«Protecting the poor A microinsurance compendium Edited by Craig Churchill Protecting the poor A microinsurance compendium Protecting the poor A ...»
The UTM was created in 1996 and became an apex structure providing support to new and existing MHOs. Today, 32 MHOs covering 40,000 beneficiaries are members of the UTM. The Union offers a range of activities as varied as supporting the development of new MHOs, performing feasibility studies, developing new products, monitoring MHOs, representing MHOs at government meetings, and ensuring that the legal and regulatory framework is supportive of MHO activities.
Each MHO designs its own benefit package. In addition, the UTM has launched a highly standardized product, managed at the apex level, which has attracted large segments of the urban population. This product is so competitive that some formal workers covered by the statutory state-sponsored health insurance plan choose to affiliate themselves to an MHO to have access to the plan. This standard plan dramatically simplifies management at the MHO level and allows for the exploitation of economies of scale.
Source: Adapted from Fischer et al., 2006a.
Coordination Régionale des Mutuelles de Santé de Thiès Box 76 The Coordination Régionale des Mutuelles de Santé de Thiès was created in the mid-nineties by some MHO leaders in the Thiès Region. The 39 member MHOs benefit from a range of services offered by the Coordination, for example supporting the development of new MHOs, training MHO leaders, conducting feasibility studies, facilitating contracts between health service providers and MHOs and offering health education programmes. In this bottom-up process, the level of integration is lower than in, for instance, the UTM case. The variety of MHO practices (e.g. in terms of design, functioning, benefit packages and risk management) makes integration much more difficult.
Sources: Adapted from Fischer et al, 2006b.
In either case, networks play three roles: a) political role (representation of interests); b) financial support role, for example through guarantee funds or reinsurance mechanisms, and c) a technical role through management support (see Box 77). Federations also represent a way to more “easily” integrate MHOs into a broader social protection system at regional or national level.
Réseau Alliance Santé, BeninBox 77
Alliance Santé is an association of 25 MHOs representing 21,000 beneficiaries (in 2005). With assistance from CIDR, the association provides technical and financial support to the MHOs. Three mutualist agents employed by Alliance Santé help the MHOs’ board members with technical and financial management, claims processing and organizing their General Assembly.
Alliance Santé is the owner of a guarantee fund, which lends money to selected MHOs when their reserves are exhausted, as well as a reinsurance fund to help MHOs to develop their activities. The MHOs pay for these services by allocating 10 per cent of their contributions to the Alliance.
The association also has a technical unit, staffed by a medical doctor and a risk management specialist, which is responsible for the specialized functions of microinsurance management, medical auditing, premium calculation and the design of new services. The technical unit is also in charge of the annual financial reports and external controls. An additional 10 per cent of the premium is allocated by MHOs to finance the technical unit.
The community-based model: Mutual health organizations in Africa 391 Réseau Alliance Santé
The healthcare providers and, more generally, healthcare systems play a strategic role in the raison d’être of MHOs. If there is a lack of healthcare facilities, or if they do not offer minimal quality standards, there is no rationale to set up an insurance mechanism to improve access to non-existent or bad-quality healthcare. Even if healthcare providers exist, are financially and geographically accessible, and offer an acceptable level of care, the relationship between providers and MHOs can be problematic. These relationships represent a new factor for healthcare providers used to working as the sole stakeholder for all health-related matters in their districts (Wiegandt et al., 2002). The emergence of new actors in the health field that have other points of view and demand specific conditions can constitute a threat for the providers. In practice, healthcare providers can destabilize MHOs by not fulfilling what has been negotiated, through bad quality of care, unsatisfactory interpersonal relations, disruption in drugs provision and so on (Fonteneau et al., 2004; Criel et al., 2002).
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4.2 Are MHOs making a significant impact?
The impact of MHOs could be evaluated through various indicators including a comparison of utilization rates and out-of-pocket expenditure between insured and non-insured persons. It is difficult to answer whether MHOs are achieving an impact, however, due to a lack of data, especially in comparison to control groups. Little information is available on the membership profile, determinants of affiliation and participation, or reasons for drop-out. Moreover, little is also known about the effect of membership: benefits of being insured (more visits when ill, lower out-of-pocket expenditure when visiting, etc.), and the social effects of being a member (better representation, improvement of quality of healthcare). Few systematic studies have been performed to assess the effect of MHOs on accessibility to healthcare services, health service cost recovery and levels of household health expenditure.
When research has been conducted, it seems to show a positive impact (see Box 78), though a number of questions still need to be answered to understand the impact of these schemes.
Based on an action-research project in Guinea Conakry, Criel et al. (2002) demonstrated how a local MHO made a considerable impact on the utilization rate (new contact/person/year) of a healthcare centre.
CIDR also provides some interesting trends. For example, in Tanzania and Guinea, the inpatient ratio has doubled for MHO members. In Benin, the percentage of MHO women who deliver in a health facility is above 80 per cent, as compared to just 50 per cent in the overall total target population. In the MHOs in Comoros Island, Guinea, Tanzania and Benin, health providers agree that members are going to hospitals at an earlier stage.
If the level of satisfaction of MHO members is an indirect indicator of their effectiveness, then MHOs appear to be making an impact. Generally, the level of satisfaction for the services offered by these MHOs is high.
Unfortunately, member satisfaction is constantly higher than the retention ratio would appear to indicate: many members who drop out are not dissatisfied with the scheme, but are simply experiencing financial constraints.
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5 What are the origins of the problems?
The previous sections give a rather negative impression of the performance and functioning of MHOs. Although interconnected, the problems discussed above do not all share the same origin. Some are more context-specific, others are related to the model itself, and finally some are related to external support.
5.1 Context-related problems When MHOs began in the early 1990s, many were initiated by national NGOs or community-based organizations. Some problems, such as a lack of monitoring or technical skills, marketing and human resources, can be explained by the young, multi-purpose and inexperienced nature of the initiating organizations.
The limited healthcare supply, together with the low or poor quality of care offered by the public sector, was another context problem. The somewhat “closed” healthcare systems of these countries also meant that new actors like MHOs were not always welcome. Considering the internal problems of healthcare providers (financing mechanisms, lack of human resources and motivation of employees, etc.), the presence of MHOs – and even more, the presence of their external support organizations – led to expectations from the healthcare providers. If these expectations (training, financial incentives) were not delivered, healthcare providers might not act as “partners” of MHOs, but rather create obstacles to their functioning despite their official positive stance.
This micro-reality (goodwill of healthcare providers) must be combined with a more macro factor, namely the national political will to recognize and promote community-based insurance schemes. In recent years, several countries, including Benin, Senegal, Burkina Faso and Guinea, have included microinsurance schemes, and sometimes specifically mutuelles de santé, in their national health policies. In the same way, many West African Poverty Reduction Strategic Papers (PRSPs) also mention microinsurance as a potenInstitutional options tial tool for social protection or as a source of financing for the healthcare sector. However, these policies are not always translated into operational measures.
In West Africa, only Mali and Senegal5 have voted for a regulatory framework for MHOs (Senegal) in particular or mutuelles (Mali) in general. In some other countries, legislative preparatory work is under way.6 At the regional level, a project (Appui à la construction d'un cadre régional de développement des mutuelles de santé dans les pays de l'UEMOA) was launched by the West African Economic and Monetary Union, French Cooperation and ILO/STEP in 2004. Still, most MHOs operate under the national laws regulating associations or under the legal statute of their initiating organizations. Although this situation is not a major problem in the dayto-day management of the schemes (Fonteneau et al., 2004), MHOs and their support organizations are petitioning for an appropriate regulatory framework to take into account the specific characteristics of MHOs and to promote the creation of such organizations rather than to discourage it.
5.2 Model-related problems Some of the problems identified are related to the specific community-based insurance model. However, one nuance has to be recognized. The modelrelated problems presented below cannot be disconnected from the West African context where this model has mainly been implemented. This means that the model, as such, may not automatically lead to the same consequences in other environments.
Until now, most MHOs have been run by unpaid volunteers on a selfmanagement basis. Even if the model’s essential characteristics entail the active involvement of members in the political and strategic decision-making, this does not mean that the managers have to be unpaid, and possibly unmotivated, members. Financial prudence (especially at the beginning) and scarce resources explain why this has happened. With a few exceptions, the instability and dissatisfaction of volunteers are now recognized as recurrent problems. Solutions can be found (e.g. external funding, effective use of premiums), but are not always sufficient.
All participation-based or collective-action stories demonstrate that these processes take longer than top-down approaches (Esman and Uphoff, 1984).
If the specific “learning” characteristics of these organizations are acknowIn Senegal, the Loi sur les mutuelles de santé, voted in 2003, is not yet in force because application decrees have to date still not been promulgated.
6 In some countries, this process is complex because various ministries (e.g. Public Health, Social Protection, Labour, Social Affairs) claim administrative responsibility for MHOs.
The community-based model: Mutual health organizations in Africa 395 ledged – especially in the democratization processes – this also means that more time is needed to make decisions when everything depends on the goodwill and choice of the members. It also explains why it is sometimes difficult for MHOs to be effective in the short run.