This is discussion about Demystifying health insurance package design by Choosing Healthplans All Together (CHAT).
Hi! First of all let me congratulate all those at the Micro Insurance Academy for this idea which could hopefully become an important first step towards providing tailored healthplans for those who, until know, have been and for the most part continue to be, considered incapable of understanding healthplans and thus deciding what is "best for them". Empowering communties that are trapped at the bottom of the pyramid and having them decide together what health plan best suits the community's needs is a truely innovative approach and succeeds in breaking several preconceptions we have today which are in my opinion very dangerous (e.g. when you are illiterate you simply do not have the possibility of being a decision-maker of your own life, that healthinsurance is a complicated thing and is only interesting to the "better-off" etc.)
Watching the video, and the way the CHAT groups are carried out, I do have a question however on how these groups are actually created. More specifically I noticed that groups were composed either entirely by women or entirely by men... I can imagine that the health needs of males are diferent from those of females but how do you get these groups to decide which family healthplan best suit the community as a whole? What structure would a CHAT group have for that kind of a family plan? Do you think females by themselves are better suited to discuss on plans that concern their children? Or should males also take part in it? Maybe my question is irrelevant as the video just showed that a female/male division was the best strategy for the community being filmed and that it all depends on the cultural context in which you are in ....in any case, I would love to have your comments on this. Thanks!
You are right that in the CHAT video one can see groups composed of males and of females, but rarely photos of mixed groups. We also have film footage of other groups, from other villages where all groups were mixed male-female. Essentially, just as the exercise emphasizes "people's choice", the first choice the respondents make is whether they would like to participate or not. We do not pay participants, we simply invite those who wish to join. Some groups met at times of day when a mixed composition was more difficult, and in other cases the composition was a deliberate choice, which we respected.
The more interesting part is that we have not found a significant correlation between gender and the benefots chosen, except that (as you mention and as could be expected) females chose maternity more often than males. Actually, I must qualify even this choice, because we saw that in the first round of the game more women chose maternity; but in the second round of the CHAT exercise, when the entire group selected the benefiot package that would apply to the entire group/village, mateernity was selected almost in all cases by both males and females. More generally, we noticed that when the group engaged in collective choice, it included benefits that were useful mainly to the more vulnerable segments of the group, such as pregnant women, children, people with handicaps (groups chose to include medical equipment that was necessary for some but not all people) etc. We think that when the group makes a choice for the group, intra-group solidarity is more visible compared to the situation when each person makes a choice for him/herself alone. So CHAT gives people a unique opportunity to act as groups and convert the mutual help that is part of vilage life into a format insurance package.
Hope that this answers the question, and thank you very much for raising an excelent point.
Incidentally, those who have not yet seen the video and would like to, the URL is www.microinsuranceacademy.org and then clic on CHAT at the right side of the screen. Enjoy, and thanks for posting more comments/questions/suggestions.
This innitative sounds really ingenious! To empower poor communities and individuals through a "game" is really inventive and I also think - effective... as everybody, whether poor or rich, whether literate or illiterate is ready to have some fun, but also to try to get control over his/her own situation (in the game or in reality).
And trying to empower people to take decisions for their own health - not only, but also for the health of the community - that is something really indespensable in areas like that... many other countries will need that as well!
So, I congratulate the Microinsurance Academy for this undertaking and would like to pose a question, regarding the practical use of it. I am not sure whether I understood well, but is this only "in theory" aiming at empowerment and creating skills for desicion-making and consensus or these benefits are really received somehow by the community?! Or might be received at some other stage?
Dear Mariana: thanks for your comment and for your question. I am sure many readers are wondering, like you, what happens once the CHAT exercise is finished. The answer is that the interaction between the participants in CHAT and the organizers ends when the exercise ends; however, the information collected during the game in many groups is then analyzed, and provides a unique evidence-base for design of not only of insurance benefit-packages, but also health policy and decisions by policy-makers on what to fund and what to subsidize. So, the follow up includes (i) in some cases the launch of an insurance plan based on the benefit package, and (ii) quality information for policy makers, NGOs and anyone interested in health financing on what the clients want, what matters, and what poor people can pay.
Readers who would like to get references to published analysis of the results are invited to post a query, and I shall be pleased to direct you. Incidentally, readers from India can expect to read more about CHAT analysis in the Economic & Political Weekly that will appear on 11 August (next week).
Thanks again for your interest, and keep sendign your comments and questions.
Thanks for this great project. The team at MIA has really done a fantastic job in adapting this product to bring it to market for a population that needs to be consulted at every step of the insurance process. What I find the most interesting is the opportunity to scale this product. I hope that insurance companies on a wider scale (in the development, IO, NGO) context will see this initiative as valuable and can also adopt it. I'm wondering what the cost implications are for these companies? I think in due time they will see the value in having the input of the broader community and the traditional method of designing insurance solutions based on biased information will be let go.
The fact that this process is a free product that can be used to engage many stakeholders is quite appealing. By bringing together groups of people to come to a common understanding of what their health insurance needs are, the product will be more readily accepted and hopefully more appealing for market - meaning the insurance companies will be more sustainable (profit making) in the long run.
Congrats again to MIA!!
Hi everybody, nice to see we have a space to talk about CHAT and about the micro health insurance. I had the chance to participate the last year's CHAT investigation in Rajasthan, and I'd like to say something about what I've seen and what I think about the project.
