Using a community-based definition of poverty for targeting poor households for premium subsidies in the context of a community health insurance in Burkina Faso

BackgroundOne of the biggest challenges in subsidizing premiums of poor households for community health insurance is the identification and selection of these households. Generally, poverty assessments in developing countries are based on monetary terms. The household is regarded as poor if its income or consumption is lower than a predefined poverty cut-off. These measures fail to recognize the multi-dimensional character of poverty, ignoring community members’ perception and understanding of poverty, leaving them voiceless and powerless in the identification process. Realizing this, the steering committee of Nouna’s health insurance devised a method to involve community members to better define ‘perceived’ poverty, using this as a key element for the poor selection. The community-identified poor were then used to effectively target premium subsidies for the insurance scheme.MethodsThe study was conducted in the Nouna’s Health District located in northwest Burkina Faso. Participants in each village were selected to take part in focus-group discussions (FGD) organized in 41 villages and 7 sectors of Nouna’s town to discuss criteria and perceptions of poverty. The discussions were audio recorded, transcribed and analyzed in French using the software NVivo 9.ResultsFrom the FGD on poverty and the subjective definitions and perceptions of the community members, we found that poverty was mainly seen as scarcity of basic needs, vulnerability, deprivation of capacities, powerlessness, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. Criteria and poverty groups as described by community members can be used to identify poor who can then be targeted for subsidies.ConclusionPolicies targeting the poorest require the establishment of effective selection strategies. These policies are well-conditioned by proper identification of the poor people. Community perceptions and criteria of poverty are grounded in reality, to better appreciate the issue. It is crucial to take these perceptions into account in undertaking community development actions which target the poor. For most community-based health insurance schemes with limited financial resources, using a community-based definition of poverty in the targeting of the poorest might be a less costly alternative.

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abstract: In spite of the fact that feeble levels of participation have long been identified as a major constraint to the successful long-term implementation of community-based health insurance (CBI) in low-income countries, evidence on determinants of enrolment in CBI is still lacking. The application of econometric modelling has provided a partial answer to the question, but on its own it has proved to be insufficient to guide policy making. This paper aims to fill this gap in knowledge using qualitative research methods. In-depth interviews with 32 household heads were conducted in the Nouna Health District, Burkina Faso, West Africa to assess determinants of enrolment in a newly established CBI scheme. The findings highlight that factors previously neglected in the literature, such as institutional rigidities and socio-cultural practices, play an important role in shaping the decision to enrol. The discussion of the findings focuses on the policy implications, offering concrete recommendations to maximise enrolment, within and beyond Burkina Faso.

title: The feasibility of community-based health insurance in Burkina Faso.
abstract: To ensure the acceptability of community-based insurance (CBI) by the community and its sustainability, a feasibility study of CBI was conducted in Burkina Faso, including preference for benefit package of CBI, costing of health services, costing of the benefit package and willingness-to-pay (WTP) for the package. Qualitative methods were used to collect information about preferences for the benefit package. Cost per unit health services, health demand obtained from household survey and physician-judged health needs were used to estimate the cost of the benefit package. The bidding game method was used to elicit household head's WTP for the package. We found that there were strong preferences for inclusion of high-cost healthservices such as operation, essential drugs and consultation fees in the benefit package. It is estimated that the cost of the package per capita was 1673 CFA (demand-based) and 9630 CFA (need-based), including 58% government subsidies (euro 1 = 655 CFA). The average household head with eight household members agreed to pay from 7500 (median) to 9769 CFA (mean) to join the CBI for his/her household. The WTP results were influenced by household characteristics, such as location, household size and age composition. Under certain assumptions (household as the enrolment unit, median household head's WTP as premium for the average household, 50% enrolment rate), it would be feasible to run CBI in Nouna, Burkina Faso if enrolees' health demand did not increase by more than 28% or if the underwriting of the initial losses was covered by extra funds.

title: Perceptions of Risk, Vulnerability, and Disease Prevention in Rural Burkina Faso: Implications for Community-Based Health Care and Insurance
abstract: This paper examines local discourse on perceived risk and vulnerability among rural and semiurban populations in Kossi Province in the northwest of Burkina Faso. Focus group data are presented to elucidate this discourse in a number of risk domains. Local notions of disease prevention are exemplified with respect to malaria, diarrhea, and vaccine-preventable diseases. Quantitative measures on perceived severity and perceived personal vulnerability, assessed using culturally adapted scaling methods and relating to a list of selected risks, are presented. Implications of the complex local discourse on uncertainty and vulnerability with respect to community-centered development efforts such as community-based health care and insurance are explored.

title: Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso.
abstract: This study aims to identify the reasons why enrolled people decide not to renew their membership in following years.



Household survey is used to collect information on the factors influencing dropping out from community-based health insurance (CBI). Information from CBI agency databank is used to describe the general situation of enrolment and drop-out.



Since the launch of CBI the enrolment rate has been low ranging from 5.2% to 6.3%. The drop-out rate, however, has been high ranging from 30.9% to 45.7%. It is found, by the multivariate analysis, that female household head, higher age or lower education of a household head, lower number of illness episodes in the past three months, fewer children or elderly in a household, poor perceived health care quality, less seeking care in the past month positively effected on drop-out, increasing the rate. However, the household six-month expenditure and the distance to the contracted health facility did not have the hypothesised sign. In contrast, a higher household expenditure and a shorter distance to the contracted health facility increased the drop-out.



High drop-out rates endanger the sustainability of CBI not only because they reduce the size of the insurance pool, but also because they bear a negative impact on further enrolment and drop-out. The drop-out rate in the scheme of the Nouna Health District, Burkina Faso, is very high. The reasons for drop-out may be related to affordability, health-needs and health demand, quality of care, household head and household characteristics. This study represents a valuable attempt towards further increasing the sustainability of CBI schemes, by understanding not what motivates people to first enrol in CBI, but what motivates them to renew membership year after year.

title: Community-Based Targeting Mechanisms for Social Safety Nets: A Critical Review
abstract: This paper interprets case studies, and theory on community involvement in beneficiary selection, and benefit delivery for social safety nets. Several considerations should be carefully balanced in assessing the advantages of using community groups as targeting agents. First, benefits from utilizing local information, and social capital may be eroded by costly rent-seeking. Second, the potential improvement in targeting criteria from incorporating local notions of deprivation, must be tempered by the possibility of program capture by local elites, and by the possibility that local preferences are not pro-poor. Third, performance may be undermined by unforeseen strategic targeting by local communities in response to national funding, and evaluation criteria, or by declines in political support.

title: Socioeconomic stratification by wealth ranking: Is it valid?☆
abstract: This paper validates a Rapid Rural Appraisal wealth-ranking technique using standard socioeconomic indicators from a household survey in rural Bangladesh. Key informants stratified 1,637 households into three wealth groups according to a number of broad criteria and a questionnaire was subsequently administered to each household. Health, demographic and economic variables derived from the questionnaire were found to differ significantly according to wealth group. Analysis supports the construct validity and empirical validity of the wealth-ranking technique as a means of stratifying households by socioeconomic status. The requirements for external validity, as assessed through the comparison of findings with similar studies elsewhere in South Asia, are also satisfied.

title: Focus group discussion: a tool for health and medical research
abstract: Focus group discussion is a research methodology in which a small group of participants gather to discuss a specified topic or an issue to generate data. The main characteristic of a focus group is the interaction between the moderator and the group, as well as the interaction between group members. The objective is to give the researcher an understanding of the participants’ perspective on the topic in discussion. Focus groups are rapidly gaining popularity in health and medical research. This paper presents a general introduction of the use of focus groups as a research tool within the context of health research, with the intention of promoting its use among researchers in healthcare. A detailed methodology for the conduct of focus groups and analysis of focus group data are discussed. The potentials and limitations of this qualitative research technique are also highlighted.

