Using a community-based definition of poverty for targeting poor households for premium subsidies in the context of a community health insurance in Burkina Faso

Discussing poverty issues in a community is a very sensitive subject and needs to be approached with great caution. Mckendrick stated, in the case of UK, that talking about poverty is never neutral and the language may be sexist, ageist, racist or homophobic if not used appropriately [77,78]. Some other authors also noted the sensitive nature of poverty [79-82].

Community members in Nouna identified mainly three poverty groups: poor, intermediates and wealthy. We noted that only one FGD indicated 4 poverty groups including the very poor. But on the other side, no FGD mentioned the wealthiest group as a poverty group to be considered since they rejected the fact that there were wealthiest people among them. We also noted that these community members did not make any great difference between the poor and the very poor. For them the two groups faced the same difficulties with only slight differences. The Food and Agriculture Organization of the United Nations (FAO), in a study implemented in the Horn of Africa, also found three poverty groups: the lowest levels of Wealth Index, the intermediate Wealth Index and the high Wealth Index [83]. Kalisa in Rwanda studied the characterization of farming systems in southern Rwanda and found three wealth categories among the farmers: Well-off farmer, Intermediate farmer and the Poor farmer [84].

The community-based definition of poverty that we used in our study allowed us to better understand poverty from the view of the community. Souares, in Nouna, targeted the poor households for insurance enrolment subsidies by using a community-based definition of poverty [40]. The same exercise was performed in Ghana by Aryeetey who also used the community concepts of poverty to provide premium exemptions in Ghana National Health insurance scheme [46]. Many other authors have also used this community-based definition of poverty to target the poor [39,55,63,80].

Making community central to the definition of perceived poverty was guided by the fact that community members might have a better feeling for poverty and might understand all the arguments for that. This was also mentioned by some other authors [43,46,85,86].

We were convinced that the poverty criteria provided by community members reflected a realistic situation experienced by them. They were the ones concerned with poverty issues, so they were the ones in the best position to express what they felt in their own words and languages.

Most of the criteria highlighted in our study referring to the poor, like the insufficient daily meal, the ill-health …etc., were also mentioned in the study of Aryeetey in Ghana. ‘The poorest were unable to afford three meals daily and meals were often made up of cooked cassava…’[46]. She also indicated, as we mentioned in our study, that it was common to see the poorest wearing miss-matched old plastic bathroom slippers and worn out, often dirty clothes.

In our study we pointed out that poor people were sometimes excluded from the main decision making because of their poverty status. This situation was also noticed by Aryeetey in Ghana. ‘The poorest people were usually not included in group decision making processes either at the family or community level’ [46].

Our study showed, as did several other authors, that involving community members in the definition of poverty may allow poor people to make their voices heard [20,59,60,86-90], as they are often not considered in their own society. This situation of marginalization was highlighted in 2010 by Salmen [91,92]. Narayan in 2000 [54] recognized that economically marginalized groups also tend to be socially marginalized. In Kenya, Cameroon, Gabon and Zambia, he reported previously that poor people felt powerless and that they were generally voiceless [93].

In the 41 villages where our study took place, the concepts of monetary incomes and expenses remain little utilized. So using community concepts to define poverty was more informative for our study than using a monetary assessment.

The same observation was made by Saul in 1999. The community’s way of defining poverty is, thus, very important and quite relevant, in so far as the main determinants of formal poverty assessment, such as incomes and expenses, are not generally well-known in monetary terms in this rural context [94]. Coudouel also found in her research that measuring intrahousehold allocations and inequality was difficult, since the available data typically failed to directly capture individual spending and consumption [95].

Alatas found in Indonesia that the results of community-based methods were more strongly correlated with individual community members’ self-assessments of their own status than a metric of poverty based purely on consumption [63]. This has also been highlighted by Chambers and Salmen [37,92].

Our study also highlighted, as Chambers did, some aspects of poverty referring to “vulnerability and powerlessness”, which are not captured in conventional surveys [36,37,96,97]. The scarcity of basic needs as referring to the poor was also indicated by many authors [7,91,98-100].

We might assert about the process aimed at targeting the poor, that using the understanding of “who was poor” and “what were the defined poverty groups” provided by community members as key-elements for the selection of those poor, was less costly in terms of time and resources. Chambers, in 1994, published that this community-based method appeared to be an important cost-effective alternative to the normal surveys, particularly with regard to the time and budget used for the surveys [37].

We would like to mention three implications regarding our research. The first implication is the important role and place of community members in defining ‘perceived’ poverty and towards poverty alleviation in Nouna health district. Poverty was mainly defined by community members outside traditional economic descriptions, this should lead policies in Burkina Faso to put greater emphasis on the contribution of Community in defining poverty and targeting poor for poverty alleviation. The contribution of the paper to the debate about how poverty should be defined, might then be considered. The second implication is that, using community-based definitions of poverty in targeting the poor for subsidies or exemption within a community, may be cost-effective for organizations, like community-based health insurances, with limited financial resources. The third implication is that our research provides a new set of poverty criteria as seen and perceived by the community that could be used to build systematic indicators for surveys aiming to measure and alleviate poverty in the Nouna region. Indeed, Burkina Faso in its Strategy for Accelerated Growth and Sustainable Development (SCADD) from 2011 through 2015, which replaced the Poverty Reduction Strategy Paper, aims to alleviate extreme poverty and hunger as specific objective number 2 [101]. Our research could help Burkina Faso policy-makers better target the poor and more effectively address poverty issues in community areas.

We are confident that any policy or program addressing poverty issues in a specific community should consider how that specific community defines poverty.

Some limitations of our study should be mentioned, since we made the choice of inviting knowledgeable people within the community to discuss on its behalf. It was certain that the participants invited to take part in the discussions for the definition of poverty and poverty groups gave their own perceptions and concepts, which might be identical or slightly different from the general community view. Also, the study listed some relevant criteria referring to poverty within the community, without building systematic indicators for a poverty survey. Some nuances between poverty groups ‘poor vs. very poor’ and ‘intermediate vs. wealthy’ were not easy to define by community members.