Health insurance in sub-Saharan Africa: a call for subsidies.

De Allegri et al.1 rightly describe low enrolment as a principal problem related to the functioning of community health insurance (CHI) in sub-Saharan Africa. Furthermore, they identify a set of important factors affecting the decision to enrol. Nonetheless, on reflection about the evidence established by this paper and related research, I would like to suggest some additional considerations. First of all, the described (and not too surprising) fact that the educational and, importantly, the socioeconomic status of a household play predominant roles in the decision of whether to enrol in health insurance is depicted by a series of articles2 as well as several systematic article reviews.3 Some of them are quoted by the authors themselves.4,5 Second, the consistency of this observation and the clear-cut cause–effect relationship between socioeconomic well being and the readiness to embark on an expenditure (be it for health insurance or anything else) allow the conclusion that wealth is a fundamental predictive factor for enrolment into health insurance. Third, if then poverty can be understood as a risk factor for not embarking into health insurance, the discussion around an insurance approach for the poor should focus very much on the following three questions: What percentage of the population targeted by the envisaged or existing insurance scheme are too poor to enrol on their own? By which kind of corrective measures can they be included? What consequences do these measures have for the financial viability of the scheme?