For many years, cooperative and mutual businesses have played a key role in national economies around the world. Ever since the very first cooperatives and mutuals were developed over 200 years ago, this sector has been crucial in enabling people from all walks of life and in every corner of the globe to build better lives for themselves, their families, and their communities. Today cooperatives and mutuals are as relevant as ever and the Modern Mutuality and Cooperative Insurance are crucial to ensuring fair and appropriate regulatory treatment and sustaining a genuinely positive public image.
The core of the Commitment is the application of the 'associative idea' in fragile states. The focus is on associative, collaborative action, and provides the impetus for local CBHI-schemes. Experiences in Europe and in micro insurance in developing countries show that an associative structure lies at the heart of mutuality and solidarity. The usual philosophy behind this is that associations evolve best in a community where a certain kind of solidarity exists, in terms of minimal care for each other and a minimum of social involvement of community members.
Millions of people in fragile states and low income countries have no access to quality health care. Traditional efforts to strengthen public health care have thus far not been able to include the lowest income groups, while governments fail to take responsibility in low income countries.
1) Create a minimum pattern of effective health services;
2) Introduce financial discipline by using the 'performance based incentive approach;
3) Build health associations with active membership on community levels;
4) Define a 'basic package of health services; and
5) Create a CBHI Scheme.
The new initiative herein is the installation of this model of cooperative health insurance associations so as to allow for buy-in and control by the populations themselves. While Cambodia is waiting for full commitment to start implementing, the other sites are preparing.
This approach is designed to yield the following results:
- Create access to health care for the poor.
- Reduce poverty through economizing on out-of-pocket health care-related expenditures.
- Apply the association philosophy, thereby helping to repair the fabric of social life that is often destroyed by decades of warfare.
- Present governments with models that can be replicated and that will help them take responsibility in enabling cost-effective public health care.
Associative structures should have the following characteristics:
They are associations of individuals who are permitted to join (and resign) freely;
Focused on promoting the interests of members; and
Committed to practical and entrepreneurial approaches to addressing the interests of members.
Within the context of HealthNet's targeted countries, the paradox in this approach is that this social cohesion has been severely affected by wars of terror that have raged in most of the fragile states. As a result, often the solidarity among people in the local community is often challenged. A successful association realizes improved access to health services and this stimulates mutual trust. The stimulus is the very real fear of the poverty trap, whereby medical costs spiral out of control, causing families to fall into absolute poverty.
The ability to cope with medical costs serves not only the interest of the individual but also the interest of the community. The interest of the individual converges with the interest of the group/village, the very-poor and medium-poor alike.
The concept of social health insurance based on mutual solidarity and implemented through an association is therefore especially difficult to implement in countries such as Afghanistan and Cambodia. These countries have a changed idea of what constitutes a functional community. Therefore, in order to build a solid CBHI, one should have a clear notion of the local idea of community, or at least of functioning social networks. 'The challenge is to identify those structural features in (?) society that underpin individual and group resilience and coping' (Boyden & Gibbs 1997:47).
Traditional culture, religion and custom all offer lessons for a CBHI insofar as they all manage the interests of individuals within the context of the interests of the group as a whole. The participation and opinion of members needs a certain level of insight and survey. The question is how to define groups of people with a common interest in order to motivate them to participate in an insurance scheme.
This is why the idea of an associative insurance could be a helpful tool to develop new social relations that foster health and development in war-torn, fragile states - rather than building an insurance association in the expectation that solidarity is simply out there to be found.
Starting an association based on the original ideas as known in Holland is an option, but assumes that there is time to overcome the set-backs, not only of the traditional low level of special integration, but also of the deep wounds that civil war and repression under the DK regime have inflicted. The Cambodian fabric of social life was targeted by the extremely rigid ideas of the Khmer Rouge - and this attempt to building a 'new society' was partly successful since there were no mechanisms in place for people to organize resistance.
Given this special history of countries that have suffered from successful terrorist attacks on their social fabric, it is more than justified to use the idea of collective insurance in an alternative way. The introduction of the option of a collective, an organized way of mutual benefit, can be seen as a way to help people build mutual trust, rather than see the insurance schemes as an outcome of trust that is already present.
The goal remains the same: associations that are owned by their members; building a pyramidal structure that allows local groups of people to benefit from the power they have at higher levels to negotiate for their own good. The only difference is that this concept itself is now used to help people build their self-reliance, rather than expecting the existing self-reliance models in a war-torn society to be sufficiently strong to build upon.
In this document HealthNet will describe the process of gradually expanding a system of CBHI schemes to cover 4,7 million people by 2015. The document outlines the approach foreseen, but is not be regarded as a fully detailed proposal as yet. Decisions to be made in the first months after parties have made commitments include an exact description of the relations between the different parties and a clear division of roles. Later on each setting will be assessed as to be able to develop a vision of organizational models for each CBHI scheme to be developed. The contexts found will influence the nuances of the shape of the associative idea in specific fragile states. Plans will be developed per setting and include the specifics of health system reform processes, the identification of quality health providers, the relation with performance based incentive schemes, and decisions on what type of social insurance scheme needs to be developed (e.g. voluntary or compulsory participation) - and for whom?
