Growth and Key Issues of the MHO Movement in WCA

1. Growth and Key Issues of the MHO Movement in WCA Presentation at USAID/SOTA Chris Atim, PhD Abt Assocs/PHRplus 12 June 2002, Nairobi, Kenya

2. 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. 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 contributions • Democratic accountability to members • Solidarity and mutual aid between the members

3. Origins • HCF crises of ‘80s and cost recovery in health • Availability of quality care thru’ private providers • Democratisation processes • freedom of association • growth of civil society

4. Rate of growth of MHOs in WCA 1997 - 2000

5. 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

6. 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

7. Fandene MHO cont. • But • MHO pays all of patient’s bill to hospital, and then • Recovers 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

8. 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 management • Waiting period • Not covering any service 100% • Democratic participation • Low admin costs • Important for confidence and trust of community

9. 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

10. Chris Atim: E.g. membership registers, letters of guarantee, accounting and finance tools, 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

11. Number of MHOs found in Senegal 1997 - 2002

12. Innovations by newer, more successful MHOs • Extension of coverage to PHC services • At health post and health centre levels, now a widespread tendency • Decentralization of management • Decentralization tool developed by PHRplus • Using example of most successful MHO • Emergence of women-run MHOs • Providing coverage esp for maternity care

13. Ghana

14. Main features of MHO growth in Ghana • Large majority very young, less than 3 years old • Greater concern about MHO sizes and population coverage rates • Average MHO size in 2001 was over 6000 members • Ghana has largest #s & biggest MHOs in sub-region

15. Main features - Ghana • Greatest variety of MHO designs too • Lot 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

16. Number of MHOs found in Ghana 1999 - 2002

17. 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 support • Eg TA, funding for feasibility studies, expanded benefits package, support o MHOs in difficulty and health education • Example has inspired Govt efforts to support MHOs

18. 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

19. 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

20. 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

21. Key Issues & Challenges • Exploding MHO growth and finding economical ways to provide TA • New innovations in MHO development • Expansion of benefits packages • PHC, MCH services and women’s MHOs • Reinsurance as an issue • Threat and opportunities presented by Government interest /HCF policy

22. Thank You • 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