Community-Based Health Insurance in Low-Income Countries: A Systematic Review
Priyanka Saksena, Ankit Sharma, Holly Smith
Health Policy and Planning · 2021 · DOI: 10.1093/heapol/czab067
Countries: Multiple LICs
What Was Studied
A systematic review of 34 studies examining community-based health insurance (CBHI) schemes in low-income countries, focusing on their impact on financial protection, healthcare utilisation, and enrollment sustainability.
What They Found
CBHI schemes reduced out-of-pocket expenditure by 23-47% for enrolled households. However, enrollment rates rarely exceeded 30% without government subsidies. Key barriers included: inability to pay premiums during lean agricultural seasons, distrust of insurance concepts, poor service quality at contracted facilities, and adverse selection (sicker individuals enrolling disproportionately). Schemes with government premium subsidies for the poorest achieved 2-3x higher enrollment.
What This Means for Nepal
Nepal's social health insurance programme faces similar challenges — low enrollment especially in rural areas and among informal workers. The evidence strongly suggests that premium subsidies for the poorest quintiles are essential, not optional. Nepal should consider seasonal payment flexibility aligned with agricultural cycles and invest in improving facility quality alongside insurance expansion, as poor service quality undermines willingness to pay.
Contextualisation
Nepal has experimented with community-based health insurance in several districts. This review's finding that CBHI schemes struggle with adverse selection and low enrollment unless heavily subsidised is directly relevant to Nepal's rollout challenges.