title: Focus groups for qualitative research.
abstract: Focus Groups as  The Uses of Focus Groups Planning and Research Design for Focus Groups Conducting and Analyzing Focus Groups Additional Possibilities

title: Community and anti-poverty targeting
abstract: The standard theory of anti-poverty targeting assumes individual incomes cannot be observed, but statistical properties of income distribution in broadly defined groups are known. ‘Indicator targeting’ rules are then derived for the forms of transfers conditioned on group membership of individuals. In this literature the motivating notion of a ‘group’ is purely statistical, even when it is groups such as localities and ethnicities. We focus instead on groups which are ‘communities’, meaning thereby collections of individuals who have access to community-specific public goods, from which non-members are excluded. Such differential access constitutes a source of inequality among poor individuals belonging to different communities, which is not captured by monetary earnings. We show that this formulation of what constitutes a group changes many of the basic results of the indicator targeting literature. Optimal targeting for poverty alleviation leads to seemingly paradoxical rules, such as targeting transfers to the community that is richer. Total wealth of non-poor members of a community and its distribution both become relevant for specifying optimal indicator targeting rules. In addition, a poverty measure that is sensitive to the community identities of poor individuals, yet defined on nominal incomes, may be incompatible with some of the basic axioms in the standard literature on poverty measurement.

title: 'I keep myself clean...at least when you see me, you don't know I am poor': student experiences of poverty in South African higher education
abstract: There is little research exploring poverty amongst university students, which renders poverty on university campuses invisible. This study aims to begin to understand experiences and constructions of poverty among university students. The qualitative study design uses open-ended, in-depth interviews in which four students from a university in the Western Cape were interviewed. The findings suggest that poor students use multiple strategies to circumvent the psychological distress associated with poverty and to disguise their poverty. They reflect complex and seemingly contradictory views of poverty as an individually and structurally created burden when they simultaneously take responsibility for their poverty but also attribute it to structural factors. Despite this, participants expressed resilience and hope for a better future, championing education as the 'way out' of their current situation. The findings suggest that more qualitative research is needed in this area as it holds implications for student retention, access to university and drop-out rates in higher education, areas which are core to transformation in South African higher education. Some recommendations about individual and interpersonal interventions that may supplement collective or macro-level interventions are made.

title: Tourism and Poverty Reduction: An Interpretation by the Poor of Elmina, Ghana
abstract: Over the past decade, academic research into the use of tourism as a contributor to poverty reduction has grown considerably; however, there are few insights on how the poor perceive the connections between poverty and tourism. Based upon interpretive and participatory fieldwork with the poor of Elmina in Ghana, this paper explores their understanding and constructions of poverty and how they comprehend tourism as a provider of alternative livelihood opportunities. It emerged that poverty is understood as a multi-dimensional construct, including low and irregular incomes, depletion of natural resources, a lack of access to social assets and educational opportunities, and denial of meaningful participation in society. At a time of structural readjustment in Elmina's economy, the potential of tourism to enhance livelihoods and reduce poverty is high, but remains hindered by major barriers to entrepreneurship development and employment within the sector, which is worsened by the lack of access to credit, exclusion from decision-making, poor skills and excessive bureaucracy. It became evident that a focus on the use of tourism for macroeconomic gains will not necessarily benefit the poor. They need to be included in tourism policy and practice, not only as a target group, but also in participatory mechanisms to ensure the appropriate use of tourism for poverty reduction. It is argued that it is only through a better understanding of poor people's experiences of poverty, that tourism can be used more meaningfully as a strategy for its alleviation.

title: The Face of Chronic Poverty in Uganda from the Poor’s Perspective: constraints and opportunities
abstract: This paper examines the factors influencing chronic poverty in Uganda from the perspective of the poor. The findings are based on participatory poverty assessments conducted in 23 urban and 57 rural sites covering 21 districts. The paper examines: the view of the poor on the definitions of chronic poverty, the types of people who are chronically poor and why; opportunities and constraints for moving out of poverty; the effects of government policies; and suggestions for improvements. The findings suggest that the factors driving and maintaining poverty often are transmitted inter-generationally, and certain categories of people, such as the disabled, women and refugees, are more vulnerable than others. Also, ineffective local governance and government policies seem to prevent the chronically poor from escaping the poverty trap.

title: Poor People in Rich Nations: The United States in Comparative Perspective
abstract: Cross-national comparisons can teach lessons about antipoverty policy. While all nations value low poverty, high levels of economic self-reliance and equality of opportunity for younger persons, they differ dramatically in the extent to which they reach these goals. Nations also exhibit differences in the extent to which working age adults mix economic self-reliance (earned incomes), family support and government support to avoid poverty. We begin by reviewing international concepts and measures of poverty. The Luxembourg Income Study (LIS) database contains the information needed to construct comparable poverty measures for more than 30 nations. It allows comparisons of the level and trend of poverty and inequality across several nations, along with considerable detail on the sources of market incomes and public policies that shape these outcomes. We will highlight the different relationships between antipoverty policy and outcomes among several countries, and consider the implications of our analysis for research and for antipoverty policy in the United States. In doing so, we will draw on a growing body of evidence that evaluates antipoverty programs in a cross-national context.

