Funding
Population Covered
Service delivery system
Institutional structure
The institutional reform in 2000 created the National Social Protection and Economic Solidarity Department, providing better supervisory capacity with the creation of a unit dedicated to strengthening stakeholder capacities for developing the Mutuelle system. These include the Association Support Center, Mutuelle and Cooperative Societies (CAMASC). In 2002, the government of Mali adopted a national social protection policy, followed in 2004 by a national action plan to extend social protection for the 2005-2009 period. These documents indicated the contours of the universal health coverage strategy in Mali. In other words, establishing mandatory health insurance for civil servants, workers and members of parliament (MPs), implementing a medical assistance system to ensure that the poor were able to obtain health care, and developing Mutuelles for the informal and agricultural sector.
The institutional reform in 2000 created the National Social Protection and Economic Solidarity Department, providing better supervisory capacity with the creation of a unit dedicated to strengthening stakeholder capacities for developing the Mutuelle system. These include the Association Support Center, Mutuelle and Cooperative Societies (CAMASC). In 2002, the government of Mali adopted a national social protection policy, followed in 2004 by a national action plan to extend social protection for the 2005-2009 period. These documents indicated the contours of the universal health coverage strategy in Mali. In other words, establishing mandatory health insurance for civil servants, workers and members of parliament (MPs), implementing a medical assistance system to ensure that the poor were able to obtain health care, and developing Mutuelles for the informal and agricultural sector.
Despite a strong political commitment from the authorities, expressed in various documents including the Ten-Year Health and Social Development Plan, the Social Protection Policy Declaration, and the Social Protection Extension Plan, the development of Mutuelles continued, however, to be slow in the field in terms of implementation. In 2010, there were 151 registered Mutuelles, divided very unevenly throughout the country. With 44 Mutuelles, the District of Bamako has slightly over one-third of the total, followed by the regions of Sikasso and Ségou, also with more than one-third (combined), while the Kidal region still has no Mutuelles. The 151 Mutuelles had 104,986 members for a total of 375,496 beneficiaries, for a 2.9% coverage rate. Although many Mutuelles in Bamako and the regional capitals are inter-company and thus include different socio-occupational categories, the majority of them are in rural areas and their members are essentially farmers.
In 2009, the legislative provision was adopted that created the contribution system for mandatory health insurance (AMO) and the non-contribution medical assistance system (RAMED). These two systems were supposed to cover just over 22% of the population through a mandatory and formal contribution system, with the vast majority of the people covered by a voluntary health insurance system. The stakeholders in the Mutuelle movement then reached a consensus on the necessity of a major shift in the strategies for developing Mutuelles. A new strategic framework to extend health insurance to the majority of the population employed in the informal and rural sectors was deemed necessary. The Ministry of Social Protection began a process that culminated in writing a national strategy to have the Mutuelles in Mali extend health coverage that was adopted in 2011.
The social protection policy in Mali has one contributory system and two non-contributory systems. Together they will provide universal coverage for the people of Mali. The target population of the three systems is shown in Table 1.
Table 1: Target population of the social protection system in Mali:
| System | Target population | % of targeted population | Population (millions) |
|---|---|---|---|
| Mandatory health insurance | Civil servants, contractors, employees, MPs, retirees and their beneficiaries | 17 | 2.465 |
| RAMED | The indigent and their beneficiaries | 5 | 0.725 |
| Mutuelles | Informal and agricultural sector | 78 | 11.310 |
Source: Ministry of Social Protection
The AMO and RAMED are new systems for which it was necessary to implement a new institutional architecture, described later in the section entitled “Institutional Structure.” Formal sector workers, who are the target of the AMO today, were previously largely affiliated with Mutuelles on a voluntary basis. Today, this population is required to join the AMO.
The indigent that RAMED targets were not covered by insurance in the past, as they were unable to pay the Mutuelle membership dues on their own.
