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Community-based health insurance is not a theoretical model. It has been a pioneering approach to extending social protection since its development began more than 15 years ago. Based on several studies2 and on the experience of external support organizations active in this field (particularly the ILO’s STEP programme and the French NGO CIDR), this chapter explains past and current developments in this specific model.
This chapter is divided into six sections. The first section describes a specific community-based model, the mutual health organization (MHO) and its theoretical application in West Africa. The second section provides information on the proliferation of this model in West Africa while few other approaches have been tested in the region. Section 3 briefly examines the target group of MHOs in West Africa. The next section explores strategic questions, namely: do the mutual health organizations function (well) and are they having an impact? To explain some observations made in this fourth section, section 5 examines the specific origins of the problems described.
Finally, the last section illustrates the intrinsic added value of the community-based model.
1 What is a community-based model?
It is difficult to give a standard definition of community-based microinsurance. Literature on the subject has almost as many definitions of the model as there are community-based organizations (CBOs) or specialists. In practice, various insurance schemes containing some community-based elements have been experimented with throughout the world. Uganda has tried several systems governed and managed by hospitals involving community groups in the design of benefit packages and collection of premiums (Dierrennic et al., 2005). Tanzania is implementing a nationwide system called the Community Health Fund (CHF). Members are organized in management committees, which include the healthcare managers, although the rules of the CHF (including the premium amount) are fixed by district authorities (Musau, 1999). Another way of managing health microinsurance is through MFIs. If an MFI is community based, which is to say organized as a mutual like AssEF in Benin, its microinsurance scheme could be included in the community-based model.
A few NGOs have experimented with health microinsurance managed by professionals, which shares the objectives and features of a community-based model. For example, in the SKY programme launched by the French NGO GRET in Cambodia, professionals employed by the NGO manage the scheme. Clients in village committees are regularly consulted to ensure that the scheme is accountable to the policyholders (CIDR, 2005).
Notwithstanding this variety of community-based insurance schemes, this chapter focuses on one particular type: the mutual health organization or mutuelle de santé. The main geographical reference is West Africa because this model is most common in this region (Tabor, 2005).3 Mutual health organizations were originally developed in Europe in the 19th century where workers’ organizations set up mutual funds to improve access to healthcare in the absence of other kinds of social protection. In several countries, these initiatives have contributed significantly to the implementation of a social protection policy at the national level.
1.1 Essential features The essential features of MHOs demonstrate their strong community-based
nature and reflect the purposes and operations of the model:
– Improve access to healthcare through risk-sharing and resource-pooling – Not-for-profit – Mutual-interest organizations based on groups sharing common characteristics – Members are owners and beneficiaries at the same time – Participatory decision-making – Voluntary membership – Promotion of solidarity, democracy and social cohesion – Potential functions beyond insurance Like other insurance systems, mutual heath organizations are based on a mechanism of risk-sharing and resource-pooling. However, more specifically, these organizations are non-profit and do not select their members on the basis of their individual risk profiles. Access to healthcare through solidarity is thus the main objective of these organizations.
The members of mutual health organizations are the owners, the decision-makers and the policyholders, which strongly differentiates this model from other insurance schemes. This feature requires strong participation and control mechanisms to make collective decision-making effective. Annual general meetings decide on issues such as budgets, accounts, what to do with surpluses, and operational matters as well as overall strategy. Members govern their MHOs through elected representatives, who are responsible for implementing control mechanisms, such as monitoring the implementation of internal rules, controlling financial flows and collecting complaints relating to the service provided.
Membership is voluntary. This principle clearly distinguishes MHOs from compulsory insurance schemes such as most national and often staterun social security systems. As in any non-profit organization, a person may choose to become a member but is never forced to join.
In most MHOs, members share some common characteristics, such as being members of the same organizations, inhabitants of the same village or workers in the same trade, often because they are built on an existing organization (see Box 72). Bearing in mind that membership is voluntary, an MHO has to find a way of ensuring that it can gather a “sufficient” number of members to run the risk-sharing mechanisms in an efficient and attractive way: the larger the group, the greater the benefits for the members. Being organized in a (formal or informal) pre-existing group facilitates this process.
In addition, sharing some characteristics, or better, being previously involved in similar collective decision-making mechanisms with the same group, facilitates the functioning of an MHO.
The community-based model: Mutual health organizations in Africa 381
Profiles of initiating organizations of MHOsBox 72
In Burkina Faso, the Association Yekouma Dakoupa and the Association of Widows and Orphans from the Leere (Association des Veuves et Orphelins du Leere) offer a range of services such as agricultural support, microcredit and school fees for orphan children. A group of women organized an informal solidarity fund to help members and their families when facing a health event. Worried that this fund would not be sufficient to cover all needs and health expenses, they decided to set up a more sustainable system. They contacted the STEP programme with whom they set up a mutual health organization called Leere Laafi Bolem in 2001.
