2001年-世界发展银行全球_Community_Involvement_in_Health_Care_Financing___A_Survey_of_the_Literature_on_the_Impact_Strengths_and_Weaknesses_81页_838kb

Summary of "Community Involvement in Health Care Financing: A Survey of the Literature on the Impact, Strengths and Weaknesses"

Core Content

This paper presents a comprehensive review of 45 published and unpublished reports on community-based health financing (CBHF) mechanisms, completed between 1990 and 2001. The study was conducted as part of the Commission on Macroeconomics and Health (CMH) to assess the role of community involvement in health care financing, especially in low-income countries.

Main Objectives

• To explore the concept and modalities of community-based health financing.
• To assess the performance of CBHF schemes in terms of resource mobilization, social inclusion, and financial protection.
• To identify the structural determinants that influence the success of these schemes.

Key Findings

A. Resource Mobilization Capacity

• Community financing mechanisms are effective in mobilizing significant resources for health care.
• However, there is substantial variation in the capacity of different schemes to mobilize funds.
• The paper did not find systematic evidence on the contribution of community financing to local or national health revenues.
• There is limited data on the per capita amount of resources mobilized through CBHF compared to other health financing instruments.

B. Social Inclusion

• CBHF is effective in reaching low-income and socially excluded populations.
• The size of schemes varies widely, and there is no comprehensive estimate of the total population covered.
• The poorest and most socially excluded groups are often not automatically included in these schemes, suggesting the need for targeted subsidies or support mechanisms.

C. Financial Protection

• Community-based health financing schemes are consistently reported to reduce out-of-pocket (OOP) spending and increase health service utilization.
• These schemes help protect individuals and households from the financial burden of illness.
• However, they do not fully eliminate financial barriers to access, especially for the poorest segments of the population.

D. Performance Determinants

• Technical Design Characteristics: Mechanisms for revenue collection, pooling, and purchasing play a crucial role in determining the effectiveness of CBHF.
• Management Characteristics: Active community involvement in the management of schemes is associated with better performance.
• Organizational Characteristics: The structure and operations of the schemes influence their ability to provide financial protection and ensure sustainability.
• Institutional Characteristics: Strong links with formal health financing systems and provider networks are essential for enhancing the impact of CBHF.

Strengths of Community-Based Health Financing

• Outreach: CBHF schemes have a high degree of outreach, particularly in rural and informal sectors.
• Financial Protection: They contribute to reducing OOP payments and increasing access to health services.
• Social Inclusion: They help provide health care financing to populations that are often excluded from formal systems.

Weaknesses of Community-Based Health Financing

• Limited Revenue Generation: CBHF schemes generally mobilize fewer resources compared to formal systems.
• Exclusion of the Poorest: The poorest and socially excluded groups are often not automatically included.
• Small Risk Pools: The limited size of risk pools affects the sustainability and effectiveness of these schemes.
• Weak Management Capacity: There is often a lack of adequate management and organizational structures in low-income and rural areas.
• Isolation from Formal Systems: CBHF schemes are often disconnected from broader formal health financing mechanisms and provider networks.

Policy Recommendations

The CMH report emphasizes the need for:

• Targeted Subsidies: To ensure that the poorest populations can participate in CBHF.
• Insurance and Reinsurance: To enhance the financial protection and sustainability of small risk pools.
• Effective Prevention and Case Management: To reduce the variability of health care costs.
• Technical Support: To strengthen the management and organizational capacity of local schemes.
• Integration with Formal Systems: To connect CBHF with more comprehensive health financing mechanisms and provider networks.

Conclusion

The literature is rich in describing the design and implementation of community-based health financing schemes, but it lacks robust evidence on their performance as health financing instruments. While CBHF has shown promise in improving access and financial protection for vulnerable groups, its effectiveness is constrained by several structural and operational challenges. The CMH highlights the importance of community financing as a complementary approach to government-led health financing and calls for stronger policy support to enhance its impact.

Key Terms

• Community-Based Health Financing (CBHF): A method of financing health care through community participation.
• Financial Protection: Protection from the economic consequences of illness.
• Social Inclusion: Ensuring that marginalized and poor populations have access to health care.
• Resource Mobilization: The ability of a scheme to collect and pool funds for health care.

Methodology

• Scope: The study reviewed 45 reports and conference proceedings from 1990 to 2001.
• Selection Criteria: Studies were included if they focused on community involvement in health financing.
• Data Sources: Included peer-reviewed articles, reports from international organizations (WHO, ILO, UNICEF), internal documents, and conference proceedings.
• Performance Indicators: Analyzed through three levels: ultimate (health, financial protection, social inclusion), intermediate (resource mobilization, utilization, financial access), and technical (revenue collection, pooling, risk sharing).

Structure of the Paper

• I. Executive Summary
• II. Introduction
• III. Methods
• IV. What is Community-Based Health Financing?
• V. Performance of Community-Based Health Financing
• VI. Determinants of Performance
• VII. Concluding Remarks
• VIII. References
• IX. Appendix A: Performance Variables
• X. Appendix B: Core Characteristics of Community Financing Schemes