care insurance schemes improve poor people's access to health care? Evidence from rural Senegal. World Dev 2003,32(2):273–288.View ArticleGoogle Scholar
- Nations U: The millennium development goals report. Washington: United Nations; 2010.Google Scholar
- Morrisson C, Guilmeau H, Linskens C: Une estimation de la pauvreté en afrique. In subsaharienne d'après les données anthropométriques. Paris, France: OECD Working paper 158; 2010.Google Scholar
- FAO: The state of food Insecurity in the World 2010. Addressing food insecurity in protracted crises. Food and Agriculture Organization of the United Nations. Rome. 2010.Google Scholar
- BIT: Mutuelles de santé en Afrique: caractéristiques et mise en place: manuel de Formateurs. Genève: Bureau international du Travail; 2000.Google Scholar
- WHO: Achieving universal health coverage: Developing the health financing system. Geneva: Technical briefs for policy-makers No. 1; 2005.Google Scholar
- Wietler K: Mutual Health Organizations in Sub-Saharan Africa: Opportunities and Challenges. 6GTZ's discussion papers on social protection; Eschborn, Germany; 2010.Google Scholar
- Dror M, Radermacher R, Koren R: Willingness to pay for health insurance among rural and poor persons: Field evidence from seven micro health insurance units in India. Health Policy 2007, 82: 12–27. 10.1016/j.healthpol.2006.07.011PubMedView ArticleGoogle Scholar
- OMS: Régimes d'assurance -maladie communautaires dans les pays en développement: faits, problèmes et perspectives. Geneva, Switzerland: Organisation Mondiale de la Santé, Discussion paper no. 1; 2003.Google Scholar
- OIT: Protéger les plus démunis, Guide de la micro-assurance. Compendium de Micro-Assurance. Genève: Organisation International du Travail; 2009.Google Scholar
- Ahuja R, Jütting J: Are the poor too poor to demand health insurance? In. Indian council for research on international economic relations. New Delhi: Working paper no. 118; 2004.Google Scholar
- Churchill C: What is insurance for the poor? In Protecting the poor. Edited by: Churchill C. Geneva: A microinsurance compendium. International Labor Organization; 2006.Google Scholar
- Asgary A, Willis K, Taghvaei AA, Rafeian M: Estimating rural households' willingness to pay for health insurance. Eur J Heal Econ 2004,5(3):209–215. 10.1007/s10198-004-0233-6View ArticleGoogle Scholar
- Ataguba J, Ichoku EH, Fonta W: Estimating the willingness to pay for community healthcare insurance in rural Nigeria. Dakar: Poverty and Economic Policy; 2008.Google Scholar
- Preker A, Carrin G, Dror D, Jakab M, Hsiao W, Arhin-Tenkorang D: A Synthesis Report on the Role of Communities in Resource Mobilization and Risk Sharing. Geneva: World Health Organisation. Commission on Macroeconomics and Health (CMH) Working Paper Series, Paper No. WG3: 4; 2001.Google Scholar
- Woolcock M, Narayan D: Social capital: implications for development theory, research, and policy. World Bank Research Observer 2000,15(2):225–249. 10.1093/wbro/15.2.225View ArticleGoogle Scholar
- Fukuyama F: Trust: The social values and the creation of prosperity. New York: The Free Press; 1995.Google Scholar
- Sobel J: Can we trust social capital? J Econ Lit 2002,40(1):139–154. 10.1257/0022051027001View ArticleGoogle Scholar
- Putnam RD: Making democracy work. Princeton University Press, Princeton: Civic traditions in modern Italy; 1993.Google Scholar
- Coleman JS: Foundations of social theory. Cambridge/London: Belknap Press of Harvard University Press; 1990.Google Scholar
- BIT: Micro-assurance santé. Guide d'introduction aux mutuelles de santé en Afrique. Suisse, Genève: Genève, Bureau international du Travail, Programme Stratégies et Techniques contre l'Exclusion sociale et la Pauvreté (STEP); 2002.Google Scholar
- Tabor SR: Community-Based Health Insurance and Social Protection Policy. World Bank, Washington: Social Protection Discussion Paper Series; 2005.Google Scholar
- Zhang L, Wang H, Wang L, Hsiao W: Social capital and farmer's willingness-to-join a newly established community-based health insurance in rural China. Health Policy 2006, 76: 233–242. 10.1016/j.healthpol.2005.06.001PubMedView ArticleGoogle Scholar
- Donfouet HPP, Essombè EJR, Mahieu P-A, Malin E: Social capital and willingness-to-pay for community-based health insurance in rural cameroon. Global Journal of Health Science 2011,3(1):142–149.View ArticleGoogle Scholar
- Putnam R, Leonardi R, Nanetti RY: Making democracy work. Princeton, New Jersey: Princeton University Press; 1993.Google Scholar
- Wilkinson RG: Unhealthy societies: the afflictions of inequality. London: Routledge; 1996.View ArticleGoogle Scholar
- Baum F: Public health and civil society: understanding and valuing the connection. Australian and New Zealand Journal of Public Health 1997,21(7):673–675. 10.1111/j.1467-842X.1997.tb01775.xPubMedView ArticleGoogle Scholar
- Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D: Social capital, income inequality and motality. Am J Public Health 1997, 87: 1491–1498. 10.2105/AJPH.87.9.1491PubMed CentralPubMedView ArticleGoogle Scholar
- Flores M, Rello F: Social capital and poverty lessons from case studies in Mexico and Central America. Italy: ESA Working Paper No. 03–12. Food and Agricultural Organization; 2003.Google Scholar
- Durlauf SN, Fafchamps M: Social capital. Massachusetts Cambridge, USA: NBER Working Papers N°10485; 2004.View ArticleGoogle Scholar
- Hsiao WC: Unmet Health Needs of Two Billion. Is Community Financing A Solution? In Health. Edited by: Prekar AS. World Bank, Washington: Nutrition and Population Discussion Paper; 2001.Google Scholar
- Whittington D: Improving the performance of contingent valuation studies in developing countries. Environ Resour Econ 2002, 22: 323–367. 10.1023/A:1015575517927View ArticleGoogle Scholar
- Arrow K, Solow PR, Leamer EE, Radner R, Shuman H: Report of NOAA panel on contingent valuation method. Fed Regist 1993,58(10):4601–4614.Google Scholar
- Cameron TA: A new paradigm for valuing non-market goods using referendum data: maximum likelihood estimation by censored logistic regression. J Environ Econ Manag 1988,15(3):355–379. 10.1016/0095-0696(88)90008-3View ArticleGoogle Scholar
- Tendler J: Social capital Across the Public-Private Divide. Massachusetts Cambridge, USA: MIT, Department of Urban Studies and Planning, mimeo; 1995.Google Scholar
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