A wide variety of initiatives, presented below, have been implemented to increase enrolment and/or membership renewal. Approaches have varied greatly from one promoter to another. Although MHOs supported by the same promoter remained independent from one another, they tended to adopt similar initiatives. An additional file to this article summarizes the initiatives adopted to increase enrolment and/or membership renewal in Benin [see Additional file1: Table S2. Mapping of Initiatives to Increase Membership in MHOs].
“There are very hard periods where people do not have any money at all, not even to eat…” (Participant)
Some participants affiliated with MHOs supported by PISAF, PROMUSAF, and ILO-STEP reported adopting monthly payments because they found it easier to pay small portions of membership fees progressively. The main challenge of this approach was the workload it imposed on elected MHO members, who had to collect payments every month. This highly time-consuming task also incurred high transportation costs for elected members. Moreover, in some cases, it was difficult for health facilities to keep track from month to month of which patients were covered. To overcome these limitations, MHOs affiliated with the RAS opted for annual fees collected during periods of incoming revenues. Advocates of this annual fee approach argued that it was adapted to the reality of local rural populations because major decisions on income allocation are taken when harvests are sold. Participants also argued that annual premiums require much less work for elected members responsible for collecting membership fees.
Some MHOs offered individual premiums to make it easier for single persons to gather the money to enrol. This type of membership may be more adapted to the individualist mentality slowly emerging in cities. The negative repercussion was that sick individuals tended to join more than healthy ones, thus reducing risk-sharing. In contrast, MHOs affiliated with the RAS rejected individual memberships because it led to higher costs for large families. Instead, they opted for family membership, in which different group prices are set for different categories of family size and larger families pay less per person than smaller families. This encourages mutual aid among families of different sizes.
Participants reported that because cash was not always readily available in rural areas, some MHOs allowed members to pay in kind (e.g., crops). These MHOs would stock the crops temporarily and sell them when prices increased on the international market. Participants reported that this measure presents certain limitations, including the risk of the market price falling before products are sold and the fact that most MHOs do not own large and safe storage areas, such that animals may destroy or eat the crops.
ADMAB developed agricultural cooperatives to finance MHOs. Members of nearby villages collectively cultivate fields. However, it was reported that access to the field can sometimes be difficult as some villages are a few kilometres away and transportation costs limit members’ participation.
A minority of MHOs have managed to obtain subsidies from local authorities. The Ministry of Labour and Public Service is providing degressive funding to the Mutuelle de sécurité sociale du Bénin until the MHO reaches a predetermined level of beneficiaries. In return, the MHO has pledged to achieve growth objectives. In addition, local authorities in Nikki, a rural commune, provided 5 million F CFA to subsidize the RAS’ collective products for pregnant women and students. Similarly, local authorities in Sinendé offered 800 000 F CFA to PISAF MHOs to support their implementation. However, these subsidies were not used to specifically target the poor or destitute.
Participants called for more subsidies to finance MHOs:
“If every year, the local authorities gave 800 000 F CFA…we could at least get a manager in order to get some stability over there!” (Participant)
Improve the quality of healthcare and the patient–healthcare worker interpersonal relationship
“I would say that the percentage of members who leave [MHOs] because of the negative behaviour of health professionals is 30%”. (Participant)
According to participants, many healthcare workers provided inferior health services to MHO members by being rude to them and sometimes withholding medication. Participants explained that this behaviour was mainly due to the fact that healthcare workers could not sell services or medication for their own profit because costs were pre-determined with the MHO. Moreover, under-the-table payments were not possible because payments were generally made directly from the MHO’s account to the health facility’s account. This cashless system went against the personal interests of some health professionals.
Approaches to improve relationships with healthcare workers and increase the availability of medicine varied from one provider to another. All promoters but one had strengthened relationships with healthcare workers by establishing contracts that specified payment modalities, insurance coverage, conflict resolution procedures, medication availability, and workload for healthcare workers. Contracting was adopted because, according to most participants, informal agreements had negative consequences on membership levels.
Urban MHOs affiliated with the RAS worked with the Network for Coordinated Care (NCC). Established in 2002, the NCC was an alliance of eight health facilities that set rules for collaboration with MHOs. Meetings between the NCC and elected MHO members were organized every three months, with negotiations resulting in lower healthcare prices for MHOs. One benefit of the NCC was that, because it included a variety of public and private health facilities, MHO members could obtain services and technical support from whichever facilities had them available. Healthcare workers could refer patients to other NCC facilities for specific care or medication not available at their own facility.
