UHC Forward: Towards Universal Health Coverage

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

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

Source: Ministry of Social Protection

The National Health Insurance Scheme (NHIS) is the body responsible for regulation of the system and the different health insurance schemes. The Governing Board of the National Health Insurance Scheme is the National Health Insurance Council (NHIC). NHIC works to regulate the scheme (including setting standards, determining contribution rates, providing technical support, etc), license HMOs and providers, train health care providers, and manage the National Health Insurance Fund (NHIF).

HMOS are licensed by the NHIS to facilitate the provision of healthcare benefits to contributors under the Formal Sector Social health Insurance Program; to interface between eligible contributors, including voluntary contributors and the healthcare providers, ensure member registration, public education about the schemes, collect premiums from members and employers, contract with providers, process claims, and pay claims directly to providers.

The informal sector scheme under the NHIS is managed by a Board of Trustees composed of the Chairman, Secretary, Treasurer and four others. A clerk is appointed to carry out clerical and accounting duties. The Board of Trustees has executive power and is responsible for collecting contributions from participants, paying providers for services rendered, and operating a bank account with an NHIS accredited Bank.

The Nigerian system is organized as a federation and divided into three tiers: federal, state, and local. The federal government sets overall policy direction and standards, implements national immunization programs, and oversees federally funded tertiary health facilities. The states undertake policy making and regulation as well as financial responsibility for the personnel, operating costs, and capital investment of the tertiary, secondary, and primary care facilities. The 774 local government associations (LGAs) are responsible for primary health care delivery, under the guidance and supervision of federal and state departments of primary health care. LGAs tend to exert the least influence in this system, and frequently suffer from insufficient funding.

Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme.

The administrative structure of Aarogyasri is comprised of four main organizations:

• Aarogyasri Healthcare Trust: The Trust is responsible for oversight of the entire insurance program as well as some important administrative functions such as setting benefits and pricing, managing contracts with insurer(s) and in-network providers, approving claims, and monitoring.
• Insurer: The insurer is selected based on a competitive bidding process to bear risk and manage all back-end insurance administration, including claims processing, reimbursements to providers, oversight of hospitals. The Insurer is also responsible for holding health camps in villages to screen, diagnose, treat, and make beneficiaries aware of any health problems they might have; health camps are also used to enroll eligible beneficiaries.
• Network hospitals: Network hospitals provide care to Aarogyasri beneficiaries.
• Aarogya Mithras: Aarogya Mithras are patient advocates and assist Aarogyasri beneficiaries to navigate through the system and ensure beneficiaries receive quality care. Aarogya Mithras are also responsible for community outreach.

The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri: