Center for Health Market Innovations (CHMI)

The insurance is introduced and marketed through local community groups (such as self-help groups and village microfinance organizations), which also process claims and reimbursements. Any organization working with the informal sector is eligible to join the program and receive support, including marketing, servicing, and funds management support. The program works with more than 150 public and private hospitals and clinics and conducts monthly demand based health check-up camps and health talks. It also runs a 24-hour hotline staffed by qualified doctors, which assists in navigating the complex healthcare system. Where possible, patients are encouraged to use free public services to maximize the resources of the insurance pool. This allows the program to maintain a broad benefits package that includes inpatient surgical services, some outpatient services, and all primary healthcare consultations. Members are also entitled to a lost wages benefit. A claim committee composed of community members meets regularly to make claim settlement decisions, which has instilled a sense of community ownership of the scheme. The program is growing 5%–10% a month.

Key program components include:

• Community ownership. The insurance scheme is fully administered by the community. The “mutualism” principle makes communities responsible for their own health and for healthcare providers and insurers. To help set up the fund, several tools are available: community needs analysis, capacity diagnosis, product design and pricing for health or life microinsurance, microinsurance software, budget and business planning, promotional materials, an operation manual with forms for enrollment, claim settlement, and health card. These tools can be given for free or along with UpliftHealth’s technical guidance to any community wishing to join the program.

• Operational partnerships. UpliftHealth has established partnerships at all levels of its operations. It works with public and private providers to ensure adequate provision of care by establishing quality standards and prices for services. It has networked with more than 150 healthcare providers, including specialty hospitals, clinics, pathology and diagnostic labs, medicine and surgical shops as well as general practitioners to provide outpatient services. Members can access a 24/7 helpline, and service executives on the ground provide referrals to network services and patient follow-ups. The scheme also works with technology partners and international donors and agencies—for example, collaborating with Tieto, a Finnish company, to develop a detailed microinsurance software program (SYSLIFT) that can provide extensive data for management and research.

• Claim settlement. Claim settlement is one of the effective elements of the program. Each claim is carefully reviewed by a committee of community representatives, who match the amount of funds available with the number of claims filed. Claims for services at facilities part of the network are paid more than those at non-network providers. Community claim management has allocated funds better than if individuals managed their personal insurance plans. As communities are involved in the scheme, the risk of adverse selection, moral hazard, and fraud is reduced.