Philipa Mladovsky and Elias Mossialos A conceptual framework for community-based health insurance in low-income countries: social capital and economic development

Current thinking in major international development agencies construes community-based health insurance (CBHI) as a transitional mechanism to achieving universal coverage for health care in lowincome countries. The policy link between CBHI and universal coverage is implicitly determined by the historical experience of mutual health insurance in countries such as Germany and Japan in the 19 century, where the socioeconomic context was dramatically different to that of today’s much less successful schemes. This paper argues that the economic and health system frameworks employed in the analysis of CBHI have not taken into account context-dependent considerations such as goals, values and power. It is proposed that a critical engagement with social capital theories could contribute to our understanding of why CBHI schemes do not appear on course to develop according to the 19 century precedent, achieving significant levels of population coverage in a sustainable way. A framework of social capital and economic development is used to organize and interpret existing evidence and information on CBHI. This process suggests that solidarity, trust, extra-community networks, vertical civil society links and state-society relations at the local level affect the possibility of success of CBHI. To this extent, it may be possible to talk of “social determinants of CBHI”. In order to align themselves to local community goals and values, CBHI schemes may need to actively foster certain types of vertical and horizontal bridging relations which could result in the evolution of structures and operations quite different to those proposed by current models of CBHI.