“With this association, there is self-regulation. We feel the situation is more organized compared to places that don’t have it.… To be part of that, [healthcare centres] must respect certain principles, for example, pre-established tariffs ”. (Participant)
“The NCC organized a seminar to train the staff who have first contact with patients.… If this first person doesn’t greet sick people properly, it brings down the whole system, even the good parts.… After the seminar, it was three months before we received another complaint ”. (Participant)
Adopting a different approach, PISAF initiated a partnership to involve healthcare workers directly in promoting MHOs. Healthcare workers held workshops to devise action plans. They also received training to reinforce their competence to offer high-quality care. Teams composed of healthcare workers, elected members, and members of community health management committees organized activities every month to raise awareness. Teams of elected members and healthcare workers met monthly to go door-to-door or mobilized small groups to increase awareness. This partnership was reported to have strengthened the credibility of MHOs. Elected members stated that their collaboration with healthcare workers was difficult at first but improved over time.
“At first, healthcare workers did not accept that we establish this type of dialogue. But over time, they understood that MHOs are important and they accepted the collaboration.… Elected members were scared to get closer to healthcare workers but now they trust them. They work together ”. (Participant)
A few participants were concerned that directly involving healthcare workers in the MHOs’ development would be risky, given that healthcare workers have, in some cases, illegitimately prescribed themselves medication at the MHO’s expense.
Participants from ADMAB, adopting a co-development approach, stressed that it was difficult to develop MHOs without simultaneously supporting health facilities. ADMAB therefore provided health facilities with medication, equipment, ambulances, sources of water, and access to electricity. In return, those health facilities offered a 10% to 25% discount on healthcare costs. Some participants felt this approach positively influenced the quality of care and the relationship between MHO members and healthcare workers. Because of these resource infusions, healthcare workers now perceived providing care to MHO members as an opportunity to improve their working conditions. However, participants recognized that this motivation to collaborate with MHOs could be jeopardized if the promoter discontinued its support.
Participants reported that technical support from medical advisors improved the collaboration between healthcare workers and MHOs. With their knowledge and expertise in the medical field, medical advisors facilitated negotiations between healthcare workers and MHO leadership. Although there was great demand for more support from medical advisors, their high fees put a strain on available resources thereby limiting the frequency of their services.
“The presence of a medical advisor is very important because healthcare workers are uncontrollable.… He can really sensitize and negotiate with healthcare workers”. (Participant)
To improve healthcare services offered to members, the RAS identified criteria that health facilities had to satisfy in order to collaborate with MHOs. Participants described how medical advisors evaluated the health facilities’ technical equipment, human resources, material resources, and acceptance of MHO principles. While this credentialing process limited the number of health facilities available to members, it ensured a minimum standard of care. Moreover, managers of private healthcare facilities, in particular, were motivated to improve their quality of care in order to meet these standards and attract new clients.
To encourage healthcare workers to provide superior services, a few MHOs offered bonuses. Others gave them small gifts as a token of appreciation for their collaboration.
“Giving them 100 francs will not have the same value as the pen. Giving 1,200 francs will not have the same value as the T-shirt.… It changes the relationship”. (Participant)
Increase motivation of elected MHO members
The lack of motivation among elected members is a considerable constraint to enrolment and membership renewal. Elected members, responsible for recruiting new members and collecting fees, often complained that the workload is too much for unpaid work.
“The man cannot leave his agricultural activities to devote himself to the MHOs. That would be difficult”. (Participant)
MHOs were searching for ways to motivate elected members without changing the essence of voluntary work. Most promoters emphasized the importance of ensuring that elected members do not become accustomed to compensations that cannot be sustained once external funding ceases.
Various forms of financial compensation were adopted. Some promoters paid transportation costs. Others decided against it because such practice cannot be sustained once external funding ends. Other groups of MHOs offered elected members 4% to 10% of the membership fees they collected. This compensation was deducted from the MHOs’ revenues. Many participants reported that this had a positive effect on the amount of effort elected members were willing to dedicate.
“We experimented with giving a fixed amount during the collection period but we realized that it’s not viable.… We needed an amount that is proportional to what the person collects”. (Participant)
“With the 10% we feel challenged. We are obliged to give more effort to get the 10% ”. (Participant)
A few promoters offered symbolic gifts to outstanding elected members. However, this initiative was recent and had been very minimally applied to date. Lastly, some promoters motivated elected members by providing paid training opportunities in different settings. Elected members called for more of these opportunities.