Healthnet TPO will be the implementer of the program, and will be responsible for securing the funds necessary for the creation and maintenance of basic health care systems.
Achmea/Eureko commits itself to the investment costs, and contributes both in kind (the expertise and sabbatical input of its staff) and in funds (remaining part of investment costs not covered by co-funders).
Depending on the growth of the organization, more employees will be appointed in the administrative department (e.g., a cashier, a data base officer, etc.). A small office with the corresponding equipment is required for the administrative organization.
The logic of implementation is similar in each setting.
Start & Set-Up Phase (6 months)
- The staff of the CBHI pilot project will be recruited; office facilities will be obtained and equipped.
- A baseline study will be done in 25 communities of the selected first 3 HC areas.
- Promotion and membership materials will be developed and tested.
- The recruited staff will get training on CBHI schemes.
- The first group of CHW's (or other key persons) will be trained on CBHI promotion.
- Involving the HEF clients in the areas to be discussed with the HEF implementer.
- The MOU and contract will be signed.
- HC's mangers will be approached and the content of the CBHI and the contractual conditions will be discussed.
- Contract for the first quarter of the first implementation year will be discussed and signed.
- Contract with the RH will be discussed and signed.
Implementation - Year 1
- First quarter: the promoters start with the promotion of the CBHI.
- The first households become member. HEF clients receive their membership card.
- Quartely the contracts with the HC will be renewed.
- Between times studies will be done.
- If necessary refresher training for promoters will be carried out.
- Third quarter: decision will be taken based on the experience in the first two quarters as to whether the implementation will start in the second areas.
- Fourth quarter: staff for the second implementation areas will be hired and trained. Baseline study will be carried out in the new areas. Contracts with the HC in the second are will be discussed and agreed upon.
Implementation - Year 2
- First quarter: household survey will be done in the first year implementation areas and the results of the first year implementation will be evaluated.
- Implementation in the second areas. HEF clients of these areas become members.
- Based on the evaluation, a decision regarding the continuation of the pilot will be made.
- Decision to be made as to whether implementation in the third group of HC areas will start.
- Second quarter: recruitment of the staff for the third areas.
- Training of the recruited staff and the promoters for these areas.
- Baseline study to be done in the new areas.
- Third quarter: implementation starts in the areas of the third selection. HEF clients in these areas become members of the CBHI.
- Contract with the HC are discussed and signed.
- Refresher course will be given to promoters in the different areas.
- Fourth quarter: staff for the fourth selected HC areas will be recruited and trained.
- Promoters in the fourth areas will be selected and trained.
- A baseline study will be conducted in the selected HC areas.
- Contracts with the HC in the fourth area will be discussed and signed.
Implementation - Year 3
- First quarter: Baseline study for evaluation will be done in the different areas.
- Promotion and implementation will start in the fourth area and in the other ongoing areas.
- Second quarter: decision will be made regarding the continuation of a CBHI scheme in Pearang and other OD's of the Prey Veng and other Provinces.
- Discussion with other CBHI implementers to included their CBHI schemes in the National CBHI NGO and installing member associations.
- Proposal for extension will be written and shared and discussed with potential donors and other stakeholders.
- Necessary funding and support will be assured.
- In case the outcome of the evaluation is a 'no-go', the winding up phase of the project will be planned and executed.
Implementation - Years 4-7 (creation of national or regional CBHI Association)
- First year development of all required documentation for the foundation of the National -CBHI NGO as an association of the CBHI clients/members.
- Research and discussion in the communities about the associative idea and how this fits into the cultural context for the countries involved, as well as the acceptance by the respective communities.
- End of the year: the association and or NGO is founded and registered and can become operational.
- Second year: implementation together with HealthNet TPO, to be taken over by the association NGO over time.
- Third year: the association/NGO is implementing the CBHI.
- HealthNet TPO gives advice regarding the implementation.
HealthNet's target population is within the 'bottom billion' as described by Paul Collier. Conflict is one of four 'poverty traps' that the bottom billion will be unable to escape without outside intervention. Fragile states are described as those in which 'state structures lack political will and/or capacity to provide the basic functions needed for poverty reduction, development and to safeguard the security and human rights of their populations'.
Functioning health care delivery system, through Implementation contracting model.
Utilization rates (annual contacts per capita)
Realistic salaries for health workers based on performance based contracts
Reduction in out-of-pocket expenditure for patients
Installation of basic package of health care
UR quadruples in 4 years time
70% Health providers in catchments area willing to work through contracts
50% reduction out-of-pocket expenditure population
BPHC accepted by health authorities
Minimum score in quality measurement in 80%.
Base-line assessments and continued monitoring of health seeking behaviour Community surveys & actual contract registration;
MOH involvement (where functional).
HealthNet TPO is looking for partners and resources: funding to increase coverage and speed up the process to come to sustainable insurance schemes in fragile states, knowledge that may help delivering insurance schemes that address the needs of illiterate low-income communities, and media support to make this effort visible.