Sharing the Risk: A community-based approach

In the global health arena, professionals often speak in terms of ideals and make big plans for the development of stronger, better health systems. But while governments, donors and policy makers are busy coordinating strategies for future improvements to broad, multi-player collaborative systems, low-income communities across the globe are faced with how to pay for their sick now.

So how are people in low-income countries managing to pay for their sick in places that lack the infrastructure to support their financial healthcare needs?

In developing countries around the world, low-income communities mobilize to support their sick through the innovative use of informal risk-pooling strategies. In times of crisis, households rely on “extended families, traditional community support systems, nongovernmental organizations…charities and rural cooperatives” to protect them in the event of a devastating illness [1]. These strategies indicate that while resources may be scarce in poor communities, individuals have found ways to support one another through the development of their own protective community-based health insurance systems.

According to Ekman (2004), there is strong evidence that this kind of community-based health insurance provides some financial protection to families by significantly reducing their out-of-pocket spending. While these mechanisms do not necessarily improve quality or efficiency of care, there is also evidence that such schemes help individuals recover from the cost of caring for their sick [2]. As long as user fees remain in place and governments of developing countries continue to struggle to mobilize and implement improved health systems, the use of community-based insurance schemes will continue to play a vital role in protecting the poor.

While community-based insurance systems are innovative and help the poor who bear the burden of paying for their sick, more resources are needed to sustain their health needs [3]. The public health community should focus on helping countries design policies that can nurture access to health services that protect the poor from “catastrophic health spending” and acknowledge the progress that has been made locally through informal risk-sharing strategies [3]. Building on community-based financing strategies can help countries expand the role of national health plans and broaden risk pooling mechanisms. Going from smaller to larger risk pools can help to create more effective and equitable health systems.

But why should we care? In truth, this is a much larger question than I can answer here but what is important to take away is that we shouldn’t lose sight of what is already working on some level in communities that have developed these informal systems. Understanding how communities in developing countries currently share the risk of illness where a larger health system is lacking may provide some insight into best practices for implementing culturally relevant health system designs in the future.

[1] Schieber, G. Maeda, A. (1999). Health care financing and delivery in developing countries. Health Affairs,18 (3):193-205. doi: 10.1377/hlthaff.18.3.193

[2] Ekman, B. (2004). Community-based health insurance in low-income countries: a systematic review of the evidence Health Policy and Planning, 19 (5): 249-270. doi: 10.1093/heapol/czh031

[3] Peters, D. H., Garg, A., Bloom, G., Walker, D. G., Brieger, W. R. and Hafizur Rahman, M. (2008), Poverty and Access to Health Care in Developing Countries. Annals of the New York Academy of Sciences, 1136: 161–171. doi: 10.1196/annals.1425.011


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