First of all, people can understand quite well the game, regardless their education, age and wealth background. They are absorbed by the game and play it seriously.
Secondly, CHAT is really a good tool to introduce the idea of micro insurance to the poor and illiterate people. After our session, people often stayed and continued to ask question and to discuss the choices.
Thirdly, we can always find a kind of consensus on the major interests and the diversification on the minor interests which means we do be able to draw some interesting points from the survey for the design of the insurance police.
However we felt sorry that we had only a small part of picture for the moment. We would love to see what happened in other regions with other parameters of background. And that’s why I’m very glad to see this project came into being. It makes our experience to be a beginning but not an end. It calls for more attention and more reflection on the question. It builds a bridge between the scientifically research and political practice. All my best wishes to this energic new “baby”.
As a facilitator of CHAT exercise in Maharashtra, I have seen how the players gradually gain understanding of health insurance as they get involved in playing the game. I found CHAT an excellent tool to make the illiterate poor understand the health insurance concept (which is an extremely difficult thing to do, let me tell you!). It is also an excellent tool which helps the facilitators/organizers know what the poor people’s priorities in health insurance are. Though at the time I was not much aware about what the exercise was going to culminate into, I am glad an institution like MIA will continue to use the innovative game for product design.
With the recent release of Michael Moore's latest film, Sicko, it is clearer now than ever before that individuals, rather than institutions, understand the health needs and desires of populations all over the world. CHAT offers a brilliant medium of bringing that understanding and reality to the decision makers and also brings an understanding of the ground realities to the consumers which has before now been difficult to communicate. I believe that with the creativity of organizations like the Micro Insurance Academy promoting innovative tools to create social change in one of the trickiest of development sectors, India will prove to be a model in providing an insurance that the people want to those very people who need it the most--the poor.
I am doing some work on creating an affordable health insurance product for the low income market in South Africa. We realised after reviewing available research, talking to people in the target market and visiting facilities that people use that we have no idea what the market wants and would be prepared to pay for - which obviously makes it fairly difficult to design a solution that we hope will be voluntarily purchased. Critically, research methodologies and surveys that simply ask people what they want and how much they are willing to pay are not particularly helpful as we are never sure to what extent people really understand the options and to what extent they are really willing to trade off benefits and price. I showed the CHAT video clip to our client who were really fascinated with the process and felt that it would generate insights they could use to design a solution with a greater degree of confidence.
MicroInsurance must surely be the next Blue Ocean in expanding health protection to the poor.
Nine of the top ten project proposals by number of comments at time of writing discussed care giver/provider innovations, this is the only project that seeks not so much to innovate a product area... but to innovate an entire and uncontested market space; a truely disruptive and innovative "Blue Ocean Strategy" (google this for details).
This said, while I can see where CHAT and an MicroInsurance Academy fit in, social enterprises would still seem to need entrepreneurs! How can these be identified? How can we get them trained in and back out in the community making their local insurance (health and other income protection) companies? How many are we talking about? CHAT and Micro Insurance Academy can provide intellectual capital but what about start up capital? How can we link the two?
To date we have only seen small iniatives, forays in the coastal waters (certainly compared to the vast billions spent on support direct service provision), I wish you luck in gathering together enough support to mount a serious expedition to travel this Blue Ocean. I admire your courage and share your belief that if we can conquor fear of the unknown; there is a new world of enourmous untapped potential out there...
Thanks for this interesting note and the reference to Blue Ocean – was not aware of this, and makes for interesting reading! I could particularly relate to “The three key conceptual building blocks of BOS are: value innovation, tipping point leadership, and fair process.” - certainly that’s BOS words, but we could easily put it on our flag too without feeling out of place ;-)
On start up capital and (social) entrepreneurs: I’ve been following the social entrepreneurship space for several years now, and have had the opportunity to participate in several of the larger conferences (e.g Skoll – where I learned about changemakers.net and pre-registered for this competition). My feeling is that when it comes to microinsurance, or indeed other fields that do not yet have the sufficient knowledge infrastructure laid out for large(ish) investors to come and pour some of their social investment money, one still needs a certain amount of “no-cash-dividend-expectation” investment activity. We have been successful in raising some, but the field would greatly benefit from more - and MIA is no exception.
As for identifying, training and getting leaders back into their communities? Well, our answer to that is “why take them out of the community in the first place?!” The MIA, as a matter of principle, does not award any degrees or certificates to the individuals following the course, precisely to avoid the types of leakages you refer to. We also believe that it is more effective to train communities in their local environment, using local (existing) institutions, which can deliver the training in the local languages, are aware of local customs and are available for ongoing support. Not to mention the amount one saves on travel (with its related environmental consequences). So, we at the MIA aim whrever possible to promote a “social franchise” network of institutions that carry our materials and deliver them locally. The CHAT is a perfect example on how we go about this. So, shall the next entry be "the McDonalds of microinsurance capacity building?" ;-)
Onwards and upwards,
Director of Operations
Micro Insurance Academy
Why is the proposal to introduce CHAT as a tool for low-income people in developing countries a prime “changemaker”? Because (i) CHAT increases the understanding of prospective clients about the options that they can choose from, and also (ii) because, this process enhances awareness of what they can expect as advantages and limitations of health insurance.
