Rethinking the role of the state in health care financing: can community-based health insurance show the way?

Abstract

Currently there are huge problems in financing even basic health care for most people in low-income countries. Over 1.8 bn people live in countries where public expenditure on health is, on average, less than US$ 20 per capita per year. This amount falls short of the US$ 34 minimum spending for basic services estimated by the Commission on Macroeconomics and Health of the World Health Organisation. Even worse, this budget is often directed to curative health care in urban centres, leaving the rural areas largely lacking health services (Hope, 2003). To understand a health-financing system, even that of communitybased health insurance, one needs to analyse the context of the broader goals of that system (Bennet, 2004; Carrin, 2003; Carrin et al., 2005). The World Health Organisation proposes that health systems should aim to ensure quality and equality, responsiveness to people's expectations, and fairness in the financial contributions to the health system. They should have four functions: provision of health services, creation of the necessary investment and training resources, sufficient financial resources so that people can access effective health care, and government stewardship. Health financing, which is the focus of this paper, comprises three elements: revenue collection, fund pooling and purchasing (Carrin et al.,2005). The importance of investing in health is no longer in doubt. According to the Commission on Macroeconomics and Health of the WHO, extending coverage of crucial health services, including a relatively small number of specific interventions affecting the world's poor, could save millions of lives every year, reduce poverty, spur economic development and promote global security (MoH, 2002).