“We are trying to develop opportunities to exchange experiences with other MHOs. For example, members from PROMUSAF can travel to work and exchange with members from CIDR and PISAF to see the mechanisms they have implemented there that we have not and that could reinforce our strategy”. (Participant)
Increase the level of satisfaction with health insurance coverage
Participants explained that low levels of enrolment and membership renewal are often due to people’s dissatisfaction with insurance packages. While the population’s needs and desires are systematically examined when MHOs are established, these evaluations are sometimes subsequently neglected, partly due to limited time and resources. Insurance products varied greatly among MHOs. Interviews with participants revealed that some MHOs covered uncommon but severe conditions, known as small risks, while others covered benign but more frequent conditions, known as big risks. Some participants reported that modifying an insurance package to include small risks had a positive effect on membership rates.
Some MHOs chose to omit valued health services such as prenatal consultations and ambulance services from insurance packages because they would require excessive membership fees. Participants explained that MHOs have to reach a compromise between their members’ demands and the additional costs resulting from more complete packages. When new health insurance needs emerge, technicians from the AIMS conceive different product options and determine their potential costs. To keep premiums low, technicians can turn to copayments or put ceilings on the reimbursement level. These different insurance products are discussed with the administrative committees of MHOs and adjusted as needed.
“There are contradictions that arise where members are interested in having a product but they are not ready to make an effort to increase the membership fees. They are not ready to make the sacrifice.… We discuss the risk.… They have a choice to make.…” (Participant)
MHOs affiliated with the RAS aimed to improve and diversify their insurance packages in order to meet people’s expectations and attract new members.
“Our strategy is to always think of what we could propose that would fit with the needs of the population”. (Participant)
These MHOs created two innovative types of collective insurance packages. The first of these, the “Student Insurance” plan, offered schools the possibility of simultaneously insuring all their students during school activities. As a collective package, it allowed MHOs to rapidly increase the number of beneficiaries. Moreover, MHO workers hoped it would inculcate values pertaining to health insurance in children, parents, and teachers, thereby creating more openness to these types of initiatives.
“If we want tomorrow’s adults to have the notion of preparing for illness, we have to work on them now.… Second, we want to go through the children to touch the hearts of adults”. (Participant)
Although this insurance package was perceived as highly effective in increasing the number of beneficiaries, participants reported some difficulties. First, the insurance product only covered illness occurring during school activities, since full-time coverage would have entailed higher fees, which many schools could not afford. Such limited coverage, however, could trigger undesirable effects. For instance, some parents may have felt their children’s health was now the school’s responsibility. In a context of poverty, some may even have been tempted to delay seeking medical care for their child during the weekend or summer so that the school’s insurance would cover medical charges. Moreover, participants highlighted that some parents might refuse to purchase family coverage under the pretext that their children were already covered by an MHO and they did not want to pay twice for health insurance. Another difficulty associated with the Student Insurance plan was that of convincing parents to support this school-based initiative and pay a premium for their children. Given that the government of Benin had made access to education free for all children, parents did not see why they should be asked to pay for this program.
“Before, we could ask parents to contribute financially. Now, I can’t do that because the state said that school is free.… Most schools that accept are private schools”. (Participant)
Another promising collective package, called “Maternity without Risks”, systematically covered all women in a village for prenatal medical consultations and health care received during birth. Village funds were created by requiring all citizens to contribute equally. Participants reported that the product was attractive because all women in the village, and therefore also their families, were confident they would eventually receive healthcare services covered by the MHO.
“It helps people know about MHOs and it gives a better image”. (Participant)
Improve communication and information
“In our culture, it is only when someone becomes sick that we ask the community to contribute financially to help a person”. (Participant)
All participants reported that MHOs organized numerous activities to promote the importance of being prepared for illness and to increase people’s knowledge about the existence and benefits of MHOs. Some activities aimed to raise awareness through direct contact with community members.
“We provided megaphones so that [elected members] can walk in the street and tell people it’s time to pay. It works well”. (Participant)
On a weekly basis, elected members went door-to-door or gathered groups of people in public places to present the benefits of joining the plans. The large majority of participants considered door-to-door visits to be the most effective approach to convince people to join and to get members to pay their fees on time.
“Going door-to-door, that’s what important. With radio, people listen without coming. But with door-to-door, if you meet someone and you talk to them, depending on your quality, they will enrol..” (Participant)
Participants explained that the main limitations of door-to-door visits were that they required time, energy and dedication and incurred costs for elected members, who often had to travel to neighbouring villages by their own means.