In the case of the Lalane Diassap MHO in Senegal, a village youths’ organization (Association des Jeunes de Lalane) took the initiative to launch a village-based mutual health organization in the mid-nineties. Staff already working with other mutual health organizations in the Thiès Region helped to launch this initiative.
In the case of the Mutuelle de Fatako (Guinea Conakry), a women’s association (Association des Femmes Ressortissantes de Fatako) identified access to healthcare as a major problem for Fatako inhabitants. Together with the STEP Programme and the Association Guinéenne de Bien-Etre Familial (ASBEF), they created a mutual health organization in 2002.
Source: Adapted from Fonteneau et al., 2004 and Fonteneau, 2004.
MHOs actively promote some ideals like solidarity, democracy or social cohesion. These values are particularly important for the resource-pooling and risk-sharing of microinsurance, since members’ familiarity with each other can assist in controlling moral hazard and fraud, and can encourage renewals.
However, unlike other insurance providers, an MHO cannot be reduced to its insurance function. As participatory, mutual-interest organizations, MHOs fulfil functions beyond insurance. For instance, the MHOs objectives almost always include health education. They also act in a sector (healthcare) where the interests of users have only recently been represented.
By organizing potential users of health services, MHOs can represent their interests to healthcare providers. In the same way, since the state is a key actor in healthcare systems, MHOs can represent the population in policy discussions. For example, these community-based organizations may lobby on health financing issues and participate in social protection reform processes (see Chapter 1.3).
382 Institutional options
1.2 Consequential features Apart from these essential features, other characteristics are also worth mentioning to provide a more complete picture of the MHO model. These features are “consequential” in the sense that they result from the model, but are not inherent characteristics.
The setting-up of an MHO often implies the creation of a new organization even when an existing organization takes the initiative to start a microinsurance scheme. In other models, insurance can indeed be developed as a product offered and managed by an existing institution (e.g. MFIs or insurance companies). In the case of an MHO, the insurance scheme is the organization. The new organization created for the purpose of providing insurance leads to an institutionalization process that requires extra effort from the initiating organizations and/or from external support providers.
The MHO schemes are managed and controlled by members who financially contribute to them. This does not mean that an MHO has to be selfmanaged, but in reality this is often the case. Managers, who are members themselves, are elected or designated by the members of the insurance schemes. They often fulfil this function on a voluntary and unpaid basis. Voluntary “self-management” is one way to ensure continuity between the members and the institutions, and avoid conflicts between the management and the beneficiaries. However, voluntary, unpaid jobs are also chosen out of necessity due to the lack of resources. This practice reduces the costs of the insurance product, but is not a long-term solution.
As mentioned earlier, microinsurance schemes consist of members sharing some common characteristics. This feature ensures the necessary minimum level of trust and social cohesion to set up and run an MHO according to the features described (i.e. self-management, a collective decision-making process, participatory mechanisms, risk-sharing). Especially in the beginning, the membership of an MHO is often homogenous, which can have negative effects due to a lack of risk diversification. Such a situation also has a limited ability to achieve vertical solidarity, which allows for cross-subsidization between richer and poorer people.
2 Why was/is this approach implemented in West Africa?
The existence and implementation of MHOs in Africa did not occur by chance. African MHOs first appeared in the late 1980s and early 1990s, coinciding with two developments: 1) the democratization process and 2) the implementation of the Bamako Initiative.
The community-based model: Mutual health organizations in Africa 383 In many African countries, the late 1980s represented the beginning of democratization and the emergence of a civil society. As a result, many initiatives were undertaken by the population to respond to urgent needs and political issues. These initiatives were encouraged by development cooperation agencies that wanted to support the democratization process. In this context, the associational affiliation of MHOs as non-profit, autonomous, mutual-interest organizations was an easy and flexible way to launch a collective initiative.
During the 1990s, the Bamako Initiative (launched in 1987 by the World Health Organization and UNICEF) was also progressively implemented.
Designed to secure universal access to quality primary healthcare, the Bamako Initiative rests on three principles. First, primary healthcare services must attain a sufficient level of self-financing, which requires patients to contribute through user fees. The second is the principle of better access to medicines, particularly generic pharmaceuticals. The third principle is community participation to enhance the quality of care. If representatives from the local community sit on the boards of the healthcare centres, this will make the providers more transparent and responsive. This last principle recognizes that a range of actors should be involved in the healthcare system, including community-based organizations.