The proposal did not mention that in addition to the field work, the proposal submitter and his team also engaged in analyzing the choices people had made, and these results have been published in Social Science and Medicine (2007 64(4): 884–896). The results obtained by CHAT clearly challenge the conventional thought that “beggars can’t be choosers”, or the concept - underlying most top-down policies - that “the poor do not know what is good for them”. The CHAT exercise in India and the analysis of the results make it now very clear that the poor, even if illiterate or innumerate, have clear ideas about their priorities, and that they can express their priorities when given the right tools to do so, and that they make judicious choices. The message delivered through CHAT has provided new and important explanations why the existing health insurance uptake is so low in India: the existing insurance products are designed to cover rare catastrophic events (mainly hospitalizations); but what the respondents say is that they want health insurance also to cover high cumulative expenses (mainly drugs, tests and consultations ).. Through CHAT the prospective clients of health insurance gained a clear voice to express their priorities for the first time! Now, with replication and upscaling of CHAT exercises, the voice of the people at the bottom of the pyramid will hopefully be loud enough to propel a profound change in product-design for health insurance in the developing world. This is what a “Disruptive innovation in health and healthcare” is all about.
I hope you will read the evidence that has not been posted in this proposal. I think it is compelling!
Have read the proposal, watched the video and read the discussion so far. A worthy initiative with great promise for truly involving the poor in decisions about what they need and can afford in the way of health care plans.
I can't wait to play CHAT myself!
I would like to congratulate the Micro Insurance Academy with the Choosing Healthplans All Together (CHAT) method. The CHAT method is a good example of a participitory bottom up approach in which a health insurance system can be introduced that fit into the needs of villagers in terms of costs (premium) and coverage (local demands for medical care).
I hope the method will finally result that large groups will get access to an affordable health insurance system that cover their needs. I can't wait to see the real results of the game, and if the benefits are high and we have learnt lessons from this pilot, lets scale up!
Good to see all these nice comments on CHAT! I am part of the team that has been working with CHAT. Knowing that I was working on developing a very innovative and ‘world changing’ initiative, I already enjoyed the first part of the job: adjusting CHAT to the local conditions in India.
However, that was still nothing compared to how I enjoyed the fieldwork itself. To work with the people in the very remote villages in different parts of India and realize that, their illiteracy notwithstanding, they are able to ‘play’ the game and, as a consequence, have become familiar with the principles of insurance. Being there, I could see that the people clearly liked it to participate which is very important. But, even more important, they also understood the underlying message of the game and what the benefit is of having health insurance. When I was about to leave a place, almost all the time the question came: “when will you come to our village with this project? We need this to protect the sick from the costs of their illness.”
Hivos employee Caroline Mol says:
"When working with people that have very little to spend, you can probably imagine that it is difficult to explain that they have to pay a premium that is not directly linked to getting something of out of it! "
CHAT reflects priorities of the client-groups as much as possible and helps to gain an understanding about the costs of health insurance by showing what treatments are covered and which not. It enhances clients’ awareness of the link between premiums they pay and benefits they can reasonably expect from the insurance. It is not so much about the product itself but on the process of educating people to determine their own lives.
Reading the results of a CHAT experiment conducted in India (2005), it is great to see the level of satisfaction of the participants. Participants (strongly) agreed on the learning element of playing the CHAT game, were highly satisfied with the group’s decision, the fairness of the way the group reached its decision and the clearness of the information presented in CHAT.
I read your project description on CHAT with great interest. I am working with an NGO based in Hyderabad called the Society for Integrated Development in Urban and Rural Areas. SIDUR's main objective is to empower the oppressed poor - especially the marginalized rural & urban poor namely Dalits, women, street children, slum dwellers and people living in tribal areas. SIDUR has set up a number of integrated development programs in urban slums and rural communities. These include Community-based Clinics (Healthy Huts), Street Children Rehabilitation, Slum Development, Community-based Rehabilitation, Prevention and Control of HIV/AIDS, Production of Braille Books, Disaster Management, and Water and Sanitation.
SIDUR provides health services but does not provide microinsurance today. I think that it would be quite interesting investigate how to bring health microinsurance to the communities that SIDUR supports. Do you have plans to bring CHAT to Andhra Pradesh? Also could you put me in touch with any MIUs using CHAT that could cooperate with grass roots organizations like SIDUR?
Very interesting to hear about SIDUR and its activities. Will definitely read up on it some more - sounds like just the kind of organization we'd like to get involved with...
AP actually has more microinsurance then most places in India; for instance, in the recent micro insurance awards, 18 of the 47 enterants were from Andhra. We have not worked in Andhra with CHAT (yet), but this could certainly be arranged.
I'll also be happy to put you in touch with MIU's that used CHAT - drop me an email on iddo at mia dot org dot in (sorry, spam paranoia...)
David & Iddo
I have sent the YouTube link to TJPS Vardhan, the Executive secretary of SIDUR. I think David met him at the MicroInsurance Conference he organized last year in Delhi. Anyway you should feel free to write to him at email@example.com
Groups that have done such a large variety of activities with Dalits and other underserved groups can surely benefit hugely from the CHAT exercise at their catchment area. Once we leave the terrain of charity, and expect people to contribute toward the cost of services (and I believ this is the case with Health Huts etc), the paradigm shift is rather abrupt. Before we had CHAT, we experienced situations when the clients seemed to reject the introduction of services by saying "I am too poor to pay", when at the same time these people spent as much on tobacco, alcohol, festivals etc.
