31 March 2009


Health

The idea behind Health mutual fund

During illness, and especially at time of hospitalizations the problems of the poor are:

  • Financial distress of the family: hospital expenses and loss of daily wages, which is a double burden.
  • Lack of health understanding and health consciousness
  • Poor access to adequate healthcare facilities

Hence a need for a service which gives an entry point to access quality health care at most affordable prices.

Health mutual funds allow people to share the risk through saving a small amount on the basis of ‘One for all, all for one’ so that in times of health crises a lump sum amount can be made available to meet the hospitalization expenditure, smoothening the financial shock when facing such events.

While the system is similar to the insurance industry, here the risks are not “transferred” to an insurer, but shared under the community’s responsibility.

Mutual Insurance Key Features

  • Fund is created and governed by communities; fund money is kept in community’s name.
  • Claims are settled in democratic and transparent way by communities themselves
  • Referral and guidance services provided through localized branches and field workers.
  • Preventive and promotive health measures, member education is a key component of the programme

Health Mutual Fund Product

Benefits, Premium and conditions

Exclusions

  • Any intentional Self injury, suicide attempts.
  • Addictions related hospitalizations
  • Cosmetic/plastic surgery or aesthetic treatment not arising out of an accident.
  • Infertility related health care
  • Dental and optical care not arising out of an accident. Cataract operations are not excluded.
  • Epidemics, Covariant risks to be taken care of on a special requirement basis with authorities

Mutuals Main Achievements

  • Has been able to achieve 60% sustainability
  • Has been able to bargain concessions with health care providers from 10-50%;
  • In-house database management system provides effective management of information.
  • Its a people governed model where health and access to quality health care at reasonable rates, is the prime concern
  • With its focus on specific demand based health check up camps and OPD network services reduce the frequency of hospitalisation
  • Has been able to save lakhs of rupees through referral and guidance services to members (approx 30 lakhs in all three locations in 2008)

Remaining Challenges

The mutual model has still to address the following main challenges:

  • Reduce operations cost to reach a 100% sustainability level of the project
  • To reduce the out of pocket expenditure (which has risen due to rise in health care costs) through public financing as increasing premium is not an option.
  • To promote a redistribution system with public money to cater to the lowest segment of the population
  • Establish governing structures to have people’s ownership and management
  • To increase renewal ratio from 45% last year to 70% by 2008

Development Plans

  • Increase membership to reach 300,000 by 2010
  • Create a Call centre to handle member calls 24X7
  • To replicate to handle member calls 24X7 operational cost the population through public financings

Annexure

Health Care Providers Network

More than 150Private and public institutions are empanelled in Pune for providing their services to the members of this CBHI. These institutions are empanelled through through the signature of an MOU with UpLift, as a representative of these health mutual funds. This MOU is to be reviewed in 2007 and transformed into an agreement including cashless facility and packaged health care procedures in order to make the cost of care cheaper while ensuring a proper level of quality. Around each branch/community health fund, a doctor/primary health care facility is to be attached with whom /where concessions are negotiated.

Benefits matrix

Target Population Pain Points / Benefits
Financial shock at the time of hospitalization / A solidarity based financing solution for paying an hospitalization
No access to timely quality health care / A network of health care providers which acts are controlled ensuring the proper delivery of health care
No one to trust when going to an hospital / A “consumer owned” call centre provides reliable health guidance
No preventive guidance / health knowledge / Monthly meetings to review the health funds activities and learn the analysis of health care troubles provided by a medical doctor
Difficult to trust insurers / Transparent system: a monthly financial report is available with all decisions. No hidden profit.
Claims rejected / limited refund / A solidarity fund spent by a member’s committee review the requests and provides on exceptional basis an additional support.
Implementing organizations Pain Points / Benefits
Insurer keeps too much hidden profits / Transparent system: the collected contribution and co-contributions finance transparently the whole chain. Accounts are audited. No hidden cost in TPAs.
Insurer’s product doesn’t match what the implementing organization wants to do / The participative management of the mutual develops a solidarity aligned with the service purpose of the organization.
Insurer’s procedures and limitation associated with the organization’s image / The organization and members decide together of the procedures they want, under the guidance of Uplift to ensure a financial balance.
No technical internal capacity to handle mutual / Technical capacity, MIS, and other requirements to allow a mutual fund management.

UpLift Partners

UpLift has developed since 2003, relationship and partnership with various famous organisations who support in their manner the objective of building access to quality health care for the poor:

  • Inter Aide: A French NGO, catalyst at the origin of UpLift, implements development programmes for the urban poor in the domains of productive microfinance, family development, early childhood and health mutual funds.
  • MACIF: the biggest French insurance mutual recently associated with Inter Aide to provide technical support.
  • GTZ: provides funds and technical guidance to setup cashless, and BPO setup processes. GTZ has also initiated contacts with the health department of Maharashtra to setup a social health insurance system for the informal sector in Maharashtra. This plan involves UpLift as described in this proposal.
  • ILO: identified and documented Uplift’s best practices.
  • Tieto Enator: A Finland IT Development company, having a development centre in Pune allocates 1man – year for the development requirements of SysLift the UpLift’s MIS.

Operations organization

Syslift: UPLIFT MIS for implementing organizations

Software developed jointly by UpLift and Tieto Enator for community based health insurance to manage micro insurance activities and especially health insurance.

Reporting customized for various levels of decision: includes claim ratios and claims frequencies per branch, accounting, health funds balances…

Comprehensive Database for statistical research. Capacity to handle infinite products under 3 categories : Health - Accident – Property

User Friendly : Fully open to Development specification suggestions.

Coming developments: web based version, consolidation of all user-organization in a single database accessible to all.

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