BOOKS & ELECTRONIC MEDIA
Guide de gestion des mutuelles de santé en Afrique
Guy Carrin
Health System Financing, Expenditure and Resource Allocation, World Health Organization, 1211 Geneva 27, Switzerland (carring@who.int)
Publisher: International Labour Organization; Geneva; 2003
ISBN: 92-2-213872-4; 268 pages (softcover);
price: SFR 30
This guidebook is an important contribution to the literature on mutual health organizations (MHOs), sometimes referred to as micro-insurance or community health insurance organizations. Evidence is growing about the positive impact of such organizations on access to care among low-income population groups in developing countries. Although understanding about the concept and key design issues of MHOs has been increasing, no detailed account of "how" to implement and manage an MHO has been available. This book now fills this important gap.
The book is divided into seven parts. Part I presents an introductory description of the key characteristics of an MHO: risk-sharing among members, calculation of members' contributions and how these are linked to the level of protection offered, and methods of paying the providers that are contracted by the MHO. Basic issues of management, including financial management and bookkeeping, are also addressed.
Organization of an MHO is discussed in Part II: which actors are involved (e.g., the members, the general assembly, and the management committee); what they are responsible for; and which organizational set-up is required for the MHO to function properly. Highlighted also is the need to include the responsibility of the various actors in the MHO's statutes. The example of such statutes that is provided is particularly helpful for those involved in establishing a MHO.
Part III focuses on the management of membership, contributions, and payments to providers. Examples are given of essential documents, such as the membership card for the insured members, the membership register of the MHO, the contribution card for individual members, and the MHO contribution register, as well as the bill submitted by providers to the MHO. Stressed also is the importance of monitoring the costs of health care services covered or reimbursed by the MHO.
The short course on bookkeeping given in Part IV underlines how useful this activity is and that it is essential if an MHO is to succeed. Numerous examples are given which link the MHO's day-to- day operations to the revenueexpenditure and assetsliabilities accounts.
Part V covers the essential elements of budgeting and deals with the financial implications of the planned activities of an MHO, in particular reimbursement of health-care costs, investments, and other items such as marketing and training. Budgeting is essential since an MHO itself is exposed to a number of risks that are linked to the behaviour of its members (e.g., overuse and adverse selection) and the providers (e.g., over-prescription). An MHO may also be confronted with the financial consequences of sudden events such as an epidemic, for example.
The risks that confront an MHO are addressed in Part VI, where an overview is also given of methods to shield itself from such risks. These include family membership and the establishment of a waiting period (to reduce adverse selection), the introduction of a gate-keeper role for certain health-care providers (to reduce members' direct access to higher levels of health care), and the introduction of treatment guidelines (to reduce over-prescription). In addition, attention is paid to special mechanisms to protect an MHO from risks such as reinsurance and risk-sharing among mutual health organizations.
Monitoring and evaluation of MHOs are analysed in detail in Part VII.
The examples given, in combination with a series of tie-in graphical aids, will be of considerable help to users of this manual. In general, the voluntary membership of MHOs makes such organizations quite vulnerable to changes in the economic environment (e.g., reductions in the economic capacity of households due to crop failure) or to disagreements with their members over their design (e.g., the level of the contribution or the contents of the benefit packages). A practical tool for MHO management to address the issue of change is described: a yearly "synthesis- form" that traces in graphical format the evolution of crucial indicators such as MHO membership, contributions, utilization of health services, and cash receipts and outlays. This synthesis-form also covers net revenue and assets and liabilities. Use of such a form in discussions between the membership and MHO management is also explained.
One issue that would have deserved much broader attention, however, is the interaction between government and MHOs. Government can play a role in co-financing MHOs (for instance to support membership by the poorest), in promoting and monitoring them, and even in providing technical advice on the design of MHOs. The last-mentioned role is increasingly recognized in both practice (for instance the Senegalese Ministry of Health now has a special unit to support MHO development) and in the literature.
On balance, though, the overall merit of this book remains. It clearly addresses many practical concerns in the development of MHOs and will answer numerous queries by those who play a role in their management. It is currently available only in French but it is to be hoped that it will soon be translated into other UN official languages. 