The potential for social mobilisation in Bangladesh: the organisation and functioning of two health insurance schemes

Health insurance schemes art: usually assessed according to technical indic ators. This approach, however, neglects the dynamic perspective of insuranc e schemes as an element of people's mobilisation for participation in organ ising and managing health care delivery and financing. The first part of th is paper describes the technical performance and the level of community inv olvement in management of the two largest health insurance schemes in Bangl adesh, both in the rural areas and in the non-government sector. Part two d iscusses these achievements in light of the schemes' potential role as a me chanism for people's management of health care. A review of documents and k ey-informant interviews were conducted. Key findings include that (1) subscribers currently are not actively partic ipating in scheme management. However, existing family groups, involved in credit programmes may serve as entry-points fdr interaction. This is sustai ned by the 'natural link' between health insurance as a means of spreading the risks of treatment costs and credit programmes as a means of decreasing the relative impact of illness on household income. (2) The schemes' role could be further enhanced, by improving their technical performance and app lying health care systems elements with the input of all partners involved. These issues are avoidance of service duplication with other providers; be tter protection of the poorer households; inclusion of hospital care in the coverage package; simplification of scheme administration by introduction of episode-based co-payments instead of the current itemised ones and conce ntrating the schemes at the level of community-based services, which may be self-financed and also self-managed by the community, given available sens itisation, training and interaction. A shift to episode-based co-payments w ould also introduce solidarity among patients and among individuals at high er risk, such as pregnant women and under-fives. Finally, action-research i s needed to document the process of increased community involvement. (C) 19 99 Elsevier Science Ltd. All rights reserved.