Community-based health insurance in low-income countries: A systematic review of the evidence

Publication Details

Ekman, B. (2004) Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy and Planning, 19(5), pp. 249–270.

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Björn Ekman
East Asia and Pacific (includes South East Asia), South Asia, Sub-Saharan Africa
Health Nutrition and Population
Health Financing, Insurance and User Fees
Equity Focus
Review Type
Effectiveness review

Main findings

A total of 36 studies from South Asia, Sub-Saharan Africa, Latin America, and East Asia met the inclusion criteria and were included in the systematic review. Studies were classified in three different types of schemes: provider-based schemes, community-based schemes and national insurance programs with local-level operations.

The author finds evidence that CBHI schemes provide some financial protection through reduction of out-of-pocket expenses for their members. However, the author suggests that most CBHI schemes are unsuccessful in reaching the poorest.
The author also finds moderate evidence that CBHI schemes improve cost recovery, although the average reported cost recovery ratio was only 25 per cent. This leads the author to conclude that there is little evidence to suggest that CBHI is a viable solution to the problems of sustainability of health care financing faced by many developing countries.

Further, the author finds that members of schemes have better access to health care. However, the author finds no evidence that having a CBHI scheme in operating areas had an impact on the quality of the care offered, although he suggests that this finding was due partly to the extent and quality of the studies assessing this outcome.

The quality of the available evidence was low, with the majority of included studies being observational studies reporting descriptive results. Studies had short time frames and failed to assess the general scenario of scheme functioning, which might affect the validity and applicability of the results to other contexts. Future research should adopt rigorous quantitative methods to assess the cost-effectiveness, sustainability and viability of these insurance schemes.


Low and middle-income countries have faced difficulties in sustaining adequate levels of funding for health care, and many countries lack systems for prepayment and health insurance. Health care is therefore often an out-of-pocket expenditure and can be ‘catastrophic’ for many households, reducing the resources available for other essential items and pushing people into poverty (World Bank, 1999; 2000; 2001; WHO 2000). National and international policy makers have suggested a number of different measures to address this issue, such as user fees and insurance. Voluntary, not-for-profit community-based health insurance (CBHI) schemes are one option promoted recently.

Research objectives

To synthesise and assess the evidence on the effectiveness of CBHI in providing additional financial resources for health care and in providing financial protection for the target population.


The review included experimental studies, controlled before-and-after studies, interrupted time series, cost-effectiveness analysis, case studies, reviews and surveys assessing the effectiveness of CBHI schemes. Studies measured outcomes for resource mobilisation, quality of care, provider efficiency, moral hazard, financial protection, out-of-pocket spending and access to care. Studies without sufficient information on either the type of the scheme or methodology were excluded.

The author conducted a comprehensive search of the published and unpublished literature, including PubMed, EconLit, Cochrane Reviews, EconBase, ScienceDirect and the Social Science Research Network. He searched articles in English, French, Portuguese and Spanish, covering the period from 1980 to 2004. Relevant studies were also found through hand searches and by searching iteratively through references. The author developed a study quality assessment protocol to assess study quality and synthesised the evidence from the included studies narratively.

Quality assessment

There are important risks of bias in study selection and data analysis because search, inclusion decisions, data extraction and analysis were conducted by only one person. The study includes a very broad range of evidence, from causal to correlational studies. While the author mentions the low quality of the evidence in the synthesis discussion, the study does not use appropriate methods to assess the quality of the included studies, in particular in assessing risk of bias in attributing outcomes to the intervention.

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