Overcoming the Challenges of Scaling Voluntary Risk Pools in Low-Income Settings

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This paper explores risk pooling as a potential mechanism to leverage the private health sector to improve the quality, affordability, and availability of care for the poor in developing countries. It primarily explores smaller scale private risk-pooling programs, with a focus on those that have been launched in South Asia and sub-Saharan Africa among poor and informally employed populations. We hypothesize that these smaller scale programs can be a stepping stone toward broader public health financing reforms that have so far remained largely elusive in most of the world’s poorest countries.


We acknowledge that there is a great body of literature on risk pooling and health insurance1 in the developing world. Alex Preker, Guy Carrin, David Dror, William Hsiao, Johannes Jutting, and other distinguished experts in the field have studied health insurance for the poor for decades. Organizations such as the MicroInsurance Gateway and CGAP Working Group on MicroInsurance have become hubs of knowledge related to micro-insurance. In addition, bilateral agencies, private donors, and international organizations such as GTZ, the French Development Agency, the Bill & Melinda Gates Foundation, the International Labour Organization, and many others have partnered to explore how health financing can be reformed through various demand-side insurance mechanisms to benefit the poor in the developing world. We have consulted the existing literature and conducted interviews with many researchers and program implementers that work in this area. We also made site visits to several of the programs we highlight in this paper to better understand their specific program models, the hurdles they face in launching and scaling their programs, and the context in which they operate.


The second section of the paper discusses the potential for risk-pooling programs to catalyze the improvement of health systems for the poor, especially in already “marketized” country contexts, where the poor finance a great deal of their own care through out-of-pocket spending and frequently seek care from licensed or unlicensed private health care providers. In the third section, we acknowledge six major hurdles that risk-pooling programs must overcome to launch and scale up in challenging environments. Then, for each of these hurdles, we identify a number of possible strategies that innovative risk-pooling programs are currently using in an attempt to overcome the challenge. For each scale-up challenge, we list core questions that should be answered to determine which models are likely to be most effective in given country contexts. In the fourth section, we summarize a set of design dimensions that can be used to characterize various risk-pooling programs. In the final section, we offer policy recommendations for global institutions, which would facilitate the broader implementation and scale-up of risk-pooling programs to ultimately improve the quality, affordability, and availability of health care for poor and informally employed populations.