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"Ask the Expert" Series

Session No. 4


Financial risk protection for the poor


September 1 - September 20, 2008

Lead discussants

During this session you will have the opportunity to pose related questions to two lead contributors who have extensive experience in this area:

  • Dr. Xiaolin Wei
    Senior Research Fellow in Communicable Diseases Control Nuffield Centre International Health and Development,University of Leeds, UK and,
  • Dr. Tarry Asoka
    Trained family physician and independent health management consultant and advisor in Nigeria

How to participate?

Your questions and comments, along with their responses will be posted for further discussion. It is expected that other HSAN experts will also contribute to the session with comments on their experience with making affordable and effective interventions widely available. The goal is maximum sharing of experiences of what has worked well where and what factors have contributed to success.

Please send your questions directly to

View the on-going discussion


Below are the initial questions we have encountered and the responses from the lead discussants:

Question #1:

In your experience, what safety nets exist to protect the poor from the burden of health care and what other options will contribute to achieving equitable health financing?

Part A

Broadly, two main categories are being implemented especially in Sub-Saharan Africa (SSA). The first group consists of methods that assist vulnerable patients to cope with health service and associated costs, such as the costs of transport to and from health facilities. This category includes schemes such as:

  • Deferral of Fees
  • Emergency Loan Funds
  • Community Based Health Insurance

The second group is made up of methods that relieve patients of health care costs altogether. They are usually targeted at the poor, and those that are biologically vulnerable to ill health, such as children under five years of age, pregnant mothers, disabled persons, and the elderly. The schemes that fall under this category include:

  • Exemptions, and
  • Free Maternal and Child Healthcare (MCH) Services

However, some schemes such as Deferral and Exemptions (D&E) schemes have elements of both types of safety net programmes.

Part B

Apart from the safety net methods outlined above, there are a number of other options, which can be considered to ensure fair financing of healthcare especially for the poor and the vulnerable. These are:

  • Voucher Schemes
  • Conditional Cash Transfers (CCT)
  • Health Saving Accounts, and
  • Community-Based Health Insurance (CBHI)

Nonetheless, these safety net approaches should be considered as interim measures that can increase access to vital healthcare services. The most effective means of guaranteeing access to healthcare for all, including the poor in most countries is to undertake pre-payment funding mechanisms that manages whole population risks and ensure comprehensive care ‘free at the point of use’. The two major ways of achieving this goal are social health insurance and tax-based funding.

Question #2:

Community-Based Health Insurance (CBHI) has been a strategy that has been widely used in many African countries and it is growing in popularity. However, many of these schemes have only existed as pilots with variable degree of success that have not been scaled up. What is your comment on this

Community – Based Health Insurance (CBHI) is a form of pre-payment healthcare financing mechanism that assists communities to contribute on a regular basis so that members do not need to have cash on hand at the time when they need healthcare. Community here is broadly defined to include a cohesive group of households or individuals associated in a neighbourhood, village community, commercial, workplace or other occupational setting.

Many programmes have in built flexibility, in that the members determine the benefit package and the choice of providers. The members also make the decision on the amount of premium to be paid and whether this should be paid once monthly or in installments. An elected board of trustees from among the members administers the fund itself. It has been noted that this approach is likely be successful in settings where the community, neighbourhood or informal workplace setting is already organized for other purposes, such as community-based credit.

Nonetheless, CBHI has certain drawbacks. Incomes in most rural areas and in the urban informal sector are very uncertain. These schemes cover only a small portion of communities and have small risk pools, which affect their sustainability. CBHI require management capacity which does not exist in many cases. And they tend to exclude the poorest unless contributions of the poor are heavily subsidized. There has also been too little attention paid to these schemes by both national governments and development agencies.

All these problems not withstanding some good lessons have been learnt and there is now a big push for scaling up this strategy by modifying some of the operational procedures. First, payments of premiums have to be undertaken in a stress free manner, such as by tying them to income cycles. Secondly, there should be emphasis on large-scale interventions that can reach a significant proportion of the poor. The focus here should be overall population coverable by a multiple of schemes looking at those same issues as those of more sophisticated social and private health insurance schemes – building up adequate reserves, health plans being informed purchasers, consumer education, re-insurance etc. And finally, more of government and donor funds should be allocated to work on the demand side rather than on the supply side as it has been done traditionally.