[Subgroup-health] Rép. : Re: 2nd discussion - Workshop during CGAP Conferenceon Microinsurance

Thu May 8 14:44:07 CEST 2008

Dear all,
Many thanks for this very interesting discussion!

If I understand well the topic of our roundtable at the 2008 MI
Conference could be on the design and provision of the best possible
benefit package, which should at the same time
1) respond to the priority protection needs of the insured (otherwise
the product is not very attractive) >> idea ofinclusive benefit
packages
2) cover HC services that are available (it is therefore important to
negociate with HC providers and the Ministry of health to make sure that
the supply matches the demand)
3) be affordable (it is therefore important to contain costs through
various means : negotiations with pharmaceutical industry, negotiations
with HC providers on the treatment protocols to rationalize the
utilization of the HC services, etc.)

In Western Africa where the STEP programme has a long experience of
supporting microinsurance schemes, most benefit packages which are
affordable are far from being "inclusive". Among Senegalese rural
workers for instance the affordable amount of premium is assessed to be
of 3 500 CFA Francs per person per year whereas a basic health insurance
package including both primary and secondary health care in public
health structures would cost 13 000 CFA Francs (20 Euros or 30 US
dollars).

The question is then the following : If we want to provide inclusive
benefit packages how are we going to finance them ? 
Is it the State's responsibility to finance a share of the benefit
package for the poorest members of the society? For instance in the case
of the Yeshasvini scheme the State of Karnataka covers a share of the
scheme's expenditure.
Is it the responsibility of other players / stakeholders such as the
corporate sector to subsidize health insurance for the poorest? For
instance in Jharkand the corporate sector (TATA, MITAL) committed
themselves to contribute with huge amounts of money to cover the social
protection needs of the poor.
Is it the responsibility of the international community through
allocation of global funds to the financing of at least a share of the
premiums of the poorest? For instance in Rwanda the global fund for
malaria, HIV/AIDS and tuberculosis is partly used to finance the health
insurance premiums of certain categories of insured people.

The second element (availability of health care services) is also very
important and meets one of the key questions mentionned in the mission
statement "How to develop and manage relashionship with health care
sector (contracting)". It is nonsense to provide a benefit package
including services that are not available in existing health centers /
hospitals at an acceptable level of quality. To grant availability of
services it is important to develop networks of accredited hospitals
(like in India) or to negociate at all levels of the health pyramid
(like in western Africa). 
This matching between health supply and demand is all the more
important when nation wide health insurance schemes including a
community based component are developped; it is the case today in India,
in Rwanda, in Senegal, in Colombia. In such situations the allocation of
resources in the health sector (decided at the level of the ministry of
health) needs to be coherent with the benefit package.

So I guess that if our subject focuses on the design and provision of
the best possible benefit package we should also make sure that these
questions (on the affordability of the package and therefore on the
mobilization of additional resources, and on the availability of health
care services and relationship with the health sector) are addressed.

Thanks in advance for your reactions and comments,
Valérie

>>> David Dror <davidmdror at yahoo.com> 04/22/08 3:14 pm >>>
Deal all,
John Pott has raised an important issue, that of the link between cost
structure and what health insurance actually covers (or could cover).
When aggregate average costs are considered, medicines are without doubt
more costly than hospitalisations. Yet, as we know, most low-cost micro
health insurance schemes put the emphasis on covering hospitalisations,
but excluding outpatient medicines and many other outpatient
services/goods. This raises two essential issues: one: better ways to
include in the benefit package the kind of services/goods that the
clients need and would be willing to pay for; and secondly: what optimal
way to match income & expenditure: should we emphasize mainly cost
containment and restrictions of benefits (which really means exclusions,
limitations, caps), or should we give attention mainly to contracting
with providers (but then, is this the role of insurers and are they
really best trained to do so?), or should we rather stress more
inclusive rather than exclusive methods, for instance getting better
financial results through effective guidance of members where they can
get quality services that are also cost-effective (following the model
of the 24/7 hotline put into place by Uplift Health) and better pooling
across many micro insuraqnce schemes?
The exclusion-based model has been less effective simply because it
gives more attention to the concerns of the insurer and less to those of
the clients/members. We have some evidence that trusting the members to
make judicious choice pays off in many ways. If they will seek to
include medicines, and would be willing to pay a higher premium for
that, we may come across as more credibly catering to their needs.
In my view, this thinking should inspire what we plan to do within all
the sub-groups.

One final note on medicines: based on a study by Kotwani et al on cost
and availability of medicines in India (published in the Indian Journal
of Medical research 2007), generics are not cheaper in all cases than
branded, as the cost to the end user reflects not only production and
R&D costs but also the cost of distribution, which are high in
medicines. The other serious concern is counterfiet drugs, which -no
matter how cheap - are the most expensive, and end customers or micro
insurers may be ineffective in circumventing... so quality of care is
also important to the clients, not just cost.

