Implementation of Community-based Health Insurance in Post-war Settings: A Systematic Review

Background Achieving universal health coverage is the biggest challenge in post-conflict situations. Community-based health insurance is an alternative mechanism to improve healthcare utilization and coverage through a prepayment mechanism and pooling health risks in the informal sector. However, there is limited data on the feasibility of community-based health insurance in countries emerging from conflict or war. Objective This systematic review aims to summarize the evidence on the feasibility of the implementation of community-based health insurance in post-conflict situations. Methods The search process included peer-reviewed literature and gray literature published between 1990 and 2023 in the electronic databases of Global Health, Pub Med, CINAHL, Science Direct, and Gray Publications. The search was conducted manually on December 10, 2023. We conducted a systematic review of articles published since 1990 using a search strategy. The Mixed Methods Assessment Tool (MMAT) was used for quality assessment to evaluate the methodological quality of various studies. Results In this review, a total of 30 articles were included and synthesized. Out of the eligible articles, cross-sectional studies, issue reports, and strategic documents were reviewed. In general, 66.7% of the studies were qualitative, and 33.3% were quantitative. We summarize and describe the feasibility of introducing community health insurance, its impact on universal health coverage, and the limitations of financial risk allocation and protection in the post-war period. Community-based health insurance (CBHI) schemes face several significant obstacles, such as poor financial risk protection, a limited risk pool, adverse selection, a lack of professional and standardized management, and a lack of availability and quality of services. Although they are less successful in reaching marginalized populations, CBHI programs with access to external or additional funding sources are more successful in extending access to healthcare services and offering financial security. Regardless of scheme type, CBHI schemes that involve the community in the design and implementation process are more effective at guaranteeing access to healthcare and financial protection. Furthermore, households with CBHI insurance have lower out-of-pocket medical costs, high odds of overall health care utilization, outpatient service use, health facility deliveries, and a lower frequency of catastrophic medical costs at various thresholds. Conclusions Community-based health insurance (CBHI) schemes have emerged as an alternative health financing mechanism in low- and middle-income countries. These schemes aim to improve access to healthcare and provide financial protection. However, their effectiveness is limited by several challenges. Studies have found that CBHI schemes often exclude the ultra-poor and suffer from adverse selection. While there is evidence that CBHI increases healthcare utilization, particularly for outpatient services, and reduces out-of-pocket spending, the overall impact remains small. Key challenges include limited risk pools, poor financial risk protection, and a lack of quality services. Factors influencing enrollment and sustainability include awareness, trust, perceived service quality, and community involvement. Despite some positive outcomes, CBHI schemes are considered complementary to more effective health financing systems rather than a standalone solution.