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However, other regions have also been through a democratization process and have also gone from free healthcare to user fees. What explains the relative uniqueness of the insurance model implemented in West Africa?
One explanation stems from the profile and background of the external support organizations involved, and more generally from the colonial history of the region. The development of MHOs is not a purely bottom-up phenomenon since external actors played a strategic role from the beginning. In Senegal and Burkina Faso, for example, the Catholic Church helped initiate some of the earliest mutuelles in the late 1980s.
The organizations currently involved in the development of microinsurance in West Africa have some common characteristics. Since the beginning, Belgian and French NGOs (e.g. CIDR and the Belgian NGO World Solidarity) have played an important role in the dissemination of the MHO model, which they considered an appropriate mechanism in an environment lacking in social protection; it was also a model for which they could offer unique know-how. Other external support organizations (e.g. Partnership for Health Reform, United States) followed this trend in West Africa. For similar reasons, French, German and Belgian development cooperation agencies were also active in this field.
Among international organizations, the International Labour Organization through its programme STEP (Strategies and Tools against Social ExcluInstitutional options sion and Poverty) engaged in the development of health microinsurance as a strategy for extending social protection to the unprotected population. The main target group of the ILO (workers), and the reference to certain social protection models and normative framework (social economy, not-for-profit sector), also explain the ILO’s affinity for the MHO model.4 3 What is the target group of the community-based model?
Mutual health organizations are not defined by the profile of the target group and the model is not restricted to poor people (Box 73). This kind of organization, belonging to the third sector (the others being the state and the private for-profit sectors) can be adopted for normative reasons and/or because these organizations can provide some services more efficiently.
A variety of membership profilesBox 73
The members of MHOs associated with the UTM (Mali) range from state employees to groups of informal women workers producing artisan soap.
One could say that MHO members come from the entire range of population groups including formal and informal-sector employees, full and parttime workers, rural and urban dwellers, and women and men. In other words, the MHO movement penetrates every possible niche of Mali’s society and is growing slowly, but steadily.
Source: Adapted from Fischer et al., 2006a.
The MHOs affiliated with UMSGF (Guinea) generally target people working in the informal economy and those who do not have access to health insurance through their employers. In rural areas, the place of residence defines target populations. Here farmers represent the majority of the village’s working population. In urban settings, the majority of the members are artisans and traders. Retired persons, civil servants and other employees can become members as well since MHOs do not discriminate according to socio-economic or health criteria. Employed persons account for 10 to 20 per cent of the urban membership. The illiterate account for 57.6 per cent of membership. The median income is estimated at € 120 (US$150) per person per year, or € 0.33 (US$0.41) per day according to the preliminary study carried out in 2000.
4 Today, the ILO also supports other microinsurance models throughout the world.
The community-based model: Mutual health organizations in Africa 385 A common characteristic of MHO members is that they do not have access to or are insufficiently covered by social security systems, and they could not afford the insurance premiums of for-profit insurance companies, if such services were indeed available (which is rare, especially in rural areas).
In practice, most MHO members have variable and irregular incomes from their activities in the informal economy and/or agricultural sector. Nevertheless, MHOs may also cover state or formal sector employees. In West Africa, given the distribution of the population, MHOs are more present in rural settings than in urban areas (see Box 74).
The target population of the rural MHOsBox 74
In rural areas, the target population of most MHOs supported or studied by CIDR in Western or Eastern Africa can be considered poor. However, within the target population, the economic status of households that do register with MHOs is not always known.
To evaluate the profile of the members of MHOs promoted by CIDR in Tanzania, a survey of 185 households was carried out in 2005. The result shows that average and median income of members is higher than non-members’ income. The size of member households is smaller than that of nonmember households, which suggests that large households have more difficulty paying the premiums.
Although the amount of the premium does not exceed US$2.50 per individual and per year, these results clearly show that the less wealthy households are less represented in MHOs. The destitute are not the only ones who cannot join the schemes.
focused on the organizational aspects of community-based schemes. As a result, there is information on the functioning of MHOs and the difficulties experienced in their set-up phases, management and social dynamics.
However, knowing how well they function is different from knowing how they perform according to a defined norm. For example, do MHOs only have to offer social protection to their members or should they actively contribute to the extension of social protection to excluded population? Is the primary objective of an MHO to improve access to healthcare or to improve financial security when households face health shocks? Is the insurance function of an MHO more or less important than the social participation and empowerment potential it makes possible? The answers will differ according to the perspective adopted: is it from the point of view of national organizations, mutual health organizations, external support agencies or national health authorities? In accordance with their autonomous identity, this chapter tries to answer this question in relation to the objectives and perspectives of MHOs.
