|
Mali: Mutuelles |
- Central Government
- District/Local Government
- Mutuelles
|
- Decentralized to district/local level
|
|
|
- Central Government
- District/Local Government
|
Although the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one.
For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles. Read full sectionAlthough the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one.
For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.
Table 4 illustrates the institutional framework planned for the Mutuelle system.
Table 4: Institutional system for the Mutuelle system
| Committee | Role | Composition | Operating procedures |
|---|
| Pilot Phase Steering and Monitoring Committee (CPSPP) at the national level | Strategic management and decision-making that contribute to achieving the following goals:- Validate the annual development operating plans for the Mutuelle system, including the financial framework
- Recruit the implementation agencies
- Raise the funds needed to implement the strategy
- Assess the results of the activities carried out under this strategy
- Give orientation and instructions to achieve the strategy’s results
| Chairs - Secretaries General MDSSPA, MS, MPFEF
Members - CPS/SSDSPF, DNS, DNPSES, DNDS, APCAM, APCMM, CCIM, CNC, AMM, UTM, DNI, HCCT, DNB, ANAM, CANAM, FENASCOM, Health professional associations, technical and financial partners, National Federation of Mutuelles | The Committee meets twice a year and reports on its work to the Ministers of Social Protection and Health |
| National level Technical Committee (TC) | Technical coordination of activities carried out under the Strategy Pilot:- Validate the training materials
- Validate the Mutuelle management tools
- Validate the communication plan
- Assess the investment requirements
- Assess the results of activities carried out as part of this strategy
- Send the assessment of the results achieved to the CPSPP
- Submit all the corrections it deems necessary to promote achieving the objectives to the CPSPP
| Chair - DNPSES Director
Members - DNDS, DNPSES, CPS, DNS, UTM, CAMASC, DNB, AMM, National Federation of Mutuelles | The TC meets at least three times a year and reports on its work to the CPSPP |
| Regional Monitoring Committee (CSR) | Monitoring of the activities that are planned under the strategy at the regional level. All the technical parameters, the draft laws and the organizing of unions of district Mutuelles are determined and the Local (District) Monitoring Committee is fully involved:- Facilitate the implementation of scheduled activities
- Mobilize local resources
- Assess the results of the activities carried out under this strategy
- Send the evaluation of the results to the TC
- Propose to the TC all the corrections it deems necessary to help achieve the objectives
| Chair - Governor
Members - Decentralized government units (Finances, Social Development and Health), Regional Assembly, Regional Federation of Mutuelles, FERASCOM, cooperatives, women’s associations and decentralized financing systems (microfinance networks) | The CSR meets at least four times a year and reports on its work to the TC |
| District Monitoring Committee (CSL) | Monitoring of the activities planned under the strategy at the district level:- Facilitate the implementation of the scheduled activities
- Mobilize local resources
- Assess the results of the activities carried out under this strategy
- Submit the evaluation of the results to the CSR
- Propose to the CSR all the corrections it deems necessary to help achieve the objectives
| Chair - District prefect
Members -
Decentralized government units (Finance, Social Development and Health), District Council, District Federation of Mutuelles, FELASCOM, agricultural cooperatives, women’s associations and decentralized financing systems (microfinance networks) | The CSL meets at least four times a year and reports to the CSR on its work | | Communal Monitoring Committee (CSC) | Monitoring of the status of strategy implementation at the commune level:- Report on the status of implementation of the planned activities
- Make decisions to remove the obstacles that prevent the communal Mutuelle from working properly
- Report to the CSL
| Chair - Mayor(s)
Members - Decentralized technical entities, ASACO, Communal health Mutuelle, local NGOs, village councils | |
Source: Ministry of Social Protection
For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5.
Table 5: Organization and operating procedures– AMO and RAMED
| Body and system | Role | Representation |
|---|
| Board of directors (RAMED and AMO) | - Adopt the budget and annual activities program
- Determine the annual qualitative and quantitative Objectives that the CANAM or the ANAM is to achieve
- Authorize the implementing regulations for the system
- Authorize the Managing Director (MD) to sign all the contracts and conventions that are binding on CANAM or ANAM for a period longer than 24 months (for CANAM) or that exceed CFAF 10 million (for ANAM)
- Determine the organization of the Fund or the Agency
- Approve the financial statements for the fiscal year and the report on the MD’s activities
- Approve other investment and real estate transactions and real estate guarantees
| AMO - Ministry of Social Protection, Ministry of Finance, Ministry of the Civil Service, Ministry of Health, Ministry of Defense, Associations of employers, workers, retires, MPs, and CANAM
RAMED - Ministry of Social Protection, Ministry of Finance, Ministry of National Administration, Ministry of Health, High Council of Territorial Governments, Association of District and Regional Governments of Mali, Association of Municipalities of Mali, National Federation of Community Health Associations (FENASCOM), ANAM | | Managing Director (RAMED and AMO) | - Manage, coordinate, lead and oversee all CANAM or ANAM activities
| MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection | Delegated management bodies (AMO) | - Collect dues
- Pay for care services
| The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS) |
Source: Ministry of Social Protection MutuellesInstitutional structures
Key Actors in Insurance Administration: Central Government, District/Local Government, Mutuelles
Organization: Decentralized to district/local level
Collections Responsibility: Mutuelles
Operations Responsibility: Mutuelles
Oversight Responsibility: Central Government, District/Local Government
Although the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one.