In contrast, the existing Mutuelles in rural areas in Mali are already targeting the informal and agricultural sector, but they cover only a small percentage of the population. The national extension strategy plans for a systematic scale-up with an innovative organization scheme. The existing Mutuelles do not observe the contours of this new organization scheme, and there will be a need for mergers and harmonization as a result. Additionally, other Mutuelles will be created in areas that at this point are not covered.
It should be noted that in terms of effective coverage, this is the initial stage for Mali. The AMO and RAMED are becoming operational in 2011, and the Mutuelle extension strategy, approved in February 2011, includes a three-year pilot phase (2011-2014). The objective in terms of coverage rates will not exceed 40%, for all systems combined, by 2014.
Mutuelles
Reform summary
The institutional reform in 2000 created the National Social Protection and Economic Solidarity Department, providing better supervisory capacity with the creation of a unit dedicated to strengthening stakeholder capacities for developing the Mutuelle system. These include the Association Support Center, Mutuelle and Cooperative Societies (CAMASC). In 2002, the government of Mali adopted a national social protection policy, followed in 2004 by a national action plan to extend social protection for the 2005-2009 period. These documents indicated the contours of the universal health coverage strategy in Mali. In other words, establishing mandatory health insurance for civil servants, workers and members of parliament (MPs), implementing a medical assistance system to ensure that the poor were able to obtain health care, and developing Mutuelles for the informal and agricultural sector.
Despite a strong political commitment from the authorities, expressed in various documents including the Ten-Year Health and Social Development Plan, the Social Protection Policy Declaration, and the Social Protection Extension Plan, the development of Mutuelles continued, however, to be slow in the field in terms of implementation. In 2010, there were 151 registered Mutuelles, divided very unevenly throughout the country. With 44 Mutuelles, the District of Bamako has slightly over one-third of the total, followed by the regions of Sikasso and Ségou, also with more than one-third (combined), while the Kidal region still has no Mutuelles. The 151 Mutuelles had 104,986 members for a total of 375,496 beneficiaries, for a 2.9% coverage rate. Although many Mutuelles in Bamako and the regional capitals are inter-company and thus include different socio-occupational categories, the majority of them are in rural areas and their members are essentially farmers.
In 2009, the legislative provision was adopted that created the contribution system for mandatory health insurance (AMO) and the non-contribution medical assistance system (RAMED). These two systems were supposed to cover just over 22% of the population through a mandatory and formal contribution system, with the vast majority of the people covered by a voluntary health insurance system. The stakeholders in the Mutuelle movement then reached a consensus on the necessity of a major shift in the strategies for developing Mutuelles. A new strategic framework to extend health insurance to the majority of the population employed in the informal and rural sectors was deemed necessary. The Ministry of Social Protection began a process that culminated in writing a national strategy to have the Mutuelles in Mali extend health coverage that was adopted in 2011.
The social protection policy in Mali has one contributory system and two non-contributory systems. Together they will provide universal coverage for the people of Mali. The target population of the three systems is shown in Table 1.
Table 1: Target population of the social protection system in Mali:
| System | Target population | % of targeted population | Population (millions) |
|---|---|---|---|
| Mandatory health insurance | Civil servants, contractors, employees, MPs, retirees and their beneficiaries | 17 | 2.465 |
| RAMED | The indigent and their beneficiaries | 5 | 0.725 |
| Mutuelles | Informal and agricultural sector | 78 | 11.310 |
Source: Ministry of Social Protection
The AMO and RAMED are new systems for which it was necessary to implement a new institutional architecture, described later in the section entitled “Institutional Structure.” Formal sector workers, who are the target of the AMO today, were previously largely affiliated with Mutuelles on a voluntary basis. Today, this population is required to join the AMO.
The indigent that RAMED targets were not covered by insurance in the past, as they were unable to pay the Mutuelle membership dues on their own.
