Health policies and programmes may be increasing health disparities between and within households in low-income areas
. There is no consensus on the combination of health and non-health sector programmes that would offer the best protection for poor people. Working through community-based organisations is a potentially promising approach.
A study published in the journal Health Policy and Planning examines the role of community-based organisations (CBOs) in helping households pay for health care. The authors use data from rural and urban households in Kilifi district to look at the potential for reaching poor people through these organisations.
With the decline in its economy, half of Kenya’s fast-growing population now lives in absolute poverty (defined by the World Bank as living on less than US$1 a day). Most Kenyans face a drop in the quality and range of health services even as they are less able to afford them. CBOs, which draw their membership from communities, are in a potentially good position to help.
The complex range of CBOs operating in Kilifi district can be classified as strategic (international and indigenous non-governmental organisations and state departments), intermediate (those implementing activities for strategic CBOs), and local (set up by individuals, typically covering a small area). Key findings include:
* Strategic CBOs often work with intermediate and local CBOs in ways that conflict with the approach of similar organisations, causing replication, conflict and confusion in communities.
* Strategic CBOs using micro-finance can meet long-term institutional aims (e.g. improved health with reduced poverty) and short-term household needs (e.g. need for food, treatment).
* Micro-finance loans can be difficult to pay back and may not reach the poorest people.
* Intermediate and local-level CBOs are better placed to reach households and meet their expectations.
* They are compromised by poor links to other organisations, little political clout, and concerns about dishonesty among leaders and fellow members, particularly in local-level CBOs.
* Reaching the poorest households through CBOs is particularly hard: these households tend not to belong to CBOs, and the groups they form themselves are often relatively fragile.
Existing CBOs can help protect low-income households against the impoverishing effects of costs related to illness. But reducing the cost of health services remains an absolute priority for the poorest households. Policy changes have to be implemented carefully so they do not undermine existing systems of meeting and coping with illness-related costs. Key recommendations include:
* There needs to be greater unity among strategic CBOs to improve their direct and indirect impacts on household ability to pay for health care.
* There is huge potential for intermediate-level CBOs to expand their role, but greater coordination at the strategic level is needed.
* The current trend of setting up intermediate-level CBOs for each initiative should be avoided.
* It is critical to identify local-level CBOs with a strong trust base within communities to improve the success rates of programmes.
* For those who can afford community-based health insurance schemes, structures and practices that build and maintain trust are critical.
