August, 2008 - SUPPORT Summary of a systematic review | print this article |

Do risk sharing mechanisms improve access to health services in low and middle-income countries?

The introduction of user charges in many low and middle-income countries has been proposed as a strategy to increase revenues. But delayed treatment, catastrophic health expenditures and impoverishment are among the detrimental effects attributed to them. To reduce these risks, mechanisms allowing payment of care in advance or risk pooling have been increasingly advocated.

Key messages

  • Only one study was found that describes the impact of community-based health insurance schemes in Rwanda. Based on routine data collected at facility level, it seems that the introduction of these mechanisms may have increased utilization of care. But weaknesses in the design of the study limit the scope and validity of its findings.


“Risk protection mechanisms” include community-based insurance, social or private health insurance and pre-payment schemes. They all share the particularity of involving prospective payments for health care – as opposed to payment at the point of delivery. In all of the schemes funds are collected in advance. Pre-payment schemes are individual forms of health financing and offer no opportunity for risk pooling, in contrast to community-based insurance that allows pooling across all beneficiaries of the scheme. Unlike community-based insurance, social health insurance is a compulsory scheme, whose coverage may vary from a specific large group (e.g. formal employees) to the whole population of a country. Social insurance schemes are usually mainly based on payroll contribution, from employers and employees. Increasingly support for such risk protection mechanisms has been voiced on grounds of their theoretical capacity to protect vulnerable people and alleviate financial constraints to accessing health services.

About the systematic review underlying this summary

Summary of findings

The review included one controlled before-after study that evaluated a communitybased health insurance scheme in Rwanda. Enrolment in the scheme was voluntary and allowed access to a benefit package which included all preventive and curative services provided in the health centre, including essential drugs (as listed by the Ministry of Health). The only relevant outcomes collected before and after the beginning of the programme were monthly routine data from facilities located in the intervention and control districts. Health utilization outcomes measured by utilization of all available services in health centres (curative outpatient visits, prenatal care visits, deliveries, family planning, vaccinations, laboratory, hospitalization admissions and days) and in hospitals (curative outpatient visits, curative inpatient visits, deliveries, laboratory and radological tests, hospitalisation by ward, hospitalisation days). The volume of essential drugs prescribed in health centres and hospitals was also monitored.

  • There is low quality evidence that community-based health insurance can increase utilization of health care.

Relevance of the review for low-income countries

Additional information

Related literature

This systematic review is currently in press: Lagarde M, Palmer N. The impact of risk sharing mechanisms on access to health services in low and middle-income countries. Cochrane Database of Systematic Reviews.


The protocol for the systematic review above: The impact of health financing strategies on access to health services in low and middle-income countries (Protocol). Cochrane Database of Systematic Reviews 2006, Issue 3.


This chapter summarizes the financing mechanisms of health systems: The world health report 2000 -Health systems: improving performance. Chapter 5: Who pays health systems?. Geneva: WHO, 2000.


Systematic review addressing the impact of community-based health insurance: Ekman B. Communitybased health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan 2004; 19:249-70.


Review: Creese A, Bennett S. Rural risk-sharing strategies. In: Schieber G (ed.). Innovations in Health Care Financing. Proceedings of a World Bank Conference. Washington, D.C: World Bank, 1997, pages 163-93.


This summary was prepared by

García Marti Sebastían and Ciapponi Agustín. Institute for Clinical Effectiveness and Health Policy. Argentina


Conflict of interest

None declared. For details, see:



This summary has been peer reviewed by: Tracey Perez Koehlmoos, Bangladesh; Gabriel Rada, Chile.


This summary should be cited as

García Martí S, Ciapponi A. Does risk sharing mechanisms improve access to health services in low and middle income countries? A SUPPORT Summary of a systematic review. August 2008.