Formal pooling of health risks in sub-Saharan Africa: Reflections on the obstacles encountered Bruno Meessen, Bart Criel and Guy Kegels Over the past few years a number of institutional solutions to the pooling of health risks have been advanced in a great number of reform proposals for developing countries. The empirical arguments in favour of such recommendations have the full force of accumulated experience in countries that have long been industrialized. However, rural realities in Africa and Asia naturally have very little to do with past or present realities in western countries. Whereas the technical-cooperation and scientific community has relatively good knowledge of techniques, a number of recent experiences of the introduction of mutual benefit schemes in Africa seem to show that this approach is now enjoying some success. The low levels of membership in particular make it essential to tackle the problem fully. This article tries to identify the various possible explanations for this lack of enthusiasm in sub-Saharan Africa. A s regards the financing of health services in developing countries, par- ticular attention has been given over the past few years to mutual ben- efit societies, insurance schemes and micro-insurance covering healthcare (Griffin and Shaw, 1995; Atim 1998; Bennett et al., 1998; Normand, 1999; Dror and Jacquier, 1999). Individually, these institutional solutions may well facilitate access to health services and offer protection against catastro- phes. In terms of equity, they may further the introduction of a fairer shar- ing of the burden of sickness. From the point of view of health services, they are presented as one possible option to increase and stabilize financ- ing and ensure the more efficient allocation of the resources available for healthcare, both public and private. However, two surprising facts come to light when one examines accu- 71