Health insurance schemes organised at the community level can encourage members to take better care of their health, according to research by Emmanuel Nshakira Rukundo, to be presented at the Royal Economic Society”s annual conference at the University of Sussex in Brighton in March 2018.

His study of households in south-western Uganda finds membership of a community-based health insurance has substantial positive impacts on seven preventive health strategies: use of long-lasting mosquito nets, water treatment, handwashing, vitamin A, and iron supplementation, deworming and receiving a new vaccine, the Pneumococcal Conjugate Vaccine (PCV) for child pneumonia.

The results encourage governments to support the scale-up of community-based health insurance not only for health financing and financial protection reasons but also as a pathway of increasing uptake of preventive health strategies.


One way of mitigating the effects of health shocks in developing countries is community-based health insurance (CBHI). This is a prepayment mechanism often organised at a community level, targeting rural and sometimes urban informal sectors, often closely associated to informal risk sharing arrangements. These schemes have varying degrees of formality.

The growth of these schemes in developing countries in the last two decades has led to extensive research focused on its effects on financial protection (as the main purpose for insurance) and use of health services. One area where research has been thin is on use of preventive health. This research shows that CBHI can actually nudge a wide range of preventive health strategies.

Developing countries have a high burden of preventable illnesses such as malaria. But even when prices for preventive health technologies are relatively low, they are inelastic. People tend not to purchase preventive health technologies when prices are changed slightly upwards to cover costs (Cohen & Dupas, 2010; Kremer & Miguel, 2007).

But providing these technologies for free also results in wastage and misuse (Cohen et al., 2015; McLean et al., 2014; Minakawa et al., 2008). Subsidisation therefore remains an answered question (Ahuja et al., 2015; Dupas, 2014). But is there a role that CBHI can play in improving preventive health? Are there effects of CBHI beyond the conventional financial protection and access to health services?

To answer this question, data was collected from 464 households in south-western Uganda. The case study Kisiizi Hospital CBHI scheme started in 1996 and currently provides coverage to over 40,000 people in over 7,200 households. Households pay an equivalent of between US$3 and US$9 and receive coverage for basic tertiary care.

Belonging in a local burial group is the major prerequisite for enrolling. Insurance policies are not issued as group policies but rather groups simply facilitate coordination and collection of premiums, but most importantly, building on existing social support systems and controlling moral hazard.

Inverse probability weighting on the propensity score is applied on this data, controlling for many household and village covariates and study the effect of membership in CBHI on seven preventive health strategies, namely; use of long-lasting mosquito nets (LLIN), water treatment, handwashing, vitamin A, and iron supplementation, deworming and receiving a new vaccine, the Pneumococcal Conjugate Vaccine (PCV) for child pneumonia.

It is established that membership in CBHI had substantial positive impacts on all preventive health strategies. In particular, it is found that on average, enrolment in CBHI was causally associated with increasing the probability of using a LLIN by 24.6 percentage points, and water treatment, vitamin A supplementation and deworming by 22.3, and 28.2 percentage points respectively.

For the households that were in CBHI, enrolment increased the probability of using a LLIN by 35.2 percentage points, handwashing by 8 percentage points, taking iron supplements by 8.3 percentage points, child deworming by 30 percentage points and receiving the PCV by 15.7 percentage points.

One pathway through which these effects could be realised is through time-dependent social learning and behaviour change. Households in CBHI for longer were found to have larger effects than those in CBHI fewer years, implying there was important time-dependent learning aspects. Burial groups in CBHI also met more often than those not in CBHI.

This research therefore encourages governments to support CBHI scale-up not only for health financing and financial protection reasons but also as a pathway of increasing uptake of preventive health strategies such as these measured.

Does Community-Based Health Insurance Foster Preventive Health Strategies? Evidence from Rural South-west Uganda. Emmanuel Nshakira Rukundo, PhD Candidate, Center for Development Research, University of Bonn

Emmanuel Nshakira Rukundo




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