1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health February 28, 2011 Global Health Council Revitalizing Community-Based Health Insurance in Africa Toward Universal Coverage Cheikh Mbengue Health Systems 20/20, Abt Associates Inc.

2. Outline for presentation Context Why CBHI? Trends in CBHI and USAID technical approach in Africa New CBHI strategy for Africa Application in Mali Lessons and opportunities

3. Post- independence experience with social insurance CBHI and mutuelles leading to NHIS Restructuring in late 80s/ 90s Declining revenue bases and increasing crises in 70s/80s Formal sector focus and exclusion of rural and informal sectors Directly imported from and based on European models Economic crises threaten welfare state Collapse or deterioration of services User fees Growth of private sector and civil society Historical context Legitimized and validated HI for rural /informal sectors Provided model, tools, skills, etc for renewed state interest and approach to SHI – decentralized, participatory, etc

4. Out-of-pocket expenditures dominate health financing in Africa

5. OOP payments and health insurance coverage in Africa Country Total pop. (millions) % rural GDP per capita ($) Total expend. on health as % GDP Per capita total exp on health ($) OOP as % of total health expend. % pop. with health insurance Liberia3.7141141.075.61036<1 (2010) Ethiopia79.0883174.014.97322 (2010) Niger14.1984168.704.01040<5 (2010) Côte dIvoire19.2552553.643.835687 (2010) Mali12.3468289.106.030488 (2010) Tanzania40.4375354.175.5183416 (2009) Benin9.0259328.085.3294718 (2010) Cameroon18.5344696.755.2516819 (2010) Kenya37.5379459.584.6294120 (2009) Senegal12.4158509.035.4406220 (2010) Zambia11.9265386.055.2493922 (2009) Ghana23.4651306.806.2355045 (2009) Rwanda9.7382271.3110.4322375 (2010)

6. Why expand health insurance coverage through CBHI? 44% of total health expenditures in Africa come directly from households out-of-pocket (OOP) OOP: impoverishing, inefficient, limit access to care Traditional health insurance is hard to establish where: Economy is dominated by informal sector Majority of population is rural poor

7. Why expand health insurance coverage through CBHI? Social inclusion Increased access to care Income protection Potential for scale-up (Rwanda and Ghana) Reducing transaction costs Providing a benefits package tailored to rural informal sector Developing a culture of insurance

8. CBHI trends in Africa CBHI movement is active in West and East Africa Spectrum of CBHI scale-up as of 2009: Moving towards universal coverage/integration into national health insurance schemes: Ghana, Rwanda Growing population coverage: Senegal, Benin, Mali Incipient efforts: Burkina, Cameroon, Cape Verde, Ethiopia, Guinea, Mauritania, Niger, Togo

9. CBHI coverage in Africa Country Number of CBHI schemes Number of beneficiaries Total pop. (millions) % of pop. covered Rwanda (2007)3926,330,0009,907,50963.9 Ghana (2007)1439,810,00022,93129942.8 Mali (2004)56499,85611,956,7884.2 Senegal (2004)87294,06010,852,1472.7 Côte dIvoire (2004)36368,10017,327,7242.1 Benin (2006)10590,0007,862,9441.1 Guinea (2004)5596,6359,246,4621.0 Niger (2004)1284,37211,360,5380.7 Cameroon (2004)2210,09816,063,6780.1 Burkina Faso (2004)3614,58013,574,8200.1

10. Health insurance coverage in Rwanda Source: IDHS 2007 Health insurance coverage (%)

12. USAID has used a variety of approaches to support CBHI Centrally-funded project support (PHR, PHR plus, PRIME 2) Individual grassroots technical assistance (TA) to CBHI schemes; development of toolkits ; TA to develop national policies (e.g. Rwanda and Benin); research to evaluate effectiveness, and support to regional network La Concertation Regional project support – AWARE-RH Mixture of TA to CBHI support organizations, national policy development, and support to regional network La Concertation Bilateral project support, e.g. Senegal, Rwanda, Benin Rwanda: TA to CBHI schemes through district-level CBHI networks and local governments Senegal: TA to CBHI schemes through NGOs and subnational CBHI networks – TA to develop national policy Benin: TA to CBHI schemes through support to district-level CBHI networks and partnerships with local governments - national policy

13. The way forward – CBHI strategy for Africa Strengthen institutional capacity at the national and intermediate levels to advocate for and drive implementation of national strategies Local government agencies – e.g. municipal and district authorities in Rwanda Local/sub-national networks of CBHI schemes – e.g. CBHI networks in Benin National network – e.g. CNC in Niger Develop national strategic plans where they do not yet exist (e.g., Mali) Replace user fees with premium payments to CBHI schemes to promote membership and sustain financing for service providers Integrate initiatives to abolish user fees with CBHI policies Find out what works – Assess the relative effectiveness of supporting CBHI development through national networks, national NGOs, and local CBHI networks

14. 10 patients pay $10 each MOH allocates $100 Provider $200 User fees w/o CBHI Strategy: Integrate user fee policies with CBHI to promote membership, sustain financing for service providers

15. 10 patients pay $10 each MOH allocates $100 100 patients pay nothing MOH allocates $100 Provider $200 User fees w/o CBHI Free care w/o CBHI Provider $100 Strategy: Integrate user fee policies with CBHI to promote membership, sustain financing for service providers

16. 10 patients pay $10 each MOH allocates $100 100 patients pay nothing MOH allocates $100 Provider $200 User fees w/o CBHI Free care w/o CBHI 100 patients pay $1 premium CBHI pools & purchases Provider $200 Link user fees w/ CBHI MOH allocates $100 Provider $100 Strategy: Integrate user fee policies with CBHI to promote membership, sustain financing for service providers

17. Expanding CBHI in Mali No prior national strategy for CBHI Piecemeal reduction of user fees Government wants to expand CBHI and subsidize premiums for the poor USAID s strategy Partner with MOH, MSW, and international donors to develop and implement a national strategic plan for CBHI scale-up

18. Mali strategy in action Results to date: Health Systems 20/20 partnering with Gates-funded Ministerial Leadership Initiative and World Bank Worked closely with MOH and MSW to develop a national strategy and a 5-year operational plan Subcontracted with UTM, a key national NGO to strengthen CBHI schemes in Sikasso Through UTM assisted with the creation of Mali s first regional CBHI network in Segou Government officially adopted the strategy and plan

19. Mali strategy in action Next steps: Implement the pilot of the CBHI strategy in three regions Lessons learned from CBHI schemes in Sikasso and from the regional network in Segou will inform the pilot

20. What are some lessons learned? Government involvement and ownership is essential (including supportive policy environment and institutional arrangements) Different donors, organizations, and project mechanisms can effectively provide complementary inputs Constant need for program promotion when insurance membership is voluntary Need to strengthen the capacity to implement CBHI at all levels TA to individual schemes (especially by external consultants) is very labor intensive, expensive, and not locally sustainable Need for monitoring to manage risk, quality, and sustainability Need for evaluation to measure impact

21. Technical tools to support the development of integrated health insurance models, including CBHI schemes (e.g., training manuals, guidelines) Trained international and local personnel with grassroots- and national-level experience National strategies as models for the way forward (Benin, Senegal, Rwanda, Ghana) Explosive interest in health insurance and growing consensus that CBHI can be part of the health insurance scale-up Other key donors such as ILO, GTZ, French Cooperation, Belgian Cooperation, the World Bank, the African Development Bank, and European NGOs are active and engaged What strengths do we have to build on?

22. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Thank you For more information visit www.healthsystems2020.org