In contrast, the existing Mutuelles in rural areas in Mali are already targeting the informal and agricultural sector, but they cover only a small percentage of the population. The national extension strategy plans for a systematic scale-up with an innovative organization scheme. The existing Mutuelles do not observe the contours of this new organization scheme, and there will be a need for mergers and harmonization as a result. Additionally, other Mutuelles will be created in areas that at this point are not covered.
It should be noted that in terms of effective coverage, this is the initial stage for Mali. The AMO and RAMED are becoming operational in 2011, and the Mutuelle extension strategy, approved in February 2011, includes a three-year pilot phase (2011-2014). The objective in terms of coverage rates will not exceed 40%, for all systems combined, by 2014.
The intent of the social protection policy in Mali is to ensure fairness among the three systems in terms of the care that is covered, the government’s financial contribution, and the population, except of course for the indigent and retirees. The priority source for Mutuelle system resources will be membership dues. However, to boost the development of Mutuelles and to make coverage of the health risk universal for the majority of Malians in the interest of fairness, the government will make a financial contribution that aims to remedy the fact that the Mutuelle members have only a modest ability to contribute. This government contribution will be through a Mutuelle Support Fund.
The intent of the social protection policy in Mali is to ensure fairness among the three systems in terms of the care that is covered, the government’s financial contribution, and the population, except of course for the indigent and retirees. The priority source for Mutuelle system resources will be membership dues. However, to boost the development of Mutuelles and to make coverage of the health risk universal for the majority of Malians in the interest of fairness, the government will make a financial contribution that aims to remedy the fact that the Mutuelle members have only a modest ability to contribute. This government contribution will be through a Mutuelle Support Fund.
Thus, the pilot phase will be funded from two sources: membership dues and the Mutuelle Support Fund financed by the government, the technical and financial partners, and the local and territorial governments. Membership dues will be used to pay expenses incurred at the community health center level. By contrast, the Support Fund will be used to pay for expenses in the referral facilities, which are the referring health centers and the hospitals, in order to fund investments made for implementing the strategy.
Table 2: Financing planned under the social protection system in Mali, 2010
| System | Financing | Share | Coverage rate |
|---|---|---|---|
| Mandatory Health Insurance | Employer and employee contribution | Salary-based: Government: 4.48% Civil servants, MPs, workers: 3.06% Private sector employers: 3.50% Retirees: 0.75% | 70% of outpatient care 80% of hospitalization costs |
| RAMED | Government and territorial grants | Government: 65% Territorial governments: 35% | 100% |
| Mutuelles | Government grants/Territorial governments and Mutuelle member dues | Government: 50% of dues Mutuelle member: 50% of dues | In general: 70% of outpatient care 80% of hospitalization costs |
Source: Ministry of Social Protection
The different members of the AMO thus pay the same membership dues (except for retirees), and the members and their beneficiaries are eligible for the same baskets of care. A trial period of six consecutive months after the right to benefits begins is mandatory, which is not the case for RAMED.
RAMED provides the right to direct and full payment of the costs of care. The government’s contribution to funding RAMED is written into the finance law.Theoretically, the contribution from the territorial governments should also be included in their annual budgets.
Mutuelles
Funding
The intent of the social protection policy in Mali is to ensure fairness among the three systems in terms of the care that is covered, the government’s financial contribution, and the population, except of course for the indigent and retirees. The priority source for Mutuelle system resources will be membership dues. However, to boost the development of Mutuelles and to make coverage of the health risk universal for the majority of Malians in the interest of fairness, the government will make a financial contribution that aims to remedy the fact that the Mutuelle members have only a modest ability to contribute. This government contribution will be through a Mutuelle Support Fund.
Thus, the pilot phase will be funded from two sources: membership dues and the Mutuelle Support Fund financed by the government, the technical and financial partners, and the local and territorial governments. Membership dues will be used to pay expenses incurred at the community health center level. By contrast, the Support Fund will be used to pay for expenses in the referral facilities, which are the referring health centers and the hospitals, in order to fund investments made for implementing the strategy.
