A Conceptual Framework for Community-Based Health Insurance in Low-Income Countries: Social Capital and Economic Development

Abstract

Current thinking in major international development agencies construes community-based health insurance (CBHI) as a transitional mechanism to achieving universal coverage for health care in lowincome countries. The policy link between CBHI and universal coverage is implicitly determined by the historical experience of mutual health insurance in countries such as Germany and Japan in the 19 th century, where the socioeconomic context was dramatically different to that of today's much less successful schemes. This paper argues that the economic and health system frameworks employed in the analysis of CBHI have not taken into account context-dependent considerations such as goals, values and power. It is proposed that a critical engagement with social capital theories could contribute to our understanding of why CBHI schemes do not appear on course to develop according to the 19 th century precedent, achieving significant levels of population coverage in a sustainable way.A framework of social capital and economic development is used to organize and interpret existing evidence and information on CBHI. This process suggests that solidarity, trust, extra-community networks, vertical civil society links and state-society relations at the local level affect the possibility of success of CBHI. To this extent, it may be possible to talk of "social determinants of CBHI". In order to align themselves to local community goals and values, CBHI schemes may need to actively foster certain types of vertical and horizontal bridging relations which could result in the evolution of structures and operations quite different to those proposed by current models of CBHI.

Why do people drop out of community-based health insurance? Findings from an exploratory household survey in Senegal

“…As CBHI was rolled out in LMIC, policymakers and researchers hoped that the community-oriented approach would promote a set of important benefits: trust in CBHI management, solidarity and acceptance of cross-subsidisation, the flow of information, the quality of health services; and reduced fraud, moral hazard and adverse selection (Davies & Carrin, 2001;Hsiao, 2001;Pauly, 2004;Pauly et al, 2006;Zweifel, 2004). Implicit in this view was the idea that CBHI would benefit from existing social capital (Mladovsky & Mossialos, 2008), defined as "the information, trust and norms of reciprocity inhering in one's social network" (Woolcock, 1998, p. 153). It was hypothesised that the community-oriented dynamic would in turn promote high levels of enrolment in CBHI.…”

“…The health and health services variables account for the possibility that adverse selection, geographic access to health service providers, and reliance on traditional medicine explain drop-out from CBHI. The two social capital variables measure the structure of people's social networks, in order to test the hypothesis that CBHI benefits from existing social capital (Mladovsky & Mossialos, 2008), discussed above. The first variable measures having privileged social relationships (with people who may or may not also be members of the CBHI scheme).…”

Can social capital help explain enrolment (or lack thereof) in community-based health insurance? Results of an exploratory mixed methods study from Senegal

“…The study builds on the argument that social capital can promote or constrain CBHI, proposed in a literature review of CBHI by Mladovsky and Mossialos (2008). They adopt the following definition of social capital: "the information, trust and norms of reciprocity inhering in one's social network" (Woolcock, 1998):153).…”

“…Drawing on Portes & Sensenbrenner (1993), Mladovsky and Mossialos (2008) argue that distinguishing between "bonding" and "bridging" social capital is essential to understanding whether features of social capital (e.g. expectations between individuals, the trustworthiness of structures, information channels, norms and effective sanctions) have a productive outcome in CBHI.…”

Social capital and the social formation of health-related preferences and behaviours

“…Social capital, understood as 'the information, trust and norms of reciprocity inhering in one's social network' (Woolcock, 1998: 153), appears to explain differences in governance (Putnam et al, 1993;Putnam, 2000), efficiency in human capital formation (Coleman, 1988), the success of development strategies in low income country contexts (Grootaert and van Bastelaer, 2001), and the economic success of migrant groups in the USA (Portes, 1998). Only recently research has focused on the role of social capital as a key variable in understanding health production (Moore et al, 2006;Shortt, 2004;Mladovsky and Mossialos, 2008). Accordingly, the articles in this special issue offer further evidence suggesting that levels of social activity in a group (collective social capital), as well as people's perceptions of being part of a wider community, social networks, and psychosocial trust (individual social capital) influence either health-related behaviour and/or the use of health care.…”