Scheme Operations
These can be divided into 3 stages:
Pre-launch Operations
Activities are directed at securing the commitment of the state government and the target communities. At this stage all stakeholders work towards laying a foundation for the successful take off and implementation of the scheme.
Major activities include:
Formal stakeholder’s commitment
A memorandum of understanding (MOU) that defines the relationship between the interested state government or corporate enterprise and the HCHP is articulated and signed. This MOU outlines the responsibilities of each of the two parties. It also signifies the commitment of the State government to the commencement of the community health insurance scheme.
Identification and selection of target communities
The State government shall identify and select the benefitting communities. The HCHP recommends that selected communities should be rural, have a strong leadership system, and have a reasonable complement of existing public and private health care providers.
Collation of demographic and health data
The state government is required to provide demographic and health data of the selected communities. These are required in designing the programme.
Community Engagement
Community buy-in is critical to the success of the health insurance scheme, therefore as soon as participating communities have been identified, the HCHP engages the pertinent traditional and religious leaders in the target communities. The HCHP shall consult with these leaders extensively on the community health insurance scheme. It is the priority of the HCHP to create win-win relationships with the leaders and members of the target communities.
Target group studies
A reputable market research firm is contracted by the HCHP and the State government to carry out qualitative and quantitative studies that provides information on the following:
- Communities’ healthcare buying behaviour
- Communities’ understanding of insurance/pooling behaviour
- Means testing to determine level of co-payment that can be achieved
- Specific diseases/ailments to be included in the healthcare benefit package
Programme design, benefit package and co-payment
Information derived from the target group study is be used in designing the community health insurance scheme. The study identifies specific ailments that are of public health significance in the community. The benefit package covers a core provision of primary in and out-patient care, maternal, neonatal and specialist care services. HIV and AIDS counselling, testing, treatment and monitoring services is also included in the benefit package. Illnesses peculiar to that community may be incorporated in the benefit package. Premiums are determined actuarially based on the community demographic profile, disease burden and socioeconomic profile. The amount of co-payment that will be paid by individuals in the benefitting communities will also be determined from the information provided from the target group studies.
Selection of provider hospitals
The HCHP works with officials of the State government to carry out an inventory of public and private healthcare providers in the target communities. Information provided during the target group study is used to guide the selection of health care providers which will then be subjected to a rigorous due diligence assessment that will ensure that only providers that have structural and process capabilities to provide quality health care services are eventually enlisted
Upgrade of provider facilities and provider training
The diligence exercise identifies structural and process quality gaps that each selected provider is required to fill before it is contractually enlisted into the scheme. The HCHP requires that the State government should upgrade i.e. rehabilitate selected public health care facilities while the HCHP may undertake the rehabilitation of selected private facilities and/or in conjunction with the private owners. Upgrade at these facilities would address structural and process elements to ensure optimal health care services.
Enrolment activities
Minimal enrolment activities may commence a few days prior to the launch of the scheme. Enrolment into the scheme requires interested members of the target community to converge at designated enrolment points where they will be registered by enrolment officers who are paid staff of the HCHP. The enrolment officers who are fluent in English and the local language assist the community members to fill their registration forms. Enrolees are required to provide details of their bio-data and to select a primary care provider from which they can access care routinely. They pay a co-payment (contribution towards the health insurance premium) and are issued with a receipt which also serves as the health insurance policy document. Subsequently they are ushered to an on-site instant ID card production post where data on their registration forms are in-putted and their photographs are taken and the ID card is produced.
During the registration exercise each enrolee is allotted a unique ID number however spouses and dependants are registered as sub-sets of the family head who is referred to as the principal beneficiary. The unique identification number appears on the ID card of each enrolee. To ensure appropriate risk pooling, family heads are actively encouraged to register all members of their families. This reduces the incidence of adverse selection where the risk pool consists of only sick members of the community.
Awareness activities
Enrolment of members of the target communities into the scheme is hinged on the development of trust and the adequate awareness of the target population about the health insurance product and the mechanics of its operations. The HCHP therefore utilizes the following strategies to ensure adequate community awareness and enrolment:
- Continued community leaders’ involvement
- Use of local radio stations
- Group education and information sessions
- Enrolment incentives
- Posters and billboards
Scheme Launch
The state government, the community and the HCHP jointly coordinate the launch of the scheme. The launch event is held in the benefitting community. The ceremony is also used to reach out to previously uninformed community members. It also provides a platform for all parties to reiterate their commitment to the success of the scheme. The State government could also highlight the launch of the scheme as an investment in the community and a discernible dividend of democracy.
Post Launch Operations
Following the launch the enrolee access to care commences:
Enrolled individuals can now access care at their selected primary care provider without out-of-pocket payments for covered services. They are also eligible for referrals to designated secondary care facilities whenever there is a medical indication.