It has taken us quite some time to understand that "I am too poor to pay" sometimes really meant "I want to choose what I spend my money on". We saw that the notion of choice is a critical feature in development generally, and in introducing health insurance in particular. We now know, from the results we already have with CHAT, that when given choices, poor and underserved people want the insurance, provided the pacakge they pay for will address their top-priorities. And we also kow now, that those top priorities are not identical everywhere, and hence "one-size-fits-all" top-down solutions cannot respond well to the need to respond to local priorities.
We would love to meet the SIDUR and other groups in AP, and provide the platform that facilitates the dialogue between clients and providers on the benefit pacakge that would suit best locally. How to do this? by "Choosing Healthplans All Together". We have had many expressions of interest from SHGs and other client groups, less so from insurers... so your suggestion to link up with SIDUR is most welcome indeed.
Thank you for this lead.
A great initiative it is. I participated in the project ‘Strengthening Micro Health Insurance Units for the Poor in India’. I especially like the community based thinking of this project: a bottom-up approach which empowers the people in the communities involved.
The CHAT exercise is a very elegant, simple and democratic way to make difficult decisions about benefit package design. The people themselves, knowing best what their needs are, decide what health care services are included in the benefit package. It makes health insurance acceptable and affordable to the poor.
This is one giant step towards making health insurance available for the poor: a world changing initiative!
The competition is read by many people who do field work. Therefore, I would like to take this opportunity to invite those person/groups that wish to consider experimenting CHAT as the entry point for micro health insurance to please get in touch with us. We would certainly be keen to be in touch with as many grassroots groups in many more areas in India where we have not yet had the opportunity to work.
Thanks for contacting info at mia dot org dot in
It is very interesting to see the CHAT game. Making health insurance available for the poor is a very hard work. Congratulation, you have make made an innovative one.
I am also studying the relevant issues in Burkina Faso. It is very difficult to absorb the poor to enroll the health insurance. I found there was a big difference in enrolment rate between the poor and the rich. By income quintile, the poorest only had enrolment rate of 1.1% while the richest had 16.8%. I face big challenges to making health insurance available and affordable for the poor. Many thanks for the CHAT game which may help the poor in Burkina Faso to exercise sensible rationing of resources, based on their own conditions.
Dear Dr. Dong,
Very interesting figures - would love to hear more about your work and findings in Burkina Faso.
One immediate question that comes to mind when looking at the low enrollment rate at the poorest question is whether the products match customers' needs and wants. We find, only to often, that products offered to the poor are poor products... usually watered down versions of upper and middle class products that do not take into account what the poor actually need.
One clear example of this is the micro health insurance packages that offer hospitalization only, with exclusions on maternity, children under 5 and "seniors" over 50. It may seem like a ridiculous package (well, it arguably is), but that's the reality for a good number of the products that are out there. Would you buy such a product? I wouldn't, and to me, opting out of such offers is the logical economic choice.
CHAT can help address this by involving the clients in the benefit design, dramatically increasing their willingness to opt in, and purchase a product that meets their needs. Sounds like it might be a good idea for the groups you're studying in Burkina...
Best regards, and good luck with your research - will keep an eye out for it!
It is indeed very interesting to see all the comments centered on CHAT experiment.
I am actively involved in the CHAT game, and I could see the active response it created among the rural communities in India. The very interesting aspect that we could observe that even the illiterate and innumerate could understand very well of the CHAT experiment, which is an appreciation to the way the tool is developed, CHAT speaks the language of the commons. In India, the insurance companies are struggling to come up with standard HI schemes, but they don’t have any idea what all should be the components of the benefit package; nobody knows what people really want. Here is this tool, which is giving an opportunity for the communities to express their preferences for Health Insurances (HI) benefits in a completely enjoyable game manner, and come up with a viable HI package for themselves. The participants opined they learned a lot and the game was very interesting.
Furthermore, it is commonly believed that in India people are not aware the importance and necessity of HI, the CHAT experiment is generating awareness on HI in the communities where we conducted the experiment, and also could see the news is spreading to the neighboring communities too. It was also observed people began to approach local community HI provider and to ask for HI scheme, an impact after playing CHAT game.
CHAT is not only promoting awareness on HI among the common people, but also helping to allocate the limited resources in a more rational way. CHAT is developed completely in way taking in to account the low ability to pay of the rural people, and it gives them to express their preferences for a viable HI packages within their limited budget.
Of course, it is just a start. The coming months and years will witness more and more CHAT experiment in all rural communities in India.
CONGRATULATIONS MIA, on your excellent innovative tool !!! One of the biggest challenges to realizing the Millennium Development Goals is to find innovative solutions to public sector or welfare system gaps in social protection such as in health care for the poor and illiterate people in rural settings and the urban low income communities through appropriate, affordable, reliable and sustainable micro insurance coverage. While it is increasingly being recognized that 'mutual health protection schemes' or 'community/group-based health financing' is the key solution to this problem, designing concrete micro insurance products on the ground, (where the members themselves design and develop the product) is still a very difficult question. Thus, policy makers, insurance agencies, development experts, NGOs and microfinance practitioners are faced with serious challenges to create more reliable health scheme with better outreach, and member retention opportunities, especially in areas with bad health-care infrastructure. The importance of community involvement is great in overcoming the two serious pitfalls of micro insurance, namely, moral hazard and adverse selection. Micro insurance is a complex matter requiring a certain degree of technical expertise that most MFIs simply do not possess. In this context, the innovations made by the Micro insurance Academy (MIA) of India are path breaking in terms of localizing the MDGs, and holds immense opportunities for addressing the health security needs of huge numbers of excluded and under-served people through scaling-up this innovative, pro-poor, and community-driven methodology. CONGRATULATIONS once again MIA, on behalf of the development community – indeed we look upon your leadership to enable more and more microfinance institutions and empower communities across the developing world through your tools.
