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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
Source: interviews in Bembèrèkè and Sinendé
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
Source: interviews in Bembèrèkè and Sinendé
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
Source: interviews in Bembèrèkè and Sinendé
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
Source: interviews in Bembèrèkè and Sinendé
QUESTIONS & WRAP UP