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Removing financial barriers is only the first step towards better access to care for poor people
In this week's BMJ, a cluster randomised controlled trial by Ranson and colleagues describes a community based health insurance scheme run by the Self Employed Women's Association (SEWA) in Gujarat, India.1 Community based health insurance is a valuable way to finance the delivery of health services in developing countries. By combining the risk of falling sick with resources, such insurance facilitates access to care and offers financial protection against the cost of illness. In doing so, community based health insurance aims to overcome inequities in access and socioeconomic status by reducing existing gaps between the poor and the less poor.
Research from Asia and sub-Saharan Africa shows that community based health insurance has been less effective in securing equity than expected. Poor people are less likely to enrol in such schemes,2 3 4 and limited evidence shows that once enrolled their use of the services is not great enough to compensate for pre-existing inequities in access.5 6 7 Therefore, the major challenge for community based health insurance is how to secure greater equity across socioeconomic groups, in terms of both enrolment and access to services.
The scheme described by Ranson and colleagues aimed to make access to health services and protection from the cost of illness more equitable among its members.1 SEWA focused on interventions after enrolment because many poor people have already enrolled, but it is unclear whether they use the services as much as those who are less poor. The trial compared four interventions in 16 rural sub-districts: after sales service with supportive supervision, prospective reimbursement, both packages, and neither. The trial found that none of the interventions secured greater equity, measured by the ability of poorer members to enjoy a greater share of the scheme benefits.
We believe that the disappointing results of the current trial should not discourage policymakers from implementing similar schemes or be used as a reason to abandon efforts to test the impact of similar interventions aimed at increasing equity in developing countries. Our experience in sub-Saharan Africa mirrors that reported by Ranson and colleagues, and it suggests that removing financial barriers to access through enrolment in such schemes is only the first step towards better access to care and greater financial protection against the cost of illness for poor people.
Distance to services as well as social and educational deprivations have a central role in determining poor people's access to services,8 9 10 including health insurance.2 4 11 12 Future research could test whether greater equity can be achieved by targeting interventions exclusively to people most in need—the very poor. Given the limited resources usually available to community based health insurance schemes, targeted interventions may prove to be more cost effective than interventions aimed at all members, as attempted by SEWA.
The structure of the scheme itself could be another reason why the interventions implemented by SEWA did not increase equity as much as expected. The SEWA scheme uses an ex-post reimbursement policy—people have to pay for care in advance and claim reimbursement afterwards. Even the increased support provided by the interventions described in the study may have been insufficient for poor people to learn “how to work the system.” We realise that the structure of some schemes may require them to use ex-post reimbursement, but our experience in sub-Saharan Africa suggests that systems that do not require members to advance cash in times of illness may increase equity in access (data currently under analysis).
The success of community based health insurance in developing countries depends on discovering which interventions increase equity between very poor people and those who are less poor. In doing so, we must remember that although schemes can learn from one another's experience, each scheme is set within its own context and has its own set of challenges. Thus, while SEWA may be trying to improve equity in use of health services, many schemes still struggle to secure equity in enrolment in the first place.3 4 12 In any case, we should be encouraged to follow the example set by SEWA, which rather than adopting standardised “prepackaged” solutions, first identified barriers to access5 and then developed and tested interventions aimed at overcoming these specific barriers.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.