Thanks for your comment. I think you point to a valid fact that micro health insurance can help achieving the MDG and localize the MDGs. We have conducted a big comparative household survey in 2005 in India covering seven microschemes in 4 states. Insured and uninsured were randomly sampled. Insurance status leads to a higher utilization of health services, which can contribute to better health. However, the narrow benefit package in many schemes left even insured clients with limited financial protection - a fact which can be removed by tailoring the insurance benefit package to local needs using CHAT.
Ralf Radermacher, Director (Research & Training), Micro Insurance Academy
If you want to see the 5 minute CHAT video (really worth more then a thousand words), then you can also watch it on YouTube at the following URL:
Even though I have seen the CHAT video many times, it was exciting to see it again on the YouTube site. I have forwarded the link to a number of people. I am sure you will get some interest from this.
I see this innovative approach viable and should be tested and assessed.
I certainly have seen the video more then once or twice now, but still find it such a powerful tool for communicating the promise that CHAT holds for communities at the bottom of the pyramid.
Will get working on producing more videos ;-)
Thanks for sharing
I want to congratulate you for taking action in an area that sorely needs attention. the ingenious and socially intelligent, inclusive and caring method in which you put this program together is SO impressive. I wish and hope that the United States took note and learned from you. Good luck you deserve to get all the possible support for the good of all.
It is very innovative to see that you could communicate with the rural people about health insurance benefit and also designed health insurance scehems with their participation, especially when majority of the Indians are not aware of health insurance. Congrats, and keep it up.
Dear Mr. Renjith V,
I think you hit the nail on the head by saying that " majority of the Indians are not aware of health insurance".
The low insurance penetration in India (only 3% - yes, you read this right) suggests that there are serious issues with awareness. But that's exactly where you, me and everyone else can come in with creatibe ideas to change this.
At the MIA, we've been thinking about this for a while, and have now taken it a step further. We've launched a prize-bearing "Innovation Contest" in which we invite proposals for innovative, intuitive and original ideas to explain the value proposition of health insurance for poor people and grassroots groups.
Proposals could include good stories, anecdotes, games, simulations, picture-stories, scripts for video clips or short movies and the like, to explain insurance to persons with no prior insurance experience.
The one proposal that will be considered most attractive will be awarded a prize of: € 1,000 (Euro one thousand only). Proposals should not exceed 3 A-4 pages, and must be submitted in English.
So, will you join us and submit? ;-)
To me this CHAT tool is a comprehensive tool that covers very many aspects:
1 Self diagnosis tool for a community
2 Community budgeting for better health
3 Community Thinking Today for Better Tomorrow
4 Thought provoking tool for stakeholders
5 Best community Choice through consensus
6 Efforts to Create Community Health Asset
7 CHAT is an exemplary for the statement ' Participation facilitates best choices'
8 Enjoy joy of giving(saving) for health
i have two years experince in the field of health insurance in which we attempted to deliver the system of community based health insurance scheme for the marginalised groups. the major challages we found that there are number of schemes for these marinalised groups, but unfortunately they donot have any idea on these schemes. Even if they know, there certain problems hidden on these schemes like high insurance premium, and high exclusions, time constraint for delivering the result. We have tried to manage the health insurance by community itself, as a innovative tool in the rural economy which received much attention.
On the one hand we hear that insurers are not interested in the poor clients, and do not know very much what the clients want; and on the other hand, you say that the marginalised do not have an idea about community-based health insurance for the poor. We have seen that CHAT, which is a social and game-like activity, attracted much attnetion among the groups we would like to reach, and we have seen that when these people are offered to be involved in the decision-making process, rather than just offered a products that was desighned and priced by others, people make good choices and express high degree of satisfaction.
Our team is convinced that "playing CHAT" is the netry-point for introducing micro health insurance among rural, poor and other marginalised groups. We would love to know more about your efforts, and if you wish, we can jointly explore ways to bring CHAT to your area.
A few weeks ago, I have started writing my master thesis about pro-poor health insurance by conducting a market analysis of benefit packages in India with focus on the clients´ needs. Mainly, I have decided to write about this topic because it reflects a current and innovative movement with a high practical reference. During the last years, the number of community-based health schemes in India increased continuously. In my master thesis I would like to figure out systematically how all these schemes cover the risks and needs of the poor clients. Thus, gaps in the coverage of risks will be described. Finally, improvement potentials will be evaluated and possible solutions will be suggested. In my opinion, CHAT is useful solution that makes sense in this respect and should be executed before implementing a micro-insurance health scheme. Furthermore, CHAT created a new quality in communication processes between experts in micro-insurance and local people who are in need of it. The tool helps to establish a learning culture for both sides by emphasizing a respectful dialogue and partnership. CHAT makes it possible that the participants communicate, discuss, question, answer, listen or reflect their thoughts to find the best benefit package for their needs. This learning culture can clear misunderstandings and, consequently, people will have confidence in the scheme. Hence, the growing trust of local people in the idea of micro-insurance becomes a pillar of implementing successful micro-insurance schemes. That´s why I hope that this approach will be spread in many communities in India and abroad.
Thanks for you comment and for sharing the news about your master thesis.
In your comment I think you emphasize an important point: CHAT enables learning on “both sides” as you call it, i.e. creates an understanding in the community but also for insurance providers who are willing to engage in a client driven business process. This makes CHAT the starting point for redefining the whole business-process, making the client a partner and not a consumer of predefined packages.
Ralf Radermacher, Director (Research & Training), Micro Insurance Academy
I’m South African and understand that MIA’s approach is exactly right. Knowledge is power; we could do with a CHAT in South Africa .
We actually did a fair bit of research and preparatory work on community based health insurance in SA, and would be more then happy to return to assist communities in implementing CHAT there.
Please feel free to contact us, or pass our contact details to others that you think might benefit from this.
I want to express my admiration to the Social Re team for having developed CHAT which really provides poor people with a concrete instrument to get peple to act together as groups to get insurance coverage. I wonder how the CHAT exercise and more in general MIA could work in countries such as the United States (where 50 million people are uninsured) or Australia where some (aborigenal) communities choose not to make use of the public insurance scheme. Congratulations again for such a great innovative initiative. Francesco
Believe it or not, CHAT was actually "born" in the USA, where it is still being run under the leadership of Dr. Marion Danis and her team at the NIH - you can read more about - notably in another submission to this competition under a similar title ;-)
There is a lot of scope for running CHAT in other places then India, and in fact this is already taking place. However, not yet with aboriginal communities in Australia - though that would certainly be an interesting place to go!
Commentary in English
This is a very innovative game like way to break down the complexities of actuarial claculation of premiums to a simplicity that is intriguing. I know David Dror as an outstanding expert in both the technicalities of insurance design and in its adaptation to settings of poverty.
I myself am working on community health insurance in south Asia, China and Africa and we are contacting David to share his new tool with us.
Chair, Public Health and Tropical Hygiene, Heidelberg University
Dear Rainer Sauerborn,
You are completely right; the easy to understand 'sticker costs' (simply 'pasting different amounts of stickers for different benefit types at different coverage levels) have indeed a very complex story behind it. For each of the benefit types the actuarial costs need to be calculated based on utilization and expenditures data of the target population for health care covered under that specific benefit type. The defined coverage levels need to be taken into account in the end as well and all those things combined ultimately determine the sticker costs (premium) of each benefit type at each coverage level. Normal people, even the ones who are used to having health insurance, have no knowledge and don't think about this. This transferring into sticker costs as is done in the CHAT tool is therefore the easy way to do it realistic but without bothering the people with the boring background of the calculations.
One more observation from my participation with CHAT experiment: CHAT promotes solidarity and strengthens community feeling among community members as in the Round 2 of CHAT game, we have seen pariticipants are listening to each others preferences for health insurance benefits with so much respect and coming to concensus. The group discussions also give weightages and respect for the preferecnes for women and elderly without compromising the principle of rationing.
I'm new on the subject of health insurance in general and especially outside industrial societies. First I want to check if I understand the problem and the proposed solution to it:
As far as I understand the main problem is that the potential client has no or very little understanding of what health insurance is, why it is important/beneficial for him/her and how to use it once he/she has health insurance. To overcome this limitations you introduce CHAT, a game like education about health insurance. You do not offer any kind of insurance product, do you?
Now, my first question would be: Why do you have "copyrighted" your material? Wouldn't it be more effective to have an "open source" kind of approach? I saw in your video that the material shown were written manly in English. Wouldn't your program get a better penetration if you would allow the local representatives to translate your material in the local dialect and print it out for them self (or translate online, print in a central facility and than have the material shipped)? I am aware of the underlying assumption that the necessary infrastructure is available and reliable, which may not be given. Why do you copyrighted your material to begin with?
My other questions are of more general nature:
- Do you have experienced a follow up reaction from the participants to actually get health insurance? Did the percentage of people having health insurance increase in the communities you visited (or wasn't that the goal)?
- Did the insurance companies modify their plans to fit the needs of the poor communities better or are you aware of plans of doing so?
- Is 12$ premium per year and household realistic to cover the most important needs? My fear would be that the plans that can be offered are more expensive and false expectations are raised.
- How good can the communities project their needs? Are they aware of their medical needs and the costs of the required treatments? That may include the question of what can be treated (he/she may or may not be aware that a high children death rate can be lowered with simple measures, but wants full eye and dental treatment).
I have to say that educating about health insurance (and health risks) is important and I like the general idea.
Thank you for the questions you raise. I am sure you are not the only reader wondering about some of these issues. In fact, I would strongly invite you to read the article describing methodological issues and the results of the analysis, published in Social Science & Medicine; the exact reference follows: Dror DM, Koren, R; Ost A, Binnendijk, E; Vellakkal, S, Danis, M: Health insurance benefit packages prioritized by low-income clients in India: Three criteria to estimate effectiveness of choice, Social Science & Medicine, 2007 64(4): 884–896
There is another article that will soon be published in Economic and Political Weekly (published in Mumbai), but I am not sure it is accessible through the internet.