For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.
Table 4 illustrates the institutional framework planned for the Mutuelle system.
Table 4: Institutional system for the Mutuelle system
| Committee | Role | Composition | Operating procedures |
|---|
| Pilot Phase Steering and Monitoring Committee (CPSPP) at the national level | Strategic management and decision-making that contribute to achieving the following goals:- Validate the annual development operating plans for the Mutuelle system, including the financial framework
- Recruit the implementation agencies
- Raise the funds needed to implement the strategy
- Assess the results of the activities carried out under this strategy
- Give orientation and instructions to achieve the strategy’s results
| Chairs - Secretaries General MDSSPA, MS, MPFEF
Members - CPS/SSDSPF, DNS, DNPSES, DNDS, APCAM, APCMM, CCIM, CNC, AMM, UTM, DNI, HCCT, DNB, ANAM, CANAM, FENASCOM, Health professional associations, technical and financial partners, National Federation of Mutuelles | The Committee meets twice a year and reports on its work to the Ministers of Social Protection and Health |
| National level Technical Committee (TC) | Technical coordination of activities carried out under the Strategy Pilot:- Validate the training materials
- Validate the Mutuelle management tools
- Validate the communication plan
- Assess the investment requirements
- Assess the results of activities carried out as part of this strategy
- Send the assessment of the results achieved to the CPSPP
- Submit all the corrections it deems necessary to promote achieving the objectives to the CPSPP
| Chair - DNPSES Director
Members - DNDS, DNPSES, CPS, DNS, UTM, CAMASC, DNB, AMM, National Federation of Mutuelles | The TC meets at least three times a year and reports on its work to the CPSPP |
| Regional Monitoring Committee (CSR) | Monitoring of the activities that are planned under the strategy at the regional level. All the technical parameters, the draft laws and the organizing of unions of district Mutuelles are determined and the Local (District) Monitoring Committee is fully involved:- Facilitate the implementation of scheduled activities
- Mobilize local resources
- Assess the results of the activities carried out under this strategy
- Send the evaluation of the results to the TC
- Propose to the TC all the corrections it deems necessary to help achieve the objectives
| Chair - Governor
Members - Decentralized government units (Finances, Social Development and Health), Regional Assembly, Regional Federation of Mutuelles, FERASCOM, cooperatives, women’s associations and decentralized financing systems (microfinance networks) | The CSR meets at least four times a year and reports on its work to the TC |
| District Monitoring Committee (CSL) | Monitoring of the activities planned under the strategy at the district level:- Facilitate the implementation of the scheduled activities
- Mobilize local resources
- Assess the results of the activities carried out under this strategy
- Submit the evaluation of the results to the CSR
- Propose to the CSR all the corrections it deems necessary to help achieve the objectives
| Chair - District prefect
Members -
Decentralized government units (Finance, Social Development and Health), District Council, District Federation of Mutuelles, FELASCOM, agricultural cooperatives, women’s associations and decentralized financing systems (microfinance networks) | The CSL meets at least four times a year and reports to the CSR on its work | | Communal Monitoring Committee (CSC) | Monitoring of the status of strategy implementation at the commune level:- Report on the status of implementation of the planned activities
- Make decisions to remove the obstacles that prevent the communal Mutuelle from working properly
- Report to the CSL
| Chair - Mayor(s)
Members - Decentralized technical entities, ASACO, Communal health Mutuelle, local NGOs, village councils | |
Source: Ministry of Social Protection
For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5.