Table 2: Financing planned under the social protection system in Mali, 2010
| System | Financing | Share | Coverage rate |
|---|---|---|---|
| Mandatory Health Insurance | Employer and employee contribution | Salary-based: Government: 4.48% Civil servants, MPs, workers: 3.06% Private sector employers: 3.50% Retirees: 0.75% | 70% of outpatient care 80% of hospitalization costs |
| RAMED | Government and territorial grants | Government: 65% Territorial governments: 35% | 100% |
| Mutuelles | Government grants/Territorial governments and Mutuelle member dues | Government: 50% of dues Mutuelle member: 50% of dues | In general: 70% of outpatient care 80% of hospitalization costs |
Source: Ministry of Social Protection
The different members of the AMO thus pay the same membership dues (except for retirees), and the members and their beneficiaries are eligible for the same baskets of care. A trial period of six consecutive months after the right to benefits begins is mandatory, which is not the case for RAMED.
RAMED provides the right to direct and full payment of the costs of care. The government’s contribution to funding RAMED is written into the finance law.Theoretically, the contribution from the territorial governments should also be included in their annual budgets.
The Mutuelle system is still voluntary, and thus steps must be taken to bring about large-scale enrollment of the people. Thus, the “national strategy to extend health coverage through Mutuelles” contains solutions for the slow pace at which Mutuelles grew in the past, for the poor capacities of the players involved in promoting the Mutuelle movement, the management of Mutuelle movement organizations, and the lack of information and awareness about the Mutuelle movement on the national level. It was found that the principal actors were not enlisted sufficiently at the local level in the past. Health care workers, the ASACOs, and the territorial governments were only marginally involved in promoting the Mutuelle movement. By organizing Mutuelles at the commune level, the strategy seeks to have the mayors and local elected officials play an active role in mobilizing the population.
The Mutuelle system is still voluntary, and thus steps must be taken to bring about large-scale enrollment of the people. Thus, the “national strategy to extend health coverage through Mutuelles” contains solutions for the slow pace at which Mutuelles grew in the past, for the poor capacities of the players involved in promoting the Mutuelle movement, the management of Mutuelle movement organizations, and the lack of information and awareness about the Mutuelle movement on the national level. It was found that the principal actors were not enlisted sufficiently at the local level in the past. Health care workers, the ASACOs, and the territorial governments were only marginally involved in promoting the Mutuelle movement. By organizing Mutuelles at the commune level, the strategy seeks to have the mayors and local elected officials play an active role in mobilizing the population. The main challenge in promoting the Mutuelle movement for large-scale enrollment thus continues to be implementing a major information and awareness campaign for Mutuelles at the national scale. This is part of the national strategy and advocacy activities that also include local and national leaders .
Since the AMO is mandatory, beneficiaries are enrolled automatically by withdrawing dues from their wages. Benefit eligibility begins on May 1, 2011 for those who have paid dues for six months.
With regard to identifying the indigent for RAMED, the social services in each commune routinely conduct a social survey to assess the situation after interested parties submit an application. The social services or other persons may also prepare an application on behalf of someone else who has not taken the initiative to do so for several reasons. Based on the social survey, the communal authorities issue an indigent card that serves as physical evidence to enroll the member and to obtain the card from the National Medical Assistance Agency (ANAM – the management agency for RAMED) and to obtain care (including the beneficiaries whose applications are submitted to ANAM staff). The status of indigence is always considered temporary, so that the insured member’s card is annual.