Let me offer short replies to your queries, below:
1. You say: “As far as I understand the main problem is that the potential client has no or very little understanding of what health insurance is, why it is important/beneficial for him/her and how to use it once he/she has health insurance. To overcome this limitation you introduce CHAT, a game like education about health insurance”. I agree with your formulation. We know that uninsured persons also spend money on healthcare. We also know that the funding of healthcare out-of-pocket as and when people need medical services is the least effective mode of financing, often more expensive (zero negotiating position when you come to hospital with a sick child or an accident victim, or a women who is about to deliver. OOPS also discourages preventive care or care-seeking at the earliest stage (that often is cheaper and better). From the clients’ viewpoint, the one big advantage of OOPS is that people have a sense of getting something in return for their money. Compared to this, paying a premium to insurance makes many people feel that they may not get anything for this money. CHAT offers an interaction to people that enables them to relate to their health needs in an interactive way resembling familiar transactions in which people decide what to buy and what not to buy within their limited budget, with enough information on the options, and with a possibility to make a choice. Making a choice is sometimes the key issue whether people will spend or will not. So add to your formulation of the problem/solution the component of giving people choice, and you get CHAT
2. Why do you "copyright" your material? Wouldn't it be more effective to have an "open source" kind of approach? Let me start with the main point: we allow the use of CHAT free of charge. We nevertheless need to copyright it (not only because people have created intellectual property that should be recognized, as this is not an apple growing on trees) because what the casual viewer does not see is the complex metrics underlying the CHAT “wheel”, which are required to adjust prices of each benefit to the local circumstances of different locations and different people. The three most critical parameters that must be adjusted to context and location are needs, demand and supply. Imagine how useless the whole exercise would be if, for instance, we were to use prices of healthcare in the USA to compose a CHAT wheel in rural India… The entire exercise would be futile, irrelevant and even counterproductive. Copyrighting the material is our only safeguard that the CHAT Board or the video, which are accessible freely on our website and elsewhere, would not be used by others wrongly, and the responsibility for such wrong use would befall on us. So we must copyright the material to ensure that those who seek to use CHAT will also adapt the metrics to local conditions, and that the data they use is valid. We invested the time and money to adjust the CHAT material to local data in several locations in India; we allowed the use of it free of charge in its customized format. And we would be happy to collaborate with other groups that are willing to do the same, by providing the good quality local data needed to adjust CHAT to many more locations, in many countries.
3. You say: “I saw in your video that the materials shown were written mainly in English” Wrong: look well in the video and you will see that the CHAT Board is printed in three languages: English, Marathi and Hindi. And the colors and stickers are sort of “sign language” that fits everywhere.
4. “Wouldn't your program get a better penetration if you would allow the local representatives to translate your material in the local dialect and print it out for them self (or translate online, print in a central facility and than have the material shipped)?” We have done that; we translated the material, and all explanations are given verbally as well (many of the respondents are challenged by reading in any language) in the local dialect.
5. You say: ”I am aware of the underlying assumption that the necessary infrastructure is available and reliable, which may not be given”. We ran CHAT sessions in candle-light, in places without electricity (let alone internet or printers or downloading of documents or printing of material). The other aspect that we cannot stress enough is that for us, CHAT is a group exercise, not something we would like people to do in isolation from each other. Life in rural areas in India, Africa and even among the underserved in the USA is not lived strictly individually. Coping with difficulties is done by groups; income is shared within households and sometimes beyond. So, decisions on spending money are also done by groups, not each one alone. And this aspect cannot easily be translated to internet (even if all the other problems with infrastructure were solved, which of course they are not).
6. You say: “Do you have experienced a follow up reaction from the participants to actually get health insurance? Did the percentage of people having health insurance increase in the communities you visited (or wasn't that the goal)? The goal of CHAT is actually to scope whether it is possible to involve grassroots people in benefit-package design. CHAT is not an insurance underwriting programme. We can agree that ultimately we wish to see more people covered by health insurance. But there are many intermediate steps to achieve this goal, and those steps are worthwhile and necessary on their own. This is true for most other domains. Would you say that basic medical research is worthless unless is heals people under each and every research item? I dare say that surely you agree that, for instance, the genomic project is of major value to humanity even though it will take many more years before its full impact on healing can be commercialized. Same thing here, Sebastian.
7. Did the insurance companies modify their plans to fit the needs of the poor communities better or are you aware of plans of doing so? I think that commercial insurance companies are taking note of what we do, but for the time being are not yet taking action that is directly related to CHAT. It is bound to come, this is part of the disruptive nature of our innovation.
8. Is 12$ premium per year and household realistic to cover the most important needs? My fear would be that the plans that can be offered are more expensive and false expectations are raised. The actuarial calculations were done by an expert with experience in India and reflect the reality as we know it, with real prices. If you were to look into the prices of health services in India you would understand that $12 buys different things here than in your reality. The tension that we face is that even this amount, which seems so small and insufficient to some, could be too high for poor people here. The premium must therefore be relative to what people would be willing to pay. Local WTP levels were assessed as part of the baseline (more on this in another scientific paper: Dror DM, Radermacher R, Koren R: Willingness to pay for health insurance among rural and poor persons: Field evidence from seven micro health insurance units in India. Health Policy, (2007) 82(1):12-27) and this amount of $12 reflects around 1.5% of estimated income of the households. If they perceive getting value for money, they will subscribe. Otherwise no. So the issue is not only a supply-side one, but a demand-driven activity.
