Usaid presentation v13

UNIVERSITY OF MICHIGAN

SUSAN ALLEN

SANDER DOLDER

MATTHEW DOWNER

PREETI GUPTA

APRIL 2012

Initial Findings from Bembèrèkè & Sinendé

Agenda

Overview of research approach and interviews

Professional structures of mutuelles in Bembèrèkè and Sinendé

Customer feedback on value proposition of mutuelles

Next Steps

University of Michigan MAP Team: Abt Associates, Benin

University of Michigan MAP: Multi-disciplinary Action Projects

Interactive learning experience pairing teams of students with global organizations to solve real problems

Team comprises multiple disciplines and industries: travel, consulting, development, marketing, healthcare

Our Sponsor: Abt Associates

Key research question: How do mutuelles boost the adoption rate in rural communities in Benin?

Length of project: 7 weeks— 4 on-site in Benin, 3 synthesizing and performing research in Ann Arbor Michigan

Matt Preeti Sander Susan

Source

Bios

Problem Statement

Source

Since RAMU’s announcement in October 2011 mandating universal

health coverage, the mutuelles have been brought to the spotlight

as the model for universal coverage in Benin. However, the limited

uptake suggests problems with the value proposition that must be

addressed, and steps need to be taken to professionalize the

mutuelles in order to make them a scalable business able to

accommodate universal coverage. How can the mutuelles become

self-sustaining, scalable enterprises?

Mutuelles Health Insurance is a prevalent model throughout Western

and Central Africa

Source

Uganda, Ghana, Senegal examples…

Despite having been launched more than 10 years ago, mutuelles in

Benin have limited uptake

Source

• 5-8% adoption of mutuelle in most communities in Bembèrèkè

• 10% in areas with mutuelle scolaires1

• Sinendé adoption is much lower, 1-2% in most communities (more

prevalent in Sinendé centre)

• Of mutuelle members, only ~20 percent also pay for hospital insurance

through the Union

Thus far, we completed field research and synthesized our findings

from Bembèrèkè and Sinendé

Project Immersion

March 9-16

Field Research

and Interviews

March 17-30

Synthesize Research

March 31-Apr 2

Follow-on Research

April 1-23

Deliver recommendatio

ns

April 24-27

Phase complete

Key research questions and interviews completed…..

Source

Accomplishments from the field:

• Interviews with Union leaders of Bembèrèkè and Sinendé

• Sessions with 4/10 mutuelles in Bembèrèkè and 3/4 mutuelles in Sinendé

• Interviews with 64 community members (27 members, 37 non) across both

communities

• Additional visits to 2 health centers, and 1 Hospital (includes interviews with

2 nurses, 1 doctor, and 2 hospital admin) 98

interviews

total

There are three areas where the mutuelles need to professionalize:

Source

Value Proposition

• Cost

• Services offered

• Healthcare quality

• Culture

Capabilities

• Decision-making/controls

• Data aggregation

• Succession planning

Capacity building

Adoption in Benin has been slower than other countries, and recent

national health legislation has brought mutuelles center stage

Source

The value proposition of mutuelles currently does not attract a large

percentage of the population, even in well-managed areas

5-8% adoption of mutuelle in most

communities in Bembèrèkè

10% in areas with mutuelle scolaires1

Sinendé adoption is much lower, 1-

2% in most communities (more

prevalent in Sinendé centre)

Of mutuelle members, only ~20

percent also pay for hospital

insurance through the Union

Standard mutuelle offering Adoption rates

Value Propositio

n

Cost

Quality of Care

Services Offered

Mutuelle: 2400

CFA/member

Union: 3000/house

hold

Basic coverage of

illness &

prevention

Health center is

primary provider

Details to

follow

Source: interviews in Bembèrèkè and Sinendé

While premiums are affordable for individuals, certain groups can

not meet current price point for mutuelle membership

Indigent population

At highest risk, but unable to

afford full coverage

Offer basic coverage to the poor at a lower

cost?

Large Families

Most families can only afford 4-5 beneficiaries regardless of

actual family size

Offer an incentive for large

households (6+ members)?

Seasonal income earners

Inconsistent annual earnings

make it difficult to pay monthly

Create flexible payment plan

that allows farmers to match

premiums to income?

Issue Opportunity


Offer multiple basic plans to meet varied consumer needs while

avoiding adverse selection

Advantages

Attract a large, un-tapped segment of the population

More members sooner decreases consumer pain point with mandatory plan

Potential to increase the risk pool

Generates incremental income for the mutuelle

Creates affordable option for families who wouldn’t otherwise join

Attractive to groups who don’t typically join (e.g. men hernias)

Offers low-risk introduction to mutuelle services

Challenges

Is it necessary to make it equitable

Increased risk for higher payout

Daily operations more complicated for mutuelle volunteers

Additional education would be required for staff and consumers

Adverse selection

How to keep people committed for longer than one year – contracts?

Could cannibalize existing full-plan members

Need to conduct cost analysis to determine pricing


Plan Offerings could include:

large-household incentives or plans to generate incremental income

a range of offerings to cover specific illnesses (malaria, pregnancy and infant care, hernias, etc.)

Example of success: Vaccination coverage provided by government for children up to age 5

Our observations from Bembèrèkè and Sinendé isolated barriers

limiting functional capacity and effectiveness of the mutuelles de santé

Source: Interviews

Professionalization

Organizational structures

Checks and balances

Role specialization

Organization design

Operational efficiency

Fee collection

Technical Administration

Outreach

• Lack of decision making autonomy

• Financial accountability degrades consumer trust

• Need for professional liaison on care issues

• Specialized training for outreach & management

• Co-op versus agency structure• Constraints of volunteer

reliance

• Dispersed communities make distance a problem

• Lack of urgency to pay

• Infrastructure for accountability• Lack of ability to aggregate

and use data to improve

• Ineffective sales force• Tie-ins with larger community

education issues

Details to

follow

Post withdrawal from involvement in Sinendé, PISAF’s role in management

and strategic planning has not been filled by local operations The model is

not self-sustaining

Function PISAF

2006-2010

Mutuelle

s/Union

2011+

PISAF

2011+

GAP

S

Research & set mutuelle

premiums

X X

Ensure meeting cadence with all

parties present

X X

Conduct financial audits X X

Address inconsistencies in

medical care given(medical

counselor)

X X

Maintain relationship between

health centers and mutuelles

X X

Collect premiums & process

claims

X

Conduct outreach X X

Raise and address mutuelle

issues at the Union level and

above

X

Set strategic vision for mutuelles X X

• Since 2011,

strategic

planning and

financial

oversight have

lapsed for

Sinendé,

creating issues

with

accountability of

the mutuelles to

the community

• Currently no

structure exists

about Union and

Mutuelle for

issue escalation

& support

Checks and Balances: organizational structure needs to support a self

sustaining model

Necessary checks

performed by

Union Manager

• Financial Audits of

premiums

collected and bill

payment

• Liaison with health

care providers for

contracts and

issue resolution

• Perform data

aggregation and

healthcare audits

• Facilitate

execution of

strategic plans

Administrative

Council

Executive

Board

General

Assembly

Surveillance

committee

Auditing

Manager

for

oversight

on

Operations,

Controls,

and

Strategy

Union Level

Hospital


Proposed decision model based on

Bembèrèkè

Case

Example

Fee Collection: Neighborhood network of mutuelle agents to

collect premiums and conduct outreach

Assessing the Numbers

(example):

Problem addressed: Distance of villages to the mutuelle

makes fee collection and outreach difficult, and volunteers

spend most of their time returning 2-3 times per house to

collect premiums.

Benefits:

• Reduces dependence on volunteer administration

structure

• Eliminates expense and time traveling to distant

villages

• Encourages local entrepreneurship

• Trusted member of the local community is the face of

the mutuelle

Challenges:

• Requires significant financial controls to prevent fraud

• i.e. Use stickers instead of stamps to track

membership

• Critical mass of membership required for sustainability

• Unclear fit to existing volunteer-based structureSource: PAPME Director interview, mutuelle interviews

Case

Example

A Mobile Money infrastructure would help revamp the current

fee collection system to induce growth and financial stability

Current System

Mobile Money

System

Multiple visits for

single collection by

family

Limited displacement

Via Phone House

Local

Agent

5,000

Mutuelle

Volunteer

Mutuelle

Volunteer

Members

Members

Mutuelle Bank

Account

Cash Payment

Central Village

Central Village

Source: Mobile Money for the Unbanked, GISM 2010

Case

Example

Professionalization of data aggregation and analysis could create a

platform for future connectivity between mutuelles

Individual identification numbers

- Information tracked by beneficiary

- Enables tracking of enrollment fees and care

by the individual

- Makes future reciprocity between regions feasible

Data aggregation at Union level

- Enables performance evaluation of mutuelle results to Union goals

- Ability to stage interventions promptly

-Financial accountability through regular audits

Succession planning: passing down

management knowledge

- Creates a plan for sustainable operations for

mutuelles in the future

- Promotes continuity & consistency for day-to-

day operations

- Builds skills in the community


QUESTIONS & WRAP UP

Education

Usaid presentation v13