Above and below the poverty line: Is community-based health insurance an effective tool to prevent impoverishment related to healthcare expenditure in low-income countries?

Purpose: Community-based health insurance (CBHI) has been promoted as a means to prevent catastrophic healthcare expenditure and household impoverishment in low- and middle-income countries. This study aims to assess how the generalization of CBHI would impact poverty in Burkina Faso. Data & Methods: 1604 households were surveyed about their healthcare consumption. Impoverishment attributable to direct healthcare expenditure was measured by comparing the incidence levels of poverty and the poverty gaps before and after health expenditure. The results were compared to the level of impoverishment under two simulated scenarios: 1) all households are subscribers of a CBHI; 2) same scenario, with external subsidies to fund poor households' premiums. Results: Without insurance, out-of-pocket health expenditures impoverish the poor further and drag some previously non-poor households below the poverty line. Being insured does not meaningfully modify the average level of households' spending on health. Since most households can only afford low premiums, balancing inflows and outflows implies leaving some health expenses uncovered and imposing co-payments. Reimbursements often do not offset the premiums and co-payments. The implementation of insurance benefits mostly the wealthier households (decrease in their health expenditures). For poor households, the balance of gains (reduction in the economic burden of healthcare) and losses (premium costs) is not favorable, unless their premiums are subsidized. Intermediate households' total health expenditures increase when insured. The CBHI does not reduce the proportion of households falling into poverty due to health expenditure. Policy implications: CBHI is not a magic bullet to mitigate the impoverishing impact of user fees. Countries and the international community cannot withdraw from their responsibilities in finding new solutions to the crisis of health financing in low-income countries.