Lessons from Community-Based Health Insurance for Scaling Universal Health Coverage in Cameroon

By Regina Sinsai & Dr Constantine T. Asahngwa

Executive Summary

Cameroon’s Universal Health Coverage (UHC) program, launched in 2023, aims to reduce financial barriers to healthcare. However, coverage remains low (6.4%). Community-Based Health Insurance (CBHI) schemes, despite their limitations, offer valuable lessons for UHC implementation—particularly in governance, community engagement, and risk pooling. This brief outlines these lessons and provides actionable recommendations to strengthen UHC.

Introduction

Access to quality healthcare services in Cameroon remain a challenge for a large portion of the population, particularly those living in rural and conflict affected areas. Uneven distribution of healthcare facilities, clustered in urban areas as well as high cost of treatment serve as significant barriers leading to direct payment of health care services. (1) As a result, many Cameroonians are pushed deeper into poverty, while a large proportion lack any form of health insurance coverage. Despite the presence of multiple health insurance schemes—including community-based health insurance (CBHI), private health insurance, universal health coverage (UHC), and the National Social Insurance Fund (NSIF)—health insurance remains underutilized in Cameroon, with less than 8% of the population benefiting from insurance coverage. (2)

The launch of the national UHC program in recent years promises Cameroonian residents access to the necessary preventive, curative, rehabilitative, and health promotion services without incurring financial hardship. (3) Despite recent efforts, access to healthcare remains constrained by high out-of-pocket expenditures, limited insurance coverage, and persistent rural–urban disparities. While large-scale national insurance is the goal, community-based health insurance (CBHI) has been promoted in Cameroon since the early 2000s with a goal of improving access to healthcare services and reducing health expenditure particularly among low earning citizens. Despite the failures of most of the CBHIs, two of these schemes stood the test of time in the North West Region, offering valuable lessons towards the progressive implementation of UHC. This policy brief examines CBHI experiences to inform UHC scaling, highlighting successes, and challenges.

Current state of UHC and CBHI

Cameroon’s UHC rests on four pillars: universality, compulsory membership, national solidarity, and state responsibility. (4) The first phase of UHC, official launched in April 2023, is financed with an estimated budget of about 95 billion CFA francs, with half coming from the state and half from development partners. (5) The benefit package covers treatment for children under five suffering from malaria and other selected conditions, maternal health including caesarean sections, vaccination, and the management of HIV, tuberculosis, and dialysis. A voucher program has been introduced for pregnant women, requiring a contribution of 6,000 CFA francs, which entitles them to antenatal care through delivery, including emergency obstetric services, as well as care for newborns up to 42 days of age. (3) As the health voucher mechanism drives Phase 1, its legal framework—which outlines household contribution management and service purchasing funds—remains pending parliamentary adoption. (4) Despite the government efforts, coverage stands presently stand at an estimated 6.4%. (6)

CBHI, by contrast, has operated on a much smaller scale in many rural and semi-urban areas for over two decades, namely in the Anglophone regions of Cameroon. Mutual health organizations such as the Boyo Mutual Health Organization (BMHO) and Kumbo Mutual Health Organisation (KMHO) in the North West Region of Cameroon are examples of relatively successful mutual health organisations (MHO). These schemes are often small in size, with annual contributions from members, permitting access to outpatient and inpatient care with minimal financial constraint. Moreover, such schemes possess a strong community oversight, but are also supported by other national and international institutions, such as German Technical Cooperation Agency (GIZ), the HIPC Funds of the Ministry of Health, the French Development Cooperation Agency (AFD) etc…. (7,8) Because the success of these schemes, the financing, heavily relies on the voluntary participation and annual contributions of community members, their impact has remained marginal, with enrolment rates rarely surpassing 2 percent. (9) Studies show that CBHIs suffer from limited risk sharing, because schemes are small and localized, and they struggle with adverse selection, as mainly high-risk or better-off individuals are able to participate. Regardless of their collapse, CBHI has demonstrated that community-driven approaches can improve access and reduce out-of-pocket spending in underserved areas (10) through fostering  trust, acceptance, and ownership.

Lessons from CBHI for UHC

Local governance and accountability

CBHI schemes are typically governed by community-elected committees, whereby community members are responsible for the identification and nomination of community representatives. The elected members who are often personally known, are responsible for ensuring financial flows, contract conditions, community sensitisation activities, and decision making on premiums and many more; decentralising functions to reflect local priorities and realities. However, this was not the case in the early 2000’s as most Mutual Health Organizations generally had only one manager assuming all administrative and technical tasks. (8) Resulting to the low subscription and small-scaled risk pooling, which eventually led to their collapse.

Currently, UHC is managed by the government and its partners, with little or no autonomy given to community members. Although it has attempted to address transparency, and accountability issues through the adoption of digital management tools such as open IMIS, which enables systematic enrolment, claims processing, and payment monitoring (11), a strong regulatory frameworks and financial oversight remain essential. Additionally, involving community members such as local and religious leaders in critical decision- making processes would enhance transparency and accountability while preventing fraud at a local level. (12)

Community engagement

Community engagement and local participation is a key feature in CBHIs. The participation of local leaders, religious figures and civil society organizations in sensitization activities, decision-making processes, and the overall management of the scheme are crucial in fostering trust and social responsibility among members. (13) UHC has already benefited from similar approaches, as enrolment campaigns have succeeded when community health workers, youth groups, and local influencers were mobilized to discuss and communicate in the program. (14) However, because the implementation of UHC is dependent on the government and its funders, community members are largely underrepresented during decision making procedures, reducing a sense of ownership and trust among members and potentially influencing enrolment and retention. (15) Moreover, low or inconsistent community engagement has shown to negatively impact the sustainability of the scheme, especially in Cameroon where the number of schemes reduced from 158 to 58 between 2010 and 2014 (8) representing a sign of diminished trust and perceived value.

Risk pooling and resource mobilization

Community members finance CBHI schemes primarily through yearly contributions, thereby emphasizing shared responsibility for health costs. Individuals and families who register successfully and pay an annual contribution of approximately 5,000 francs benefit from these schemes. (16) Although CBHI schemes in Cameroon face challenges in sustainability due to small risk pools, high and difficulty collecting contributions from the poorest, (10) they offer UHC a chance to overcome this limitation by creating a large and a national risk pool. In 2014 alone, the CBHI in the North West region recorded 21,000 subscribers and over 90million francs in premiums. (17) In effect, higher subscriber enrolment would have generated more funds. However, many CBHI programs have relied heavily on voluntary household contributions, and this reliance has limited their financial capacity and long-term sustainability, revealing the challenges of mobilizing sufficient and predictable resources through community-level initiatives alone. Similarly, within the current UHC packages, only two groups—pregnant women and children, and patients with renal dysfunctions—contribute financially to access health services, while the government and its partners fund the remaining packages. Ensuring fair contribution by community members would not only mobilise sufficient funds but enhance a sense of social responsibility.

Recommendations

Strengthen Community Engagement Mechanisms: Empower local leaders and municipalities to lead hybrid CBHI-UHC schemes, enhancing trust improving understanding of benefits, and encourage participation through transparent governance.

Institutionalize Community Representation in UHC Governance: UHC decision-making frameworks at the national, regional, and district levels should formally include community and civil society representatives, leveraging existing CBHI leadership networks. There clear involvement planning, oversight, and communication will assist UHC remain responsive to local needs and concerns.

Strengthen Local Oversight of Financial Management and Provider Performance:
UHC should establish district-level oversight committees, which would include CBHI representatives, to oversee provider payment, stock management, and user fees, as well as to discover and eliminate informal charges that contradict UHC’s guarantee of free care.

Expand and Stabilize Risk Pooling. Make UHC enrolment mandatory, and strengthen mechanisms that promote broad and inclusive participation to enhance financial sustainability

Conclusion

Cameroon’s attempts to lower financial barriers and increase access to healthcare have benefited greatly from community-based health insurance. While CBHI schemes have demonstrated the potential of prepayment and community involvement, their limited coverage, constrained risk pooling, and administrative challenges highlight structural issues that must be addressed under Universal Health Coverage in Cameroon. CBHI schemes therefore highlight the importance of community ownership and prepayment mechanisms. UHC can scale these lessons to achieve equitable, sustainable healthcare access nationwide.