Elsevier

Health Policy

Volume 69, Issue 1, July 2004, Pages 45-53
Health Policy

The feasibility of community-based health insurance in Burkina Faso

https://doi.org/10.1016/j.healthpol.2003.12.001Get rights and content

Abstract

To ensure the acceptability of community-based insurance (CBI) by the community and its sustainability, a feasibility study of CBI was conducted in Burkina Faso, including preference for benefit package of CBI, costing of health services, costing of the benefit package and willingness-to-pay (WTP) for the package. Qualitative methods were used to collect information about preferences for the benefit package. Cost per unit health services, health demand obtained from household survey and physician-judged health needs were used to estimate the cost of the benefit package. The bidding game method was used to elicit household head’s WTP for the package. We found that there were strong preferences for inclusion of high-cost health services such as operation, essential drugs and consultation fees in the benefit package. It is estimated that the cost of the package per capita was 1673 CFA (demand-based) and 9630 CFA (need-based), including 58% government subsidies (€1=655 CFA). The average household head with eight household members agreed to pay from 7500 (median) to 9769 CFA (mean) to join the CBI for his/her household. The WTP results were influenced by household characteristics, such as location, household size and age composition. Under certain assumptions (household as the enrolment unit, median household head’s WTP as premium for the average household, 50% enrolment rate), it would be feasible to run CBI in Nouna, Burkina Faso if enrolees’ health demand did not increase by more than 28% or if the underwriting of the initial losses was covered by extra funds.

Introduction

Health services in rural Burkina Faso, as in many Sub-Saharan countries, are characterised by low and inequitable utilisation and poor quality [1], [2], [3], [4], [5]. These problems prevent health care from having a notable impact on health, in particular among rural poor in Burkina Faso. Low utilisation of health services is directly related to their high price in relation to the household income. Health care in Burkina Faso has imposed considerable financial costs on the users [6].

User-fees were introduced in Burkina Faso in 1993 as a supplement to tax-based financing of government health services. The user-fee policy combined modest fees for services and cost-recovery fees for drugs. However, utilisation of health services continued to decline following the introduction of these fees [7], [8].

One of the ways to improve the utilisation of health services is through insurance. However, formal health insurance in Burkina Faso has been limited to certain sections of the population largely excluding the rural population. For example, in Burkina Faso social insurance is offered to salaried and state employees through the Caisse National de Sécurité Sociale (CNSS, national social security fund) and the Caisse de Retraite des Fonctionnaires (CARFO, national social security fund for retired state employees). So the only rural residents likely to have health insurance are government employees.

In addition, community risk-sharing schemes, which are prevalent in rural Africa, can be viewed as another way to improve health care utilisation. At present, these schemes cover a wide variety of non-health-related risks but a few cover health care expenditure [9].

Community-based insurance (CBI) is therefore being seen as a promising new tool to improve health system for rural populations in low-income countries, particularly in Sub-Saharan Africa [10], [11]. Community members pool their resources to share the financial risks of health care, own the scheme and control its management, including the collection of premiums, the payment of health care providers, and the negotiation of the benefit package. Unlike private insurance, premiums are paid by households and are not based on individual risk assessments. CBI has the advantage of dissociating the time of payment from the time of use of services, which is clearly better adapted than user-fees to the seasonal fluctuations of revenue and expenditure flows of rural households [12]. The Government of Burkina Faso, in its recently published health plan, has also advocated community-based financing mechanisms to alleviate the health care financing crisis [13].

It is found that there are four well-identifiable types of community-based health care financing schemes in developing countries. In community-managed user-fees, resource mobilization relies mainly on out-of-pocket payments at the point of contact with providers but the community is actively involved designing these fees and managing the collection, pooling, and allocation of the funds mobilized in this way. In community-based prepayment schemes, the community collects payments in advance of treatment and then manages these resources in paying for providers. In community provider-based health insurance, providers serving a particular community collect the prepayments themselves. In linked community health fund or revolving fund, the community acts as “agent” to reach rural and excluded populations on behalf of the formal government or social health insurance system via contracts or agreements. In our study, we plan to design a scheme similar to community-based prepayment schemes [14].

To ensure the CBI’s acceptability by the community and its possible sustainability a series of studies related to the feasibility of CBI were conducted in Burkina Faso. The studies include preference for benefit package of CBI [15], costing of health services and costing of the benefit package [16], [17], and household valuations of the benefit package using contingent valuation methods [18], [19]. The paper aims to link the results of the relevant studies in order to understand the feasibility of running CBI in Nouna by examining community’s acceptability for CBI, examining local people’s preference for the CBI benefit package, and estimating the CBI premium on the basis of cost of the package and household head’s WTP for the package.

Section snippets

Study site

Burkina Faso has an estimated population of approximately 10.7 millions [20]. It is divided into 11 administrative health regions, which comprise 53 health districts overall, each covering a population of 200,000–300,000 individuals. Each health district has at least one hospital with surgical facilities [21]. The districts themselves are again sub-divided into smaller areas of responsibility that are organised around either a hospital or a so-called Centre de Santé et de Promotion Sociale

Benefit package

People preferred that the CBI covered essential drugs, laboratory tests, inpatient stays, surgery, X-rays, consultation fees and urgent transportation (ambulance services) in the benefit package.

Drugs included all essential and generic drugs prescribed by doctors at local CSPS or Nouna hospital, which could be purchased in pharmacies, either at CSPS or at the Nouna hospital. The CBI would not pay for drugs sold in private drugstores. Laboratory tests included tests prescribed by doctors at

Discussion

To our knowledge, this is the first article in developing countries to study the feasibility of CBI by examining community’s acceptability; examining people’s preference for the benefit package; estimating professionally defined health care needs on the basis of comprehensive population-based morbidity data, rather than on hospital or health post records; and using these data with the cost of the package and household head’s WTP for the package together to estimate premium level for CBI.

From

Conclusion

It is feasible to implement CBI in Nouna, Burkina Faso based on the results and assumptions of this study. The average household premium for the insurance based on the median household head’s WTP is about 6.3% of the annual household expenditure. However, it is needed to have more support for the success of the CBI. The underwriting of the initial losses need to be covered by extra funds. Community needs to take part in more relevant process of decision-making. CBI-oriented providers’ training

Acknowledgements

This work was supported by the collaborative research grant ‘SFB 544’ of the German Research Society (DFG). The authors would like to thank Sanou Aboubakary, Adjima Gbangou, Yazoumé Yé and Mamadou Sanon from Nouna Health Research Centre for their valuable help during the data collection process. The authors would like to thank Manuela De Allegri, Subhash Pokhrel and Budi Hidayat in the Department of Tropical Hygiene and Public Health, Heidelberg University for their valuable comments.

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