Hope this helps focus the discussion toward customer-orintation of our
deliberations.

Regards,
david Dror   

mukti bosco <mukti.bosco at healing-fields.org> wrote:

Dear All,
i agree with john.  Cost of medicines is a very important and critical
element in lowering relapses as well as loss of working days for the
poor.  We need to look into different ways that have been used to tackle
this.
The other important aspect is how do we bring in Out Patient care into
Insurance? Many of the illnesses requiring hospitalisation now can be
avoided and this reduces work days lost for the poor as they cannot
afford to fall ill.
Rgds
mukti bosco
Secretary General
Healing Fields Foundation
Hyderabad
india

----- Original Message ----
From: John Pott <john.pott.ext at akdn.org>
To: Valérie Schmitt-Diabate <schmitt-diabate at ilo.org>;
subgroup-health at microfinance.lu 
Sent: Monday, April 21, 2008 2:28:06 AM
Subject: Re: [Subgroup-health] 2nd discussion - Workshop during CGAP
Conferenceon Microinsurance

Dear Fellow Work Group Members,

The cost of medicines is a very major concern of the micromarket
because in many instances for them more than 50% of their out of pocket
expenditures for health constitute payment for medicines.

Perhaps I am jumping the gun, but I would like to suggest within the
innovative products section - strategies to design an effective low cost
benefit package - there should be an activity component that comprises
taking an inventory of the approaches that have been adopted so far by
insurers to lowering the costs of medicines component of a health
package.

 The stronger purchasing power of an insurer with a large number of
insured ( eg. medicine discounts for members at hospitals and
pharmacies); the ability of the insurer to wield some control over the
prescribing practices (e.g. strong pressure for generics which are
usually so much cheaper than branded); as well as the ability through
education of its insured membership to influence patient behaviour and
expectations ( e.g. not to expect that risky, expensive and unnecessary
vitamin injection at every visit) should I believe yield promising cost
savings and therefore lower premiums for our market.

With best regards

John Pott
Project Manager 
AKAM Microinsurance Initiative,
1-3 Avenue de la Paix,
1211 Geneva 2,
Switzerland
Geneva Office Phone 00 41 22 909 7355
Swiss based Mobile phone 00 41 79 2011 468 
email: john.pott.ext at akdn.org 

From: subgroup-health-bounces at microfinance.lu on behalf of Valérie
Schmitt-Diabate
Sent: Fri 4/18/2008 15:53
To: subgroup-health at microfinance.lu 
Subject: [Subgroup-health] 2nd discussion - Workshop during CGAP
Conferenceon Microinsurance

Dear workgroup members, 
We have done already some progress in the joint definition of a mission
statement and key questions that we want to adress in our Subgroup on
Health Microinsurance (the second round of comments is arriving ; a
final version will be ready beginning of May).
This mission statement is the starting point for the planning of
concrete activities of our workgroup. In november the CGAP Conference on
Microinsurance will be held in Colombia and we think it is a good
opportunity for our workgroup to :
- meet on this occasion (organize an "internal" working session of the
health microinsurance subgroup)
- organize a workshop / round table on one of the key questions
mentioned in our mission statement. 
We would like the workshop to be a joint activity of the workgroup and
ask for your input in its design and realisation. 
The topic of our workshop should fit in one of the 4 themes of the
conference: 1) technology, 2) capacity building, 3) regulation,
supervision and policy issues, 4) innovative products and distribution
channels
Combining these themes with the key questions of our mission statement
we come up with the following suggestions for the topic of the
workshop:
Regulation, supervision and policy issues 
The role of HMI in national health systems: Initiatives of national
governments to extend coverage of health services through HMI (With
cases of for example India, Colombia, Ghana, Peru). 
Innovative products and distribution channels 
Strategies to design of an essential cost effective benefit package
adapted to the specific needs and priorities (economically and socially)
of the targeted groups 
Models of providing health microinsurance: the role of social security
institutions, CBHI, MFIs, insurance companies and cooperatives. 
Microinsurance and provision of health: improving health care quality
through innovative models of purchasing services 
Off course, other suggestions are welcome !!! 
Questions we would like you to answer: 
What should be the central topic of the workshop (choose one of options
above, or suggest another topic) ? 
Suggestions on speakers and cases 
Input your organization is able to give to the workshop (case studies,
documents, exponents, methodology..) 
We would like you to give your input before the 1st of May. We then
will present the results of this election and propose a workplan to
prepare the workshop. 
Harrie Oostingh, Oxfam Novib and Valerie Schmitt, ILO / STEP

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Hon. Professor of health insurance, Erasmus University Rotterdam
Chairman, the Micro Insurance Academy, New Delhi
(www.microinsuranceacademy.org (
http://www.microinsuranceacademy.org/ ))
Access my publications freely at: http://ssrn.com/author=183410 (Social
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