“It seems to be the strategy that results in collecting the most premiums. But it’s a strategy that requires resources! [We have to pay for] the gasoline to travel and so forth”. (Participant)
Many MHOs recruited multiplying agents within their communities to promote new memberships and renewals. Some MHOs, for instance, collaborated with religious communities, schools, and political leaders. Beginning in 2005, some MHOs from the RAS created committees, each composed of a few villagers selected based on their social status and their commitment to developing MHOs in their communities. Their tasks were to share information, increase awareness, and act as resource persons when needed. They developed action plans and carried out promotional activities.
“There are cases where the person is not educated but because of the place they occupy within the community, the position they have as community leader, religious leader or traditional leader, people listen when they talk.… When we don’t go through the person who is well listened to by the community, we often fail ”. (Participant)
PROMUSAF encouraged members to pay their premiums regularly by offering loyal members insecticide-treated bed nets at a low price. Selling these nets even at a modest price, rather than giving them away, established an ongoing source of revenue that would help sustain this strategy if ever the promoter were to withdraw its support and MHOs became entirely autonomous.
MHOs also attempted to raise awareness through mass communication campaigns, including radio broadcasts, theatrical plays, and village parties. The costs of these events represented a financial burden for MHOs. Participants had mixed opinions concerning the efficiency of theatrical plays, village parties, and dances.
“We need to question ourselves concerning the efficacy of some activities.… Personally, I have reservations concerning theatre.… But I did see one case where traditional dancing and microphones really had an impact. The whole village danced. It created a good image ”. (Participant)
Participants agreed that radio broadcasting facilitated door-to-door activities by increasing knowledge about MHOs. However, they pointed out that mass communication generally did not, in itself, lead people to actually enrol. Thus, some participants highlighted the importance of carrying out awareness activities at both the individual and community levels.
PROMUSAF also trained its elected members to give educational sessions on subjects related to health and prevention. At these sessions, people were given preventive items, including prophylactics and insecticide-treated bed nets. According to one participant, there was a noticeable increase in enrolment after health education sessions.
“We have observed that the day after we give educational sessions on malaria where insecticide-treated bed nets are given, there is an increase in enrolment in MHOs.… Over time, we realized that this is helpful and motivates people to join the MHOs”. (Participant)
Increase the level of trust in MHOs
The need to adopt strategies to increase the level of trust was reported in four of the 23 semi-structured interviews. These participants were affiliated with three different promoters, suggesting that this problem is not unique to a specific context. Some people wait before enrolling because they do not trust elected members and MHO managers.
“They want to see whether the MHO is serious and whether it is managed well before they enrol”. (Participant)
During communication activities, many MHOs presented testimonials of members who had previously received healthcare services covered by the MHO. Witnessing that MHOs had positive effects on others was reported to have increased people’s trust in MHOs.
“This allows people to understand that this initiative is real!” (Participant)
Trust is also built on democratic management. Members are encouraged to select leaders based on the candidates’ honesty. Transparency is also promoted by hosting a general assembly where financial statements are presented.
Reinforce governmental involvement
Efforts to involve local authorities varied among the different MHO promoters. One promoter representative reported having been hesitant to develop strong partnerships with political leaders at first.
“We have to leave a separation between politics and the MHO. There are risks of political profiteering.… That’s why we waited before we approached these decision levels ”. (Participant)
Most promoters reported that they systematically tried to involve local authorities in the long-term development of MHOs.
“We recommend establishing a start-up committee, with the involvement of elected leaders from each district, to drive the project of creating an MHO.… After they are created, we have exchange workshops with local leaders to discuss their development.… Then we help them establish what we call a local mechanism of continuing support to MHOs.…” (Participant)
In some instances, local leaders have displayed strong political will by helping to finance insurance packages. However, mobilizing political leaders remains a challenge.
“The first difficulty is to convince elected leaders and to help them understand the importance of their involvement”. (Participant)
“Some people think that [the MHO] is free money that has come in….When they feel they aren’t gaining anything, they refuse”. (Participant)
PISAF contributed, both financially and technically, to the creation of a Strategic Plan to Develop MHOs 2007–2011 for the government, which aimed to promote the development of MHOs across Benin. Among other things, the document proposed adopting a legal framework for MHOs. At the time of the interviews, participants reported that the document was in the process of being validated by the Ministry of Health.
“It seems like [the document] is going in the right direction…but when we say in the right direction, in our country, we know what that means! It could take two, three, four years and still nothing comes out”. (Participant)
Overall, participants called for more governmental involvement. Many of them believed that, ultimately, the development of MHOs will require a legal obligation for people to be covered by health insurance.
“For me, the solution is that [health insurance] becomes obligatory and that there’s a real constraint to enroll. Without this, MHOs will not survive”. (Participant)