Health services and insurance systems

Challenge of appropriate health insurance models for the population in the informal sector

a. Perspectives of health insurance schemes and their impact

In West African countries, voluntary health insurance schemes is considered as the most appropriate way for reaching the people of the informal sector. So far, the mutual management option has been chosen in most cases because it presents potential comparative advantages. However, the various initiatives that have been developed have not yet demonstrated this management option to be viable. The actual challenge is to support these mutual organisations to find their proper means to ensure their technical autonomy and sufficient resources to reach their financial viability.

In East African countries, there is a marked preference for compulsory health insurance schemes or for funding health care through public resources. Voluntary insurance schemes are usually used by people with stable sources of income. In some countries, centralised redistribution mechanisms of compulsory contributions are envisaged, even for the informal sector. In a context of foreseeable decrease of public sector resources, it is important to demonstrate that participatory health insurance schemes are effective. Their specific role in protecting people from the informal sector should become recognised.

b. Mutual health insurance schemes and HIV/AIDS

The international community finances national programmes aiming at preventing HIV/AIDS transmission and at providing care for those in need. However, for lack of resources, the rural population is often left behind. The viability of health insurance mutual organisations in area with a heavy incidence of the disease, is questioned. Financial capacities of these mutual organisations are rapidly drained when the number of people affected becomes important or when the costs of specific treatments rise. In these zones, mutual organisations can only become viable if the costs of AIDS patients are met by external funding. It is necessary to seek a proper linkage between insurance and assistance mechanisms.

Still, health insurance mutual organisations have a useful role to play in fighting the advance of HIV/AIDS and its consequences. They can mobilise their internal communication networks to broadcast information and prevention messages. They have a financial and sanitary information system that can be useful for channelling resources in an efficient way. Because they are not selective, they offer a proper insurance coverage in case of hospitalisation to people affected.

Strategic objectives for the period 2004 - 2008

a. Sustainability of health insurance mutual networks in West African and Indian Ocean countries

In West African and Indian Ocean countries, the “Health services and insurance systems” CIDR department will put emphasis in consolidating three existing networks, in Benin, Guinea and Comoros. The first objective will be to increase their outreach. The second one will concentrate on implementing guarantee and reinsurance schemes. The third objective will be to strengthen their technical viability by enhancing the professional capacities of local teams and defining performance standards. So far, none of these three countries has a legal and regulatory framework for such mutual insurance organisations. The networks’ executives will be supported in their policy dialogue with national authorities for the definition of a appropriate framework.

Three new networks will be promoted, one in Benin, one in Guinea and one in a new country to be chosen. Methodologies will be adapted in order to reach their viability within a shorter period of time; this will be possible because of the lessons learned in older networks.

An impact assessment methodology will be developed and applied to each network. Results will be documented and disseminated trough exchanges with other practitioners and academics.

b. Promoting and defining the position of participatory voluntary health insurance scheme in East Africa

In East Africa, health insurance mutual organisations must reach a “demonstrative threshold”: they must increase their outreach in order to be recognised in their environment (by public health care authorities and by health care professionals). The “Health services and insurance systems” department will start a research/action initiative to understand the incentive factors for membership. This initiative will also design appropriate promotion mechanisms to diversify the clients/members public and to propose a wider range of insurance products. It will look for management and governance modes that can be adapted to different contexts. Further, the health insurance networks will encouraged to build alliances with other initiatives and operators, in order to reach a respected position as stakeholders in the national health insurance policies.

Within three years, the “Health services and insurance systems” department will install a regional co-ordination body in charge of documenting, analysing and disseminating results observed in different systems.

In a context with a heavy HIV/AIDS incidence, the viability of the networks will depend upon their capacity in taking care of AIDS patients and in linking with national mechanisms. The department will support the health insurance mutual organisations in the definition of their support strategies towards AIDS patients and in their negotiation processes with appropriate partners.

c. Developing links between health insurance schemes and existing institutions

A technical and methodological evaluation of programmes linking health insurance systems with microfinance institutions will be made, in order to compare the advantages of this approach to that of stand alone mutual insurance systems. Another type of linkage will be experimented between heath care providers and health insurance schemes. Feasibility studies will allow for a precise and adequate distribution of management functions between both parties and the definition of co-management procedures.

d. Dissemination of know-how in mutual health insurance

The health insurance mutual organisations are diverse in terms of performance and they work in a wide variety of environments. Therefore, it will be necessary to look at the theme in a transversal way: pre-conditions and pre-requisites; differentiated development stages; monitoring and support tools; technical, institutional and financial options; governance; etc. The “Health services and insurance systems” department will organise workshops on experience gained on these thematic issues and will share the results within the sector.