Thanks to their proximity to the beneficiaries and to the high level of social cohesion among their members, decentralized systems of social protection and health micro insurance schemes can strengthen the community awareness of the HIV/AIDS epidemic, spread prevention messages, and facilitate access to treatment. Such prevention campaigns can be integrated in broader financial support programmes.

In the Dominican Republic, in the fourth year of the Social Responsibility Plan for the Prevention of HIV/AIDS, with 35 member cooperatives participating, the prevention message had reached more than 265,000 people by July 2008, 84% of the overall target of 315,000 to be reached by the end of the programme, scheduled for May 31, 2009. The cooperatives have focused their work on their members, young people and schools, where school cooperatives and young savers’ groups operate.

For more information, please read the 4^th issue of Prosper, the ICMIF newsletter, page 13.

In Bangladesh, BRAC initiated in July 2001 a pilot project on health microinsurance in Madhabdi Upazila of Narshingdi District. BRAC MHIB was formally launched in November 2001, when BRAC signed a 3-year agreement with the ILO. With this support, the project was scaled up in the initial pilot area and extended to another area, Phulbari Upazila in Dinajpur District. One of the goals of BRAC MHIB is to promote preventive health care to its target population. The organization holds various forums for all community members, which are used to deliver preventive information and health education while promote the insurance scheme. In October 2002, BRAC MHIB launched an HIV/AIDS/STD Awareness Pilot Program in MHIB areas to raise awareness.

For more information, please read the case study of the CGAP Working group “Health Microinsurance, a Comparative Study of Three Examples in Bangladesh”, 2005.

In the context of the HIV/AIDS epidemic, there are two types of linkages for microinsurance schemes to get funds and to provide health care to their beneficiaries.

The example of Rwanda illustrates a diagonal approach. This approach is targeted on risk pooling as the funds allocated to the fight against HIV/AIDS are used to subsidize the premiums of the poorest and of those living with HIV / AIDS; these additional sources of funding contribute to the development of an universal health insurance system (87% of people covered in 2007) and contribute at the same time to the strengthening of the health system..

The example of Cambodia illustrates a partnership between two community based organizations: an association working with families affected by HIV/AIDS (Khemara) and a community based health insurance scheme (SKY). People living with HIV/AIDS receive ARVs at the hospital free of charge. Their affiliation to Khemara provides them a number of social services; they can through Khemara be affiliated to Sky and receive a health insurance coverage. 

For more information about linkages, please read: Linkages between statutory social security schemes and community-based social protection mechanisms, a promising new approach, Alain Coheur, Christian Jacquier,Valérie Schmitt-Diabaté and Jens Schremmer, AISS, 2007.

• The example of Rwanda: The diagonal approach of the Global Fund

Between the “vertical financing” and “horizontal financing” of health, there exists a third way, labelled “diagonal financing”. This diagonal approach seems to be an essential concept for the positive evolution of the global structure of health assistance.

In a vertical approach, extra resources are channelled into disease-specific programmes, meaning that the treatment of certain diseases is adequately provided for (the ‘island of sufficiency’). However, in general health systems remain vastly inadequate and understaffed, and in the long run these fragile ‘islands of sufficiency’ come up against major difficulties because of dysfunctional health systems and the problem of staff shortages.

In the horizontal approach, an additional layer is supplied to the vastly insufficient current health expenditure targeting the improvement of health systems in general. Yet total health expenditure remains well below the minimum and the health systems remain largely inadequate.

The diagonal approach is based on the idea that programmes targeting specific diseases (e.g. AIDS) must be accompanied by a broader range of activities for the reinforcement of shared health systems (e.g. training and expansion of the health workforce, integration and coordination with other disease programmes, strengthening laboratories, health management, health insurance schemes) if they are to be successful in the long term.

It was in this vein that the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria began a five year project to strengthen health systems in Rwanda in January 2006. Faced with the knowledge that the three diseases were collectively contributing to the highest disease burden in the country, and in view of the very low utilization rates of healthcare services in Rwanda, the Global Fund set out to improve access to quality care. Since evidence indicated that those people within the low-income populations who were members of mutual health organisations had a higher level of contact with health services than those who were not members, the Global Fund centred its project on strengthening the development of mutual health organisations in line with the Government policy.

The objective of improving access was facilitated by the decision of the Rwandan Government to introduce obligatory family health insurance in 2006. The national obligatory health insurance contribution rate for a basic universal healthcare package was set at FRW 1000 per person per year as from January 2007, with a 10% co-payment due upon treatment at a health centre or hospital. As this seemingly minimal contribution was still out of reach for the poorest Rwandans, the Global Fund set the objective of financing health insurance premiums for the poor, orphans and people living with HIV/AIDS. In 2007 the Global Fund paid premiums for around 800,000 of the poorest Rwandans.

The report, “Mid-term evaluation of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) 5th Round Project on Health Systems strengthening” (2007) describes the progress made and identifies future challenges relating to the implementation of this project in Rwