Growth and Key Issues of the MHO Movement in WCA

Presentation at USAID/SOTAPresentation at USAID/SOTA

Chris Atim, PhDAbt Assocs/PHRplus12 June 2002, Nairobi, Kenya

What are MHOs?

MHOs are autonomous, non-profit community or enterprise based health financing schemes based on:

Pooling of resources by many people for health care costs of unfortunate few

Community, not individual, rated contributionsDemocratic accountability to membersSolidarity and mutual aid between the members

Chris Atim:

MHO broader than CHI because latter does not truly describe schemes like the Ejisu-Juaben one; also one in north. Former refers to any conscious organisation of a community or group to address their problems of health care costs by contributing money in advance so that when the unfortunate event happens, they can rely on this fund to help those who are affected.

Chris Atim:

MHO broader than CHI because latter does not truly describe schemes like the Ejisu-Juaben one; also one in north. Former refers to any conscious organisation of a community or group to address their problems of health care costs by contributing money in advance so that when the unfortunate event happens, they can rely on this fund to help those who are affected.

HCF crises of ‘80s and cost recovery in health

Availability of quality care thru’ private providers

Democratisation processesfreedom of associationgrowth of civil society

Origins

Rate of growth of MHOs in WCA 1997 - 2000

0

500

1000

1500

2000

Benin Burkina Cameroon Coted'Ivoire

Ghana* Guinea SenegalPerc

ent g

rowt

h

Key features of MHO movement in Thies, Senegal

1st MHO set up in 1989, in village of Fandene With help of local priest from village together with Catholic

Hospital and Diocese

Services: initially only hospital admission, and emergency evacuation (surgery excluded)

From start, hospital agreed to offer 50% reduction on prices to MHO members

50% includes services not covered by MHO Dues charged at 100CFA (<20¢) per person per

month for all family members

Fandene MHO cont.

MHO’s cover fixed at max. of 15 days of admission

Later reduced to 10 days due to:Hospital discount being reduced to 35%Analysis showing that average hospital

stay was 8 days Hospital bills MHO only agreed flat rate per

hospital day – no extras

Fandene MHO cont.

But MHO pays all of patient’s bill to hospital,

and thenRecovers any member’s share afterwards

directly from member Waiting period of one year

To accumulate sufficient funds for paying bills and

Pay caution fee of 500,000 CFA to hospital

Reasons for perceived success Basis in village and community solidarity Support by Church and Catholic hospital Quality of care by hospital a major attraction

Previously inaccessible to poor but now thru MHO most can afford the hospital care

Cautious and prudent managementWaiting periodNot covering any service 100%

Democratic participation Low admin costs

Important for confidence and trust of community

Reasons for success cont. Good risk management techniques

Family membership Social control Flat rate per hospital day

MHOs know max costs for each admitted member Eliminates need for complex admin skills Therefore suitable for villagers

Guarantee letters Regular visits to sick Small groups reduce anonymity

Enhances control over fraud and abuse Encourages responsible behaviour

Influence of Fandene MHO Fandene’s success made it a model for MHOs in

Thies region, and elsewhere Other villages began to copy this example

wholesale 25 functional mutuelles covering 35,000 people in

Thies Most dynamic are women’s MHOs

Cover especially maternity services Most innovative implemented very successful

decentralization

Chris Atim:

E.g. membership registers, letters of guarantee, accounting and finance tools,

Chris Atim:

E.g. membership registers, letters of guarantee, accounting and finance tools,

Number of MHOs found in Senegal 1997 - 2002

24

68

120

0

20

40

60

80

100

120

140

1997 2000 2002

Num

ber o

f MHO

s

Innovations by newer, more successful MHOs

Extension of coverage to PHC servicesExtension of coverage to PHC services At health post and health centre levels, now a At health post and health centre levels, now a

widespread tendencywidespread tendency Decentralization of managementDecentralization of management

Decentralization tool developed by PHRplusDecentralization tool developed by PHRplusUsing example of most successful MHOUsing example of most successful MHO

Emergence of women-run MHOsEmergence of women-run MHOs Providing coverage esp for maternity careProviding coverage esp for maternity care

Ghana

Main features of MHO growth in Ghana Large majority very young, less than 3

years old Greater concern about MHO sizes and

population coverage ratesAverage MHO size in 2001 was over

6000 members Ghana has largest #s & biggest MHOs

in sub-region

Main features - Ghana

Greatest variety of MHO designs tooLot of experimentation

Provider-based, co-managed, community owned, church & enterprise schemes, trade union based

Capitation arrangements, FFS, budget, Most adapted to local context and previous

forms of community organization

Number of MHOs found in Ghana 1999 - 2002

4

47

157

0

20

40

60

80

100

120

140

160

180

1999 2001 2002

Num

ber o

f MHO

s

Ashanti King’s example Recent interest of Ashanti King to support MHOs

in Ashanti a big boost Set up a social reinsurance fund with TA from

PHRplus Aim is to make MHOs viable by providing extra

supportEg TA, funding for feasibility studies, expanded

benefits package, support o MHOs in difficulty and health education

Example has inspired Govt efforts to support MHOs

Government involvement

Ghana Govt initially promised to abolish all user fees Expressed desire for rapid ‘big-bang’ results thru

universal social insurance Later modified position based on force of arguments

from nearly all stakeholders in favour of MHOs

Govt’s approach now based on promoting SHI thru district-based schemes and central funding

Some Key features of MHO growth in West Africa

Usually built around good quality provider Usually means a private provider MHO resolves problem of associated high prices for low

income population Initiators acquire skills from:

Copying directly from local, pioneering example Fandene in Senegal, Nkoranza in Ghana

Managing other community organizations in past Coops, credit unions, susu, etc

Training organized by partners like PHRplus, ILO Lack of insurance skills & design flaws pose major

problems

Focus of PHRplus TA

MHO design flaws Lack of insurance & managerial skills Coverage of PHC, MCH and

management of HIV/AIDS in benefits packages

Increasing demand & high costs of feasibility studies

Reinsurance – TA on feasibility

Key Issues & Challenges

Exploding MHO growth and finding economical ways to provide TA

New innovations in MHO developmentExpansion of benefits packages

PHC, MCH services and women’s MHOsReinsurance as an issue

Threat and opportunities presented by Government interest /HCF policy

PHRplus is funded by the U.S. Agency for International Development and implemented by Abt Associates Inc. and partners:

Development Associates, Inc. Emory University Rollins School of Public Health Philoxenia International Travel, Inc. Program for Appropriate Technology in Health Social Sectors Development Strategies, Inc. Training Resources Group Tulane University School of Public Health and Tropical Medicine University Research Co., LLC

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