The same problem arises for the second part of the question concerning their impact: against what criteria can performance be measured and are MHOs effective? In addition, is there enough solid data to address this question fairly? With a few exceptions, the answer is no, which will limit the possible analysis on the performance of mutual health organizations in West Africa.
4.1 Do MHOs function (well)?
In a study of 11 francophone African countries, 622 health microinsurance schemes were identified (Concertation, 2004). This estimation covered not only MHOs, but also a broader range of insurance models. Nevertheless, 88 per cent of the schemes defined themselves as mutuelles de santé (MHOs).
Of the 622 health insurance schemes, 366 were functional (58.8 per cent).
Most of the remainder had just been set up (22.8 per cent) or were in a pilot phase (12.4 per cent). The last 5 per cent were unable to cover their members’ claims.
The functioning of MHOs has received a lot of attention from researchers and practitioners. Based on several studies, this section summarizes what has been reported in this area.
Most MHOs have a small membership. With a few exceptions, most cover less than 1,000 persons. Besides the voluntary nature of membership, there are other reasons for this limited penetration: the recent introduction of this mechanism, the limited capacity of the initiating organizations to provide technical assistance and the difficulty in reaching populations beyond The community-based model: Mutual health organizations in Africa 387 the members of the initiating organizations. In addition, many schemes encounter marketing problems as they strive to raise awareness and educate members. Considering that this function has to be constantly carried out, marketing problems constitute serious obstacles to the stability and growth of MHOs.
Management of MHOs is undertaken by unpaid volunteers, generally elected or designated by the members. A certain discontinuity of daily management occurs due to the voluntary nature of the work, as well as a lack of motivation and management skills. For the same reasons, participation mechanisms and collective decision-making organs do not in practice function as intended. The learning phase of these young organizations, the lack of human resources (leading to some concentration of power), and the continuous administrative work needed to run an insurance scheme could also explain the above observation regarding management. Nevertheless, these organizations show some positive trends towards institutional viability. They constantly try to adapt their management systems to make them more efficient, taking into account their limited resources. For instance, some MHOs decentralize their management system (or put external persons such as healthcare providers in charge) to bring the organizations closer to the members as well as to enlarge their target group.
As shown in Table 44, insurance premiums are often low. The target group frequently cannot afford more, due to its modest and variable income.
These low premium levels are also due to the essential objective of MHOs, namely improving access to healthcare by providing insurance that is affordable to a majority of people. Finally, and especially in the early stages, MHOs charge low premiums to attract the target market, since they need to cover many people to make risk-pooling mechanisms effective. It has also been observed that members involved in making decisions about the premium level often prefer to start with small amounts to gain experience with the performance of insurance. When confidence in insurance increases, and an insurance culture begins to take root, willingness to pay might be expected to increase, though this assumption needs to be verified.
388 Institutional options A comparison of premiums and benefits for selected MHOs Table 44
Source: Fonteneau et al., 2004 (data collected in 2003). €1 = 656 FCFA, US$1 = 514 FCFA.
If premiums remain low, it is not surprising that benefit packages are also limited. The premiums mainly give access to primary and secondary levels of healthcare in the public facilities (since they are the most important providers in West Africa, especially in rural areas). In some cases, the lack of providers limits the choice of scheme design. In other cases, the premium levels simply do not allow coverage at private healthcare providers.
Even though the premiums are low, there are low premium collection rates as well as high drop-out rates. Combined with the small membership, these factors raise a number of questions relating to member satisfaction (benefit packages, procedures), distribution (premium collection systems) and financial accessibility (levels of income, level of premium, etc.).
To become viable in the face of these challenges, some MHOs join networks, unions or federations. At present, a few effective federations can be
found in West Africa, including:
In some cases, the creation of a union was part of the initial project (e.g. the UTM in Mali (Box 75) and the MHOs in Benin supported by CIDR). This design implies more expensive and technically complicated interventions, but increases the likelihood of sustainability.
Union Technique de la Mutualité Malienne Box 75 The UTM was created after the Mali Government called on the Mutualité Française and French Cooperation to help develop a network of MHOs targeting workers in the informal economy. The Government did so after observing that increasing the availability of basic health services did not result in a significant increase in demand for these services because the population faced difficulties in paying the user fees required under the Bamako Initiative.