Worldwide there has been a renewed interest in the role of community financing in increasing financial protection against the cost of illness in low-income countries. Community financing comprises a multitude of schemes (equity funds, revolving drug funds, employer-subsidised prepayment schemes etc.) but in this session we will specifically focus on community health insurance. Strengthening the insurance function of the health financing system is increasingly seen as central to poverty reduction strategies, and community insurance can be instrumental towards this objective in the absence of capacity for more universal models.

Evidence demonstrates that community insurance schemes can mobilise additional resources, increase access to care, improve local responsiveness and accountability of service providers. Although, insurance schemes tend to provide a degree of financial protection, it is often dependent on external subsidies, technical and logistical support and political will. Research has also shown that such schemes are often inequitable and fail to cover the poorest sections of the population.

A number of countries are considering scaling up community insurance and/or integrating it with other financing schemes. Scaling-up can be horizontal (expanding coverage) and vertical (extending benefits covered and linkages with other levels of care). While there are historical examples of voluntary insurance schemes aggregating over time and facilitating a transition towards universal coverage (e.g. Germany), there are fewer contemporary examples. Countries with low levels of resources, and limited regulatory and managerial capacity are facing challenges when seeking to integrate these schemes into national finance and delivery systems. This session will consider three case studies in seeking to discuss the theme of scaling up community financing schemes:

- Scaling up is often focused on expanding membership mass, but community-based insurance schemes often have persistently limited membership and the underlying determinants of participation are poorly understood. The study from Lao will explore levels of enrolment and the factors that influence the decisions to enrol in a CBHI scheme (population-specific, service delivery model, scope of benefits, managerial procedures etc.).

- Furthermore scaling up often requires vertical integration of services covered by insurance with the rest of the system, and this is often a factor that influences the likelihood of people joining the scheme. This is demonstrated by the study from Armenia which will explore the different forms of vertical integration between rural primary health care and higher levels of the system (information-sharing, referrals, linkages in terms of training and support for health post staff, synchronised financial flows). The very limited scope of benefits removed the incentives to join the insurance scheme. It provided only basic PHC but not care for common chronic disease. However the distribution of benefits among scheme members has shown to be equitable.

- Another approach to scaling up community-based insurance schemes goes beyond vertical and horizontal expansion. This means that the focus is not on the expanding the schemes per se, but on their fit within overall financing strategies. The study of Azerbaijan shows that the lack of clear strategic fit within the overall financing system undermines the process of expanding membership and vertical/horizontal integration with the rest of the health system. Integration of CBHI within national systems may involve its phasing out as an independent donor-funded initiative to give space for a national compulsory health insurance scheme.

The case studies in this session combine qualitative and quantitative data analysis of primary and secondary data.