The potential for social mobilisation in Bangladesh: the organisation and functioning of two health insurance schemes.

Health insurance schemes are usually assessed according to technical indicators. This approach, however, neglects the dynamic perspective of insurance schemes as an element of people's mobilisation for participation in organising and managing health care delivery and financing. The first part of this paper describes the technical performance and the level of community involvement in management of the two largest health insurance schemes in Bangladesh, both in the rural areas and in the non-government sector. Part two discusses these achievements in light of the schemes' potential role as a mechanism for people's management of health care. A review of documents and key-informant interviews were conducted. Key findings include that (1) subscribers currently are not actively participating in scheme management. However, existing family groups, involved in credit programmes may serve as entry-points for interaction. This is sustained by the 'natural link' between health insurance as a means of spreading the risks of treatment costs and credit programmes as a means of decreasing the relative impact of illness on household income. (2) The schemes' role could be further enhanced, by improving their technical performance and applying health care systems elements with the input of all partners involved. These issues are avoidance of service duplication with other providers; better protection of the poorer households; inclusion of hospital care in the coverage package; simplification of scheme administration by introduction of episode-based co-payments instead of the current itemised ones and concentrating the schemes at the level of community-based services, which may be self-financed and also self-managed by the community, given available sensitisation, training and interaction. A shift to episode-based co-payments would also introduce solidarity among patients and among individuals at higher risk, such as pregnant women and under-fives. Finally, action-research is needed to document the process of increased community involvement.