The document provides an initial findings report from research conducted in Bembèrèkè and Sinendé, Benin on mutuelles de santé, or community-based health insurance organizations. A team from the University of Michigan conducted over 90 interviews with mutuelle leaders, community members, and healthcare providers. Their research identified several areas needed for the mutuelles to become more professionalized and sustainable, including improving their value proposition, organizational structure, fee collection processes, and data management capabilities. Addressing these issues could help boost adoption rates of the mutuelles and position them for their new role in Benin's universal healthcare system.

1. UNIVERSITY OF MICHIGAN
SUSAN ALLEN
SANDER DOLDER
MATTHEW DOWNER
PREETI GUPTA
APRIL 2012
Initial Findings from Bembèrèkè & Sinendé

2. Agenda
 Overview of research approach and interviews
 Professional structures of mutuelles in Bembèrèkè and Sinendé
 Customer feedback on value proposition of mutuelles
 Next Steps

3. 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

4. Bios
Matt Preeti Sander Susan
Source

5. Problem Statement
 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?
Source

6. Mutuelles Health Insurance is a prevalent model throughout Western
and Central Africa
 Uganda, Ghana, Senegal examples…
Source

7. Despite having been launched more than 10 years ago, mutuelles in
Benin have limited uptake
• 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
Source

8. Thus far, we completed field research and synthesized our findings
from Bembèrèkè and Sinendé
Phase complete
Field
Deliver
Project Research Synthesize Follow-on
recommendatio
Immersion and Research Research
ns
March 9-16 Interviews March 31-Apr 2 April 1-23
April 24-27
March 17-30

9. Key research questions and interviews completed…..
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
Source interviews
total

10. There are three areas where the mutuelles need to professionalize:
Capacity building
Capabilities
• Decision-
making/controls
Value Proposition • Data aggregation
• Cost • Succession
• Services offered planning
• Healthcare quality
• Culture
Source

11. Adoption in Benin has been slower than other countries, and recent
national health legislation has brought mutuelles center stage
Source

12. The value proposition of mutuelles currently does not attract a large
percentage of the population, even in well-managed areas
Details to
follow
Standard mutuelle offering Adoption rates
Mutuelle: 2400  5-8% adoption of mutuelle in most
CFA/member communities in Bembèrèkè
Union: 3000/house Cost
hold  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
Value percent also pay for hospital
Basic coverage of Propositio Health center is insurance through the Union
illness & n primary provider
prevention
Services Quality of
Offered Care
Source: interviews in Bembèrèkè and Sinendé

13. While premiums are affordable for individuals, certain groups can
not meet current price point for mutuelle membership
Issue Opportunity
At highest risk, Offer basic
Indigent but unable to coverage to the
population afford full poor at a lower
coverage cost?
Most families can
Offer an incentive
Large only afford 4-5
for large
Families beneficiaries
households (6+
regardless of
members)?
actual family size
Create flexible
Seasonal Inconsistent payment plan
income annual earnings that allows
earners make it difficult to farmers to match
pay monthly premiums to
income?
Source: interviews in Bembèrèkè and Sinendé

14. Offer multiple basic plans to meet varied consumer needs while
avoiding adverse selection
 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
Advantages Challenges
 Attract a large, un-tapped segment of  Is it necessary to make it equitable
the population  Increased risk for higher payout
 More members sooner decreases  Daily operations more complicated for
consumer pain point with mandatory mutuelle volunteers
plan
 Additional education would be required
 Potential to increase the risk pool for staff and consumers
 Generates incremental income for  Adverse selection
the mutuelle
 How to keep people committed for
 Creates affordable option for families longer than one year – contracts?
who wouldn’t otherwise join
 Could cannibalize existing full-plan
 Attractive to groups who don’t members
typically join (e.g. men  hernias)
 Need to conduct cost analysis to
 Offers low-risk introduction to determine pricing
mutuelle services
Source: interviews in Bembèrèkè and Sinendé

15. Our observations from Bembèrèkè and Sinendé isolated barriers
limiting functional capacity and effectiveness of the mutuelles de santé
Details to
follow
Checks and • Lack of decision making
balances autonomy
• Financial accountability
degrades consumer trust
• Need for professional liaison
Organizational on care issues
Role specialization
structures • Specialized training for
outreach & management
Organization • Co-op versus agency structure
design • Constraints of volunteer
reliance
Professionalization
• Dispersed communities make
Fee collection distance a problem
• Lack of urgency to pay
• Infrastructure for accountability
Operational Technical • Lack of ability to aggregate
efficiency Administration and use data to improve
• Ineffective sales force
Outreach • Tie-ins with larger community
Source: Interviews education issues

16. 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 Mutuelle PISAF GAP
2006-2010 s/Union 2011+ S
2011+
• Since 2011,
Research & set mutuelle X X strategic
premiums planning and
Ensure meeting cadence with all X X financial
parties present oversight have
lapsed for
Conduct financial audits X X Sinendé,
creating issues
Address inconsistencies in X X with
medical care given(medical accountability of
counselor) the mutuelles to
the community
Maintain relationship between X X
health centers and mutuelles
• Currently no
Collect premiums & process X structure exists
claims about Union and
Conduct outreach X X Mutuelle for
issue escalation
Raise and address mutuelle X & support
issues at the Union level and
above

17. Checks and Balances: organizational structure needs to support a self
sustaining model Case
Example
Proposed decision model based on Necessary checks
Bembèrèkè performed by
Hospital Union Manager
• Financial Audits of
Union Level premiums
collected and bill
Executive Manager payment
Board Auditing for
• Liaison with health
oversight care providers for
Administrative Surveillance
Council
on contracts and
committee
Operations, issue resolution
General
Controls, • Perform data
Assembly and aggregation and
healthcare audits
Strategy
• Facilitate
execution of
strategic plans
Source: interviews in Bembèrèkè and Sinendé

18. Fee Collection: Neighborhood network of mutuelle agents to
collect premiums and conduct outreach Case
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
Assessing the Numbers • Trusted member of the local community is the face of
(example): 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
• interviews
Source: PAPME Director interview, mutuelle Unclear fit to existing volunteer-based structure

19. A Mobile Money infrastructure would help revamp the current
fee collection system to induce growth and financial stability Case
Example
Current System
Central Village Members
Mutuelle Multiple visits for
Volunteer single collection by
family
5,000
Cash Payment
Mobile Money
Members
System Central Village Local
Mutuelle
Volunteer Agent
Limited displacement
Via Phone House
Mutuelle Bank Source: Mobile Money for the Unbanked, GISM 2010

20. Professionalization of data aggregation and analysis could create a
platform for future connectivity between mutuelles
Individual identification Data aggregation at Succession planning:
numbers Union level passing down
- Information tracked by - Enables performance management knowledge
beneficiary evaluation of mutuelle - Creates a plan for
- Enables tracking of results to Union goals sustainable operations for
enrollment fees and care - Ability to stage mutuelles in the future
by the individual interventions promptly - Promotes continuity &
- Makes future reciprocity -Financial accountability consistency for day-to-
between regions feasible through regular audits day operations
- Builds skills in the
community
Source: interviews in Bembèrèkè and Sinendé

21. QUESTIONS & WRAP UP