Health care costs can overwhelm households; close to 100 million people are pushed into poverty each year due to out-of-pocket health expenses. In Madagascar, where more than 70 percent of the population lives in rural areas and works in the informal sector, accessing health services and having readily available funds to pay for the services remain a significant challenge. Coverage of the population against financial risks associated with health care remains almost nonexistent, with less than five percent of men, women, and children under age 18 having health insurance coverage.
Community- based health Insurance (CBHI) schemes, which have a long history in Madagascar, can be used to reduce the cost of health care and increase access to care, when needed. CBHI schemes are one way to address the health financing burden because they allow community members to pool resources, share risk, and improve access to care. They can also provide a mechanism for community members to advocate for improved accountability and quality of services at health facilities.
In 2015, the Government of Madagascar developed the National Strategy for Universal Health Coverage, which clearly outlines the need for CBHI schemes. In accordance with this strategy, the USAID Community Capacity for Health Program supported CBHI schemes as part of its commitment to the communities it served and to ensure that community members who needed care beyond the services that CHVs provided could access these services. To address financial barriers to accessing health care, Mahefa Miaraka supported community-based health mutuals (mutuelles de santé) and worked to fill health financing gaps through the integration of health funds (caisse santé) in existing village savings and loan associations (VSLAs) and similar community-based cooperatives.