9. You say: “How good can the communities project their needs? Are they aware of their medical needs and the costs of the required treatments? That may include the question of what can be treated (he/she may or may not be aware that a high children death rate can be lowered with simple measures, but wants full eye and dental treatment).” There is a ton of literature on this topic. We do not assume that anyone knows better than you what you would consider you top priority. We also do not consider that when you have a choice to affiliate or not to affiliate, anyone can “sell” you affiliation by telling you that you don’t know what you really want, or that what you want is wrong. But beyond the positioning on how paternalistic we want to be, we also checked this question quantitatively. Surprise, (pleasant) surprise: people made very judicious choices. They opt for partial coverage because this is what they can get with the budget restriction. They understand that perfectly well. But they nevertheless prefer basic and partial coverage with more benefits included in the package than high coverage of fewer benefit types. This choice, when simulated to real-life situation, provided them with better response to THEIR stated priorities.
Well, this is the longest comment I have written, and hopefully it serves you and other readers well to better understand this proposal.
Thanks again for having raised so many issues.
I am reminded of the old saying: “To arrive at the destination starts with the first step”, and the first step in the journey towards better health cover is knowledge. One needs the knowledge and understanding of the purpose of insurance, which is to pool risk. Knowledge is what MIA (a non-proft-making organisation) is providing here and now, and MIA has provided a reliable, transparent and trustworthy process as the basis for people who want to buy insurance. Everyone knows about ill health and many of the other submissions in this competition laudibly concentrate on particular parts of the health care industry, but hardly any mentioned the financial consequences of ill health on the individual. MIA’s approach is new, and offers the prospect of replicating and scaling. Their project indicates an understanding of the worries of individuals regarding health care, and MIA’s research seems to indicate that the individuals they have interviewed understand the connection between private health care and public health. Not only does MIA inform many people about the basic facts and benefits of health insurance cover, but MIA has found that respondents want tailored health cover, which apparently at the present time large health insurance companies are not interested in supplying.
Dear all, as the dealine for posting commetns approaches, we would like to post a summary of the extensive comments exchanged on the proposal "Demystifying insurance package design by Choosing Healthplans All Together (CHAT)". The comments can be grouped into 4 categories:
1. general comments/compliments
2. personal experiences/observations of CHAT team
3. invitations/suggestions to go somewhere and do CHAT
4. questions raised
1. general comments/compliments
We have received many comments/compliments to underline the empowerment of the communities by CHAT (Mariana). The thrust of these inputs has been that only by consulting the people themselves, can the current traditional method of designing insurance solutions based on biased information be disrupted (Drew); and that CHAT facilitates overcoming the prejudice that the illiterate / poor people are unable to decide over their own lives, or to understand the complex concept of health insurance (Virrose).
CHAT is recognized by commentators as providing the link between the people and the insurance providers / policy makers, by educating both parties at the same time (Noah/Claudia: enables learning at both sides; Krishnam81: making each party aware of each other), while ensuring that the different interviewed persons have a similar level of understanding which enhances confidence (because of the use of this standardized and easy to understand instrument) (Illana). CHAT enhances clients’ awareness of the link between premiums they pay and benefits they can reasonably expect from the insurance (Caroline). This learning culture of CHAT can remove misunderstandings and, consequently, people will have confidence in the scheme (Claudia).
One commenter linked CHAT with accomplishing the MDGs. He points out that, while it has been recognized that micro insurance can help achieving the MDGs, the challenge is to create more reliable health schemes with better outreach, and enhanced member-retention opportunities. In his view, the innovations made by the MIA are path-breaking in terms of localizing the MDGs, and thus this process holds immense opportunities for addressing the health security needs of huge numbers of excluded and under-served people through scaling-up of this innovative, pro-poor, and community-driven methodology (Anup).
CHAT has even been labelled a “Blue Ocean Strategy” (Grant).
2. personal experiences/observations of CHAT team
The persons who were involved in rolling out the CHAT exercises in the field have shared personal experiences/observations that participants, illiteracy notwithstanding, come to an understanding of the concept of insurance (Anagha & Xiaoxian) and would like to see insurance reach them and their village (Erika / Sukumar). The Indian facilitators who really know the communities first-hand acknowledged that the CHAT tool can facilitate the best community choice through consensus (Sheela). From the analysis it was even concluded that the choices were judicious (Ruth).
3. invitations/suggestions to go somewhere and do CHAT
Among the comments were also several invitations/suggestions to come and bring CHAT into practice with underserved populations in other places inside and outside India (Eric/Illana/Gailo/Francesco).
4. questions raised
During the discussions there were several questions raised (and answered). These questions (and answers) dealt with the recruitment of participants (composition of groups) and the expected influence of that on the choices made (Virrose); with the theoretical and practical use of the CHAT, in theory aiming at empowerment/creating skills and the translation into actual health plans (Mariana); the reason of copyrighting the materials; the benefit of translating the materials into the local dialects; CHAT being a group exercise that should be done in groups since life in these populations is not lived individually; the modification of existing plans of insurance companies based on results of CHAT; with a realistic annual premium (compromising the actual costs and the A/WTP); and with the judiciousness of the choices made by the people. (Sebastian)
We have learned a lot from the comments, and would like to thank all for having taken the time to write to us, or remark on our proposal. We hope to see more follow up. Thanks also to Changemakers for having initiated and hosted this discussion.