Mutuelles
Population covered
The Mutuelle system is still voluntary, and thus steps must be taken to bring about large-scale enrollment of the people. Thus, the “national strategy to extend health coverage through Mutuelles” contains solutions for the slow pace at which Mutuelles grew in the past, for the poor capacities of the players involved in promoting the Mutuelle movement, the management of Mutuelle movement organizations, and the lack of information and awareness about the Mutuelle movement on the national level. It was found that the principal actors were not enlisted sufficiently at the local level in the past. Health care workers, the ASACOs, and the territorial governments were only marginally involved in promoting the Mutuelle movement. By organizing Mutuelles at the commune level, the strategy seeks to have the mayors and local elected officials play an active role in mobilizing the population. The main challenge in promoting the Mutuelle movement for large-scale enrollment thus continues to be implementing a major information and awareness campaign for Mutuelles at the national scale. This is part of the national strategy and advocacy activities that also include local and national leaders .
Since the AMO is mandatory, beneficiaries are enrolled automatically by withdrawing dues from their wages. Benefit eligibility begins on May 1, 2011 for those who have paid dues for six months.
With regard to identifying the indigent for RAMED, the social services in each commune routinely conduct a social survey to assess the situation after interested parties submit an application. The social services or other persons may also prepare an application on behalf of someone else who has not taken the initiative to do so for several reasons. Based on the social survey, the communal authorities issue an indigent card that serves as physical evidence to enroll the member and to obtain the card from the National Medical Assistance Agency (ANAM – the management agency for RAMED) and to obtain care (including the beneficiaries whose applications are submitted to ANAM staff). The status of indigence is always considered temporary, so that the insured member’s card is annual.
The social protection policy aims to have the three systems cover the same services. The laws and decrees assured consistency in the services between the AMO and RAMED when the two organizations were founded.
The social protection policy aims to have the three systems cover the same services. The laws and decrees assured consistency in the services between the AMO and RAMED when the two organizations were founded.
For the Mutuelles, payment for services is not yet consistent. The risks that the Mutuelles cover as they exist today in Mali are paid for partially or completely for the following:
- Preventive and promotional health: pre- and post-natal consultation, monitoring of healthy infants, vaccination, family planning, health education, sanitation, etc.
- Curative care: consultations, nursing care, drugs, laboratory tests, chronic diseases, malnutrition and nutritional rehabilitation, etc.
- Hospital care: hospital stays, medical and surgical procedures, and drugs
- Specialized care: consultation of specialist physicians, medical procedures such as radiology, clinical biology, dental and eye care, etc.
- Patient transportation: emergency transportation, referrals
Most Mutuelles limit themselves to the services provided at the first level of contact, which is the community health center (CSCOM), where patients receive the first level of care, but not for the more costly risks. The national Mutuelle extension strategy seeks to bridge this gap through the Mutuelle Support Fund by paying for care at the secondary and tertiary levels. With regard to standardizing the services that are covered, the starting point is the package of services covered by the AMO and RAMED, with certain modifications possible for more comprehensive coverage of preventive care, in particular for reproductive health.
Table 3: Package of services covered, 2010
| System | Services covered |
|---|---|
| AMO and RAMED |
|
| Mutuelles |
|
Source: Ministry of Social Protection
Mutuelles
Benefits package
The social protection policy aims to have the three systems cover the same services. The laws and decrees assured consistency in the services between the AMO and RAMED when the two organizations were founded.
For the Mutuelles, payment for services is not yet consistent. The risks that the Mutuelles cover as they exist today in Mali are paid for partially or completely for the following:
- Preventive and promotional health: pre- and post-natal consultation, monitoring of healthy infants, vaccination, family planning, health education, sanitation, etc.
- Curative care: consultations, nursing care, drugs, laboratory tests, chronic diseases, malnutrition and nutritional rehabilitation, etc.
- Hospital care: hospital stays, medical and surgical procedures, and drugs
- Specialized care: consultation of specialist physicians, medical procedures such as radiology, clinical biology, dental and eye care, etc.