Table 5: Organization and operating procedures– AMO and RAMED
| Body and system | Role | Representation |
|---|
| Board of directors (RAMED and AMO) | - Adopt the budget and annual activities program
- Determine the annual qualitative and quantitative Objectives that the CANAM or the ANAM is to achieve
- Authorize the implementing regulations for the system
- Authorize the Managing Director (MD) to sign all the contracts and conventions that are binding on CANAM or ANAM for a period longer than 24 months (for CANAM) or that exceed CFAF 10 million (for ANAM)
- Determine the organization of the Fund or the Agency
- Approve the financial statements for the fiscal year and the report on the MD’s activities
- Approve other investment and real estate transactions and real estate guarantees
| AMO - Ministry of Social Protection, Ministry of Finance, Ministry of the Civil Service, Ministry of Health, Ministry of Defense, Associations of employers, workers, retires, MPs, and CANAM
RAMED - Ministry of Social Protection, Ministry of Finance, Ministry of National Administration, Ministry of Health, High Council of Territorial Governments, Association of District and Regional Governments of Mali, Association of Municipalities of Mali, National Federation of Community Health Associations (FENASCOM), ANAM | | Managing Director (RAMED and AMO) | - Manage, coordinate, lead and oversee all CANAM or ANAM activities
| MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection | Delegated management bodies (AMO) | - Collect dues
- Pay for care services
| The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS) |
Source: Ministry of Social Protection |
|
India: RSBY |
- Central Government
- State Government
- Commercial insurers
- NGOs
|
- Decentralized to state level
|
- State Government
- Commercial insurers
|
|
- Central Government
- State Government
|
Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Read full sectionSeveral stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment.
Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household.
Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time.
The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals.
The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
- Operate a 24-hour toll free call center
- Manage district kiosks for post issuance modifications to SmartCards
- Management info system functions, including collecting, collating, and reporting data on a real time basis
- Generating reports, in predefined format, at periodic intervals, as decided between insurer and state nodal agency
- IT related functions which include running the local website/updating data regularly
- Pre-authorization function for non-package surgical interventions
- Claims settlement
- Organizing Health camps
- Publicity for enrollment and post-enrollment
- Grievance and dispute resolution
- Feedback functions
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states.
Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing.
The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
| Central Govt | State Nodal Agency | Insurer/TPA | NGOs/Other Partners | Providers of Care |
|---|
| Oversight of scheme | X | X | | | |
| Financing scheme | X | X | | | |
| Setting parameters (benefits package, empanelment criteria, BPL criteria, etc.) | X | X | | | |
| Hardware specifications (e.g, systems, SmartCard, etc.) | X | | | | |
| Contract management with Insurer | | X | | | |
| Accreditation/Empanelment of providers | | | X | | |
| Collecting Registration Fees | | | X | | |
| Enrollment | | X | X | X | |
| Financial management/planning | X | X | | | |
| Actuarial analysis | | | X | | |
| Setting rate schedules for services/reimbursement rates | X | X | | | |
| Claims processing and payment | | | X | | |
| Outreach, Marketing to beneficiaries | | X | X | X | |
| Service delivery | | | | | X |
| Developing clinical information system for monitoring/eval | X | X | | | |
| Monitoring state-level utilization and other patient information | X | X | X | | |
| Monitoring national RSBY information | X | | | | |
| Customer service | | | X | X | X |
| Training | X | X | X | | |
RSBYInstitutional structures
Key Actors in Insurance Administration: Central Government, State Government, Commercial insurers, NGOs
Organization: Decentralized to state level
Collections Responsibility: State Government, Commercial insurers
Operations Responsibility: Commercial insurers
Oversight Responsibility: Central Government, State Government
Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment.
Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household.
Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time.
The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals.
The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
- Operate a 24-hour toll free call center
- Manage district kiosks for post issuance modifications to SmartCards
- Management info system functions, including collecting, collating, and reporting data on a real time basis
- Generating reports, in predefined format, at periodic intervals, as decided between insurer and state nodal agency
- IT related functions which include running the local website/updating data regularly
- Pre-authorization function for non-package surgical interventions
- Claims settlement
- Organizing Health camps
- Publicity for enrollment and post-enrollment
- Grievance and dispute resolution
- Feedback functions
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states.
Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing.
The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
| Central Govt | State Nodal Agency | Insurer/TPA | NGOs/Other Partners | Providers of Care |
|---|
| Oversight of scheme | X | X | | | |
| Financing scheme | X | X | | | |
| Setting parameters (benefits package, empanelment criteria, BPL criteria, etc.) | X | X | | | |
| Hardware specifications (e.g, systems, SmartCard, etc.) | X | | | | |
| Contract management with Insurer | | X | | | |
| Accreditation/Empanelment of providers | | | X | | |
| Collecting Registration Fees | | | X | | |
| Enrollment | | X | X | X | |
| Financial management/planning | X | X | | | |
| Actuarial analysis | | | X | | |
| Setting rate schedules for services/reimbursement rates | X | X | | | |
| Claims processing and payment | | | X | | |
| Outreach, Marketing to beneficiaries | | X | X | X | |
| Service delivery | | | | | X |
| Developing clinical information system for monitoring/eval | X | X | | | |
| Monitoring state-level utilization and other patient information | X | X | X | | |
| Monitoring national RSBY information | X | | | | |
| Customer service | | | X | X | X |
| Training | X | X | X | | |
|
