[Subgroup-health] new member comment

Wed May 14 16:56:33 CEST 2008

Dear All,

It is good to see that our workgroup is gaining dynamism and that more
members get involved in the debate. 

The development of health insurance with a significant coverage has a
technical and a policy dimension. 

On a technical level there is a big challenge on designing a benefit
package according to the priority needs of the poor, and institutional
and contracting arrangements that can deliver on a cost-efficient basis.
I think this issue was stressed in the interventions of Jonh Pott, Mukti
Bosco and David Dror. 

Even improving methods for design and delivery of micro health insurance
there will probably be a significant gap between what people can afford
and the cost of a significative insurance coverage. David Dror mentioned
in Mumbai that health microinsurance schemes he invested in India only
cover an average of 11% of households expenditure on health. This means
that the role of microinsurance in social protection in health depends
on additional sources of funding and availability of health care
services (issues stressed by Valerie). 

The above is also illustrated by the history of mutuals in Europe, as
may'be the Benenden Healthcare Society in the UK or health mutuals in
The Netherlands. These schemes were able to develop gradually because of
strong growth of income of people (and their capacity to pay premiums)
and strong growth of tax income of governments (to be able to support
membership of certain low income groups). Still these mutuals cover only
part of total health care needs of the population. 

Therefore I think that the policy debate on the role of microinsurance
and its contribution to social health protection is crucial. The
evaluation of health insurance schemes only on the the impact for the
people able to join my'be misleading as often these schemes are
detrimental for health systems objetives as a whole. ILO revised in 2005
14 health micro insurance schemes in India, of which 12 schemes excluded
childbirth and pregnancy related illnesses, most excluded people living
with HIV. This way insurance schemes might be affordable, but place an
important part of the financial burden of diseases on people with high
health risks or on other institutions. 

Again, for me the discussion on designing benefit packages should not be
disconnected with the policy debate, taking also into account the
specifities of health microinsurance we agreed upon. 

Harrie Oostingh 
Microinsurance
Research & Development 
Oxfam Novib
Mauritskade 9
Postbus 30919
2500 GX DEN HAAG 
harrie.oostingh at oxfamnovib.nl 
(+31) (0)70 3421720 

________________________________

From: subgroup-health-bounces at microfinance.lu
[mailto:subgroup-health-bounces at microfinance.lu] On Behalf Of bill
mcpate
Sent: Wednesday, May 14, 2008 12:31 PM
To: subgroup-health at microfinance.lu
Subject: [Subgroup-health] new member comment

Dear All,

I am new to the group but have a strong belief that the experience of
the health mutual I managed in the UK could be of value to the group's
efforts to find solutions to delivering healthcare in developing
countries. This may not be the best time to introduce detail to the
discussions of the subgroup but if you will allow me to "get it off my
chest" it will also serve as an introduction to my background.

The Benenden Healthcare Society is a mutual healthcare organisation
providing affordable health services to almost 1 million members in the
UK who can be broadly identified as public servants and their families. 

The Society was first formed in 1905 to provide sanatorium care for
tuberculosis or TB.  The type and method of care was not specified and
discretion was applied by the elected members to determine the most
appropriate service for members with TB. As vaccines and treatments were
developed to deal with TB, the services changed to encompass other
medical conditions and a wider benefit range. Since the formation of the
National Health Service in 1948, these services have supplemented the
care available through the state system. The benefits are discretionary
and supported by an ethos of trust rather than contractual and supported
by insurance principles. 

Amongst the issues you have discussed to date is the dilemma between
concentrating on principles and detail. Perhaps we need to concentrate
on both. 

The principles/values of the mutual health model will be familiar to you
all- Solidarity, Autonomous management, Not for Profit orientation,
Inclusivity and non-selection.

However, there are a variety of ways that a health system can be
designed to utilise these principles.  The design features in the
Benenden model appear in other systems but the way that they combine
seem to offer a unique solution:

The community of members is based upon groups of workers. 

The affinity between member of staff provides the necessary solidarity
to support universal discretionary benefits and collective action.  Our
group, in 1905, comprised postal workers. As their confidence grew in
managing the fund, this was widened to other groups of workers and
family members. Cotton workers might be a typical start up community
today, developing to include family members later.

The Employer recovers contributions on the Employee's behalf.

Providing the workers receive payment through some form of payroll
system, deductions from pay is the mechanism used for collecting
contributions to the mutual fund. This overcomes the problem experienced
by some other forms of micro insurance of high costs for premium
collection. Employers will be motivated to cooperate in this way by the
attraction of a healthier workforce. (It is accepted that the dependence
upon a payment system for cost control will limit the scope of
application for this model). 

The Community decide themselves what services they wish to provide.    

The postal community in the UK in 1905 chose cover for TB care because
purchasing care in a sanatorium was only affordable by the rich so their
prospects of surviving TB were poor. There are numerous candidate
conditions in the developing world, for example TB, malaria or AIDS.
The range of services for those conditions would also be a matter of
member choice. It may be education, diagnostic services or clinic
facilities that they deem most important. Their health service choices
will be based not only on need but also affordability. Affordability and
therefore inclusivity can be prioritised in this model because the
benefits are discretionary. 

Suitability for Developing Countries

There are a number of reasons why I remain convinced of the suitability
of this model for developing countries:

a)      In contrast to dependence upon the external efforts of others,
such as the state or donor countries, the members take responsibility
for organising this form of health system themselves.  As widely
recognised, when people are engaged in looking after their own health
the outcomes are improved. 

b)      Compared to the enormity of the health challenge facing many
countries, this model can be introduced with a narrow benefit focus,
such as a single disease. It has the natural potential to grow and take
on a wider range of health services over time. 

c)       The trust and accountability inherent in the model will enable
funds to be safely targeted on the changing needs of members.
Governments can also trust this model to fit in with the development of
state health services.

You have more experience than me in the problems of the developing world
so please let me know why you think that this model may not be
appropriate. Returning to Valerie's e-mail of 8th May could this be one
solution to the search for a model that "responds to the priority
protection needs of the insured" that is also "inclusive"," available"
and "affordable"?   

Bill McPate

The Benenden Healthcare Society

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