- Patient transportation: emergency transportation, referrals
Most Mutuelles limit themselves to the services provided at the first level of contact, which is the community health center (CSCOM), where patients receive the first level of care, but not for the more costly risks. The national Mutuelle extension strategy seeks to bridge this gap through the Mutuelle Support Fund by paying for care at the secondary and tertiary levels. With regard to standardizing the services that are covered, the starting point is the package of services covered by the AMO and RAMED, with certain modifications possible for more comprehensive coverage of preventive care, in particular for reproductive health.
Table 3: Package of services covered, 2010
| System | Services covered |
|---|---|
| AMO and RAMED |
|
| Mutuelles |
|
Source: Ministry of Social Protection
The provision of care in Mali is organized in a pyramid with four levels. At the base there are the health districts (60), divided into health areas that have a community health center (CSCOM) with a dispensary, a maternity center, and a pharmacy warehouse, altogether offering a minimum package of activities (MPA). The professional team at the CSCOM is often managed by a nurse. In 2010, about 900 of the 1,030 health areas had a CSCOM. The health area, and thus the CSCOM, is run by a community health association (ASACO). There were 954 ASACOs in 2010. The ASACO signs a contract with the government of Mali, which agrees to work toward providing public health services, for which it has some available grants.
The provision of care in Mali is organized in a pyramid with four levels. At the base there are the health districts (60), divided into health areas that have a community health center (CSCOM) with a dispensary, a maternity center, and a pharmacy warehouse, altogether offering a minimum package of activities (MPA). The professional team at the CSCOM is often managed by a nurse. In 2010, about 900 of the 1,030 health areas had a CSCOM. The health area, and thus the CSCOM, is run by a community health association (ASACO). There were 954 ASACOs in 2010. The ASACO signs a contract with the government of Mali, which agrees to work toward providing public health services, for which it has some available grants. However, it manages the CSCOM staff and the operating budget. CSCOM has the status of a non-profit private institution, and thus the system is “community” based. Roughly 87% of the population of Mali lives less than 15 km from a CSCOM. The CSCOMs account for 56% of all consultations, versus 20% for the entirely public entities (BCG 2010). The first referral takes place at the referral health center (CSRef), which is basically a district hospital. There is a CSRef in every health district. The CSRef has a more sophisticated technical support center and more highly skilled staff than at the CSCM level. The CSRef treats the cases that are referred from the CSCOMs. At the CSRef level, which has public status, there are about 25 private facilities (BCG 2010). At the third level (second referral), there are seven (7) public hospitals (EPH) located in the regional capitals. On the private side there are approximately 70 clinics at this level of the pyramid. (BCG 2010). At the top there are four level-three referring EPHs, two of which are for general medicine, while the other two are for specialized medicine.
Mutuelles
Service delivery system
The provision of care in Mali is organized in a pyramid with four levels. At the base there are the health districts (60), divided into health areas that have a community health center (CSCOM) with a dispensary, a maternity center, and a pharmacy warehouse, altogether offering a minimum package of activities (MPA). The professional team at the CSCOM is often managed by a nurse. In 2010, about 900 of the 1,030 health areas had a CSCOM. The health area, and thus the CSCOM, is run by a community health association (ASACO). There were 954 ASACOs in 2010. The ASACO signs a contract with the government of Mali, which agrees to work toward providing public health services, for which it has some available grants. However, it manages the CSCOM staff and the operating budget. CSCOM has the status of a non-profit private institution, and thus the system is “community” based. Roughly 87% of the population of Mali lives less than 15 km from a CSCOM. The CSCOMs account for 56% of all consultations, versus 20% for the entirely public entities (BCG 2010). The first referral takes place at the referral health center (CSRef), which is basically a district hospital. There is a CSRef in every health district. The CSRef has a more sophisticated technical support center and more highly skilled staff than at the CSCM level. The CSRef treats the cases that are referred from the CSCOMs. At the CSRef level, which has public status, there are about 25 private facilities (BCG 2010). At the third level (second referral), there are seven (7) public hospitals (EPH) located in the regional capitals. On the private side there are approximately 70 clinics at this level of the pyramid. (BCG 2010). At the top there are four level-three referring EPHs, two of which are for general medicine, while the other two are for specialized medicine.
