Universal health coverage remains a global concern, particularly in developing countries where health systems have many weaknesses. In 2023, a WHO report1 on universal health coverage indicates that more than half of the world's population is still not covered by essential health services. The report goes further by indicating that approximately two billion people face serious financial difficulties when they have to pay directly for the health services and products they need. Indeed, the occurrence of illnesses leads to out-of-pocket expenses for medical tests, medicines and other health care services. These expenses can represent a significant share of the income of poor and vulnerable populations when they do not have health coverage. Out-of-pocket payments can often exceed 50% of total health expenditure in some low-income countries where private health insurance is not sufficiently developed2. Health insurance plays a vital role in access to care and enables households, especially the poorest and those living in rural areas, to avoid catastrophic health expenditure3.
The development of mutual health insurance and the challenges they face in developing countries
In the absence of universal health coverage, the microinsurance sector in developing countries has seen the rise of mutual health insurance companies that provide health microinsurance services tailored to poor and vulnerable people through modest membership and contribution fees. In the majority of cases, mutual insurance companies contribute to the financial protection of their beneficiaries, by reducing direct health expenditure with a positive effect on household savings, assets and consumption habits4. However, the development of mutual health insurance companies faces enormous challenges in developing countries. In Togo, the challenges are mainly organizational with the absence of digitalized procedures, the frequency of disputes between health providers on collections, low membership renewal rates, etc., in urban areas while in rural areas mutual insurance companies face low geographical coverage as well as low financial capacity of the populations5. In Senegal, Bonan et al. 2012 indicate that health mutuals face low membership rates which are very often explained by the lack of information, the lack of means and the lack of trust6. Other challenges are the lack of trust in health mutuals, the insufficiency of communication on the services of health mutuals and on the understanding of health micro-insurance as well as the low attractiveness of health insurance offers which are proposed to the populations. Indeed, the populations sometimes victims of cases of mass scams with certain micro-insurance and microfinance are now suspicious and have very little trust in health mutuals.
Some determinants of membership and renewal of micro-insurance with mutual health insurance companies
Investigating strategies aimed at health mutual membership, Bonan et al. 2012 showed that education through insurance awareness has no significant impact on health insurance subscription, while the marketing approach has a significant and positive impact on household membership decisions. The need to maintain trust among populations also seems to be a determining factor in stimulating demand for health mutuals, particularly among vulnerable populations, most of whom are in the informal sector. Dror & Firth 2014 explains that the informal sector populations that are the target of mutuals seek to improve their well-being by affiliating with groups with which they identify rather than by going through isolated transactions with partners they do not know. Thus, these authors suggest that to increase demand for health insurance in the informal sector in developing countries, it is first necessary to strengthen group governance consistent with group decision-making and under local conditions.
Innovation in the service of the development of microinsurance
In 2023, an NGO introduced the Innovation for the Health of People in Vulnerable Situations in Africa (ISPV-Africa) project in Togo. This is an innovation that aims to make access to health insurance possible for as many vulnerable people as possible by guaranteeing them a set of varied and quality services such as online payment of membership and contributions, medical facilitation at the health center, home visits for monitoring and health advice.
The project includes three components supported by three partner organizations:
- A welcome and support in health centers as well as home visits for medical monitoring, regular monitoring of vital parameters and health advice for prevention.
- The digital health record: a medical history transcribed into a mobile application.
- A mutual insurance offer at a solidarity rate: direct coverage for 75% of healthcare costs and reduced reimbursement of services to its network of healthcare providers.
The articulation between home visits, taking of vital parameters, health advice helps to consolidate prevention while the medical facilitation service at the health center, the use of health history through the application, instant arbitration by the medical advisor, rapid reimbursement of services will help to accelerate and facilitate the curative care of insured persons.
Some lessons learned from the implementation of the ISPV-Africa project
The pilot phase of the ISPV-Africa project was implemented from July 2023 to February 2024 following an experimental approach with the constitution of a control group and a treatment group. This design made it possible to assess the feasibility of a rigorous impact evaluation on a larger scale on the project and to understand the determinants of demand for health insurance among the target populations. The lessons learned from the pilot phase are as follows:
- The implementation of a project bringing together several actors requires the establishment of a fully mature partnership that takes into account the differences in institutional cultures of each actor. Emphasis must also be placed on the monitoring and evaluation of activities and functional approaches to communication and routine data reporting.
- Low understanding of the tangible benefit of insurance, reinforced by bad past experiences are factors that contribute to low uptake and low renewal rate of microinsurance services. Targeted communication through direct messages and marketing approaches, sharing positive experiences by word of mouth is more effective than mass communication in the media, markets and other public spaces.
- Facilitation services at the health center and especially at home with regular taking of vital parameters and health advice were determining factors in the populations' adherence. However, their operationalization requires good training of the facilitators, good organizational capacity and a good level of planning.
- The attractiveness of the care package is a determining factor in the adhesion and especially in the loyalty of members to mutual health insurance companies. It is necessary to offer several care packages to members in order to give them alternatives.
- For multi-component interventions of the ISPV-Africa type that combine several services and mobilize significant resources, the real cost of the services offered if the intervention is implemented under optimal conditions is well above the rates charged for the target population. Thus, to keep the same target of vulnerable people and knowing that they have limited financial capacity, it is necessary to mobilize more resources to support the financing gap not covered by members' contributions.
1 World Health Organization (WHO). 2023. “UHC Global Monitoring Report.”
2 WHO 2007.
3 Asfaw & Jütting. 2007
4 Habib & coll. 2016
5 Pre-project ISPV-Africa stakeholder diagnostic study
6 Bonan et al. 2012
About the author: Bio Bertrand Mama is an Evaluation Specialist at 3ie. Bio is an economist with ten years' experience in the field of economics and development. He is currently Evaluation Specialist for the International Initiative for Impact Evaluation (3ie), a global leader in funding, producing, quality assuring and synthesizing rigorous evidence. As Evaluation Specialist, Bio is leading research activities such as impact and process evaluations, literature review, evidence synthesis, etc. He is also working with country governments and different stakeholders in the West African Economic and Monetary Union (WAEMU) to provide tailored capacity building activities for policymakers and rigorous evidence for decision making.
Prior to joining 3ie, Bio worked as research officer for the Prime minister office of Benin, contributing to economic analysis and public policies evaluation. He believes that evidence-based policymaking is crucial for inclusive growth and poverty reduction in developing countries. Bio holds a master's degree in economics from the African School of Economics (ASE). He has an interest in research on public policies.
Co-authors: Anca Dumitrescu, Lead Evaluation Specialist, 3ie; Charlotte Lane, Evaluation and Learning Consultant, Food Security Evidence Brokerage; Binta Ndiaye, Research Assistant, 3rd
