A system dynamics model of community-based health insurance system in Bangladesh

Community-based health insurance (CBHI), also known as micro or mutual health insurance, is managed by local non-government organization, hospitals and cooperative societies to mobilize local resources to provide healthcare services to the underserved marginalized population. The effectiveness of voluntary CBHI as a financing mechanism for achieving universal health coverage (UHC) is widely debated and remains a global concern, with many experts questioning its long-term sustainability and feasibility. Overcoming the barriers to implement a sustainable CBHI is a policy priority for Bangladesh and will reflect on a global debate about the role of CBHI in attaining UHC. The goal of this study is to identify appropriate policies which support a sustainable CBHI and to assess the impact of these policies over time. A System Dynamics approach is used to build a model, simulate, and evaluate policy scenarios. The model was parameterized using data from the literature, primary data collected from a CBHI scheme in Bangladesh and expert opinion. Although there is potential for a sustainable CBHI scheme in Bangladesh, achieving this requires coverage of over 60 % of the target population to ensure risk sharing among insured members, external or mandatory public financing as a seed money until attaining self-sufficiency (i.e., ability to generate enough revenue to maintain the scheme without external funding), and a robust regulatory framework. Even though Bangladesh is known as the birthplace of microfinance and the land of non-governmental organizations with many successful community initiatives, it is unlikely that CBHI would achieve sustainability in the long run without these essential components. The challenging conditions for the financial sustainability of CBHI in Bangladesh raise significant concerns about its feasibility as a financing mechanism for achieving UHC in any other settings.