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.
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:
| 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:
| 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:
| 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:
| 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:
| 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) |
| 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) |
| MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection | Delegated management bodies (AMO) |
| The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS) |
Source: Ministry of Social Protection
Mutuelles
Institutional structures
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:
| 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:
| 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:
| 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:
| 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:
| 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) |
| 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) |
| MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection | Delegated management bodies (AMO) |
| The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS) |
Source: Ministry of Social Protection
In Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included.
In Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included.
For the AMO and RAMED, the health institutions, dispensing pharmacies, drug warehouses, and the laboratories approved by the Ministry of Health may sign contracts with the Government Management Agency, the National Health Insurance Fund (CANAM) for the AMO, and the National Medical Assistance Agency (ANAM) for RAMED. Although an accreditation system is planned in Mali, at startup time for the AMO and RAMED, all public and community facilities were temporarily accredited until the system became operational.
Mutuelles
Provider payment mechanisms
In Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included.
For the AMO and RAMED, the health institutions, dispensing pharmacies, drug warehouses, and the laboratories approved by the Ministry of Health may sign contracts with the Government Management Agency, the National Health Insurance Fund (CANAM) for the AMO, and the National Medical Assistance Agency (ANAM) for RAMED. Although an accreditation system is planned in Mali, at startup time for the AMO and RAMED, all public and community facilities were temporarily accredited until the system became operational.
In the long run, the National Health Coverage Extension Strategy by the Mutuelles should make it possible to scale up coverage by the Mutuelles through better mobilization of resources and restructuring of the Mutuelle landscape to ensure efficient use of these resources and to align the different players in a consensual vision to support the system. However, the scaling up should be done with caution in order to meet all the challenges that this strategy may face. In this context, the government of Mali plans to test the new strategy at three pilot sites: the regions of Sikasso, Ségou and Mopti. These three regions were selected based on the concentration of the Mutuelle organizations, poverty, and the potential for supervising the Mutuelle organizations. The experience that will be leveraged at these three sites will serve as a basis for deploying the strategy at the national level.
In the long run, the National Health Coverage Extension Strategy by the Mutuelles should make it possible to scale up coverage by the Mutuelles through better mobilization of resources and restructuring of the Mutuelle landscape to ensure efficient use of these resources and to align the different players in a consensual vision to support the system. However, the scaling up should be done with caution in order to meet all the challenges that this strategy may face. In this context, the government of Mali plans to test the new strategy at three pilot sites: the regions of Sikasso, Ségou and Mopti. These three regions were selected based on the concentration of the Mutuelle organizations, poverty, and the potential for supervising the Mutuelle organizations. The experience that will be leveraged at these three sites will serve as a basis for deploying the strategy at the national level.
The principal objective of the implementation program pilot phase is to test the mechanisms proposed in the National Medical Coverage Extension Strategy by the Mutuelles. The purpose is to improve health risk coverage for the target population groups though the Mutuelles.
The project objectives are:
- To strengthen the organization of Mutuelles and their umbrella structures so that they play their roles efficiently;
- To determine the criteria for government grants and to implement financing systems from different sources to pay for a harmonized package of services;
- To prepare and implement a communication strategy that aims to improve the knowledge and understanding of the strategy and to promote the people’s ownership and acceptance;
- To prepare the relevant systems for evaluating Mutuelle performance;
- To strengthen the synergy of actions among key players for making their projects consistent and for observing the strategy.