title: Participatory poverty assessment : incorporating poor people's perspectives into poverty assessment work
abstract: A foundation stone of the World Bank's sharpened poverty strategy is to conduct Country Poverty Assessments in all borrowing countries within the next two years. These assessments have the following principal elements: a poverty profile (which analyses the depth, social and cultural nature, gender disparities and geographic spread of poverty); a review of current government policies relating to poverty; an analysis of pertinent public expenditures and institutions; an overview of nongovernmental organizations and community-based organizations working toward the alleviation of poverty; an analysis of the safety nets (both government programs and sociocultural mechanisms) in place; and based on the above a suggested country strategy of priority measures the government should take to reduce poverty. This paper proposes to supplement conventional poverty assesments with an effort to involve key groups of vulnerable people, among them women and members of indigenous communities and racial and ethnic minority goups.

title: Validity of rapid estimates of household wealth and income for health surveys in rural Africa
abstract: To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa.  Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population.  Rural areas of Mali, Malawi, and Côte d'Ivoire (two national surveys).  Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively).  In both Mali and Malawi, the wealth proxy correlated highly (r⩾0.74) with the more complex monetary value method. For rural areas of Côte d'Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined (r=0.74, development dataset,r=0.72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings.  It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.

title: Измерение И Анализ Бедности [Poverty Measurement and Analysis]
abstract: This chapter offers a primer on poverty, inequality, and vulnerability analysis and a guide to resources on this topic. It is written for decision makers who want to define the type of information they need to monitor poverty reduction and make appropriate policy decisions and for the technical experts in charge of the analysis. The chapter takes a broad look at tools for analysis and provides a brief introduction to each topic. It also outlines why certain information is essential in policymaking and how this information can be generated. This unpublished version of the paper in Russian was translated from an English version published in the World Bank's Poverty Reduction Strategy Sourcebook.

title: Poverty and basic needs fulfilment in Africa during structural change: Evidence from Cote d'Ivoire
abstract: Much attention is given in the literature to the evolution of social indicators during periods of structural adjustment and economic reform. This paper argues that these processes are not distribution-neutral from the point of view of basic needs fulfilment and that hence the focus should not be on aggregate indicators but on the distribution of beneficiaries of social services, and changes in this distribution. Evidence is presented for Cote d'Ivoire during the second half of the 1980s—a period of intense structural change—which shows that the poorest absorbed the bulk of the decline in basic needs fulfilment as a result of structural change. This was the case for almost all aspects of basic needs and occurred regardless of the overall trend in the social indicators.

title: The basic needs approach: Overcoming the poverty of homo oeconomicus
abstract: A major issue in the controversy surrounding the Basic Needs Approach to economic development concerns the difficulty of identifying a universal set of basic needs which is capable of cross-cultural application. It is argued that the apparent conceptual infeasibility of the Basic Needs Approach stems from prominent deficiencies in our current stock of economic, political and ethical paradigms, particularly with respect to the image of humans embodied in the notion of Homo oeconomicus . Recent advances in sociobiology and neurobiology provide an adequate foundation for a concept of universal basic human needs, and a proposed typology of basic needs is suggested.

title: Basic Needs: Some Unsettled Questions
abstract: Though the large basic needs literature has clarified some issues related to anti-poverty strategies, it has also raised others. This paper identifies some of these unsettled questions: (1) who is to determine basic needs? (2) do basic needs refer to the conditions for a full, long and healthy life or to a specific bundle of goods and services that are deemed to provide opportunity for these conditions? (3) what is the purpose of participation? what form should it take? how does a right to participate (if it exists) relate to the political/administrative structures necessary for efficient implementation of basic needs approach? (4) what is the relationship between the redistribution approach to development and the basic needs approach? does the basic needs approach require fundamental systemic change, or is it a palliative? (5) what is the relation between meeting basic needs as an end in itself and as an instrument for developing human resources? (6) in what manner should international support for basic needs approaches be mobilized? (7) what is the relation between poverty eradication and reducing income inequalities?