Monitoring will entail collecting and continuously analyzing the information on implementing the pilot phase. The progress in implementing the program is evaluated based on reaching key stages for each program component. Identifying these key phases and evaluating the achievement of the phases will guide the preparation of the annual operational plans at the different levels. Progress will be monitored, difficulties will be identified, feedback will be provided, and adjustments will be made. The evaluation activities will be concentrated in the third year of the pilot phase. A matrix of indicators will be used to measure the impact of the projects and assess the achievement of the specific objectives and program outputs, monitor the program inputs, and monitor the organizational development of the Mutuelles has been prepared. From this matrix, key indicators are identified to report to the decision-makers and the technical and financial partners on the progress and performance of implementing the program.
The progress in time and space of the projects for implementing the program will create the conditions for a natural experimentation plan that will be used to conduct a rigorous evaluation of program performances and impact. The data from the CSCOMs will be used to compare the impact over time on the use and financing of the CSCOMs before and after the startup of the projects in the health districts where the projects began. There will be a comparison in space of the health districts where the projects began and of the health districts where the projects have not yet begun. During the third year of implementation, surveys of beneficiaries will assess the impact the projects have based on a comparison of the health districts where the projects began and the health districts where the projects have not yet begun. In the fifth year, similar surveys will be conducted of all the communes and health districts covered to analyze the impact the projects have on the database surveys for the third and fifth years.
Mutuelles
Monitoring and evaluation
In the long run, the National Health Coverage Extension Strategy by the Mutuelles should make it possible to scale up coverage by the Mutuelles through better mobilization of resources and restructuring of the Mutuelle landscape to ensure efficient use of these resources and to align the different players in a consensual vision to support the system. However, the scaling up should be done with caution in order to meet all the challenges that this strategy may face. In this context, the government of Mali plans to test the new strategy at three pilot sites: the regions of Sikasso, Ségou and Mopti. These three regions were selected based on the concentration of the Mutuelle organizations, poverty, and the potential for supervising the Mutuelle organizations. The experience that will be leveraged at these three sites will serve as a basis for deploying the strategy at the national level.
The principal objective of the implementation program pilot phase is to test the mechanisms proposed in the National Medical Coverage Extension Strategy by the Mutuelles. The purpose is to improve health risk coverage for the target population groups though the Mutuelles.
The project objectives are:
- To strengthen the organization of Mutuelles and their umbrella structures so that they play their roles efficiently;
- To determine the criteria for government grants and to implement financing systems from different sources to pay for a harmonized package of services;
- To prepare and implement a communication strategy that aims to improve the knowledge and understanding of the strategy and to promote the people’s ownership and acceptance;
- To prepare the relevant systems for evaluating Mutuelle performance;
- To strengthen the synergy of actions among key players for making their projects consistent and for observing the strategy.
Monitoring will entail collecting and continuously analyzing the information on implementing the pilot phase. The progress in implementing the program is evaluated based on reaching key stages for each program component. Identifying these key phases and evaluating the achievement of the phases will guide the preparation of the annual operational plans at the different levels. Progress will be monitored, difficulties will be identified, feedback will be provided, and adjustments will be made. The evaluation activities will be concentrated in the third year of the pilot phase. A matrix of indicators will be used to measure the impact of the projects and assess the achievement of the specific objectives and program outputs, monitor the program inputs, and monitor the organizational development of the Mutuelles has been prepared. From this matrix, key indicators are identified to report to the decision-makers and the technical and financial partners on the progress and performance of implementing the program.
The progress in time and space of the projects for implementing the program will create the conditions for a natural experimentation plan that will be used to conduct a rigorous evaluation of program performances and impact. The data from the CSCOMs will be used to compare the impact over time on the use and financing of the CSCOMs before and after the startup of the projects in the health districts where the projects began. There will be a comparison in space of the health districts where the projects began and of the health districts where the projects have not yet begun. During the third year of implementation, surveys of beneficiaries will assess the impact the projects have based on a comparison of the health districts where the projects began and the health districts where the projects have not yet begun. In the fifth year, similar surveys will be conducted of all the communes and health districts covered to analyze the impact the projects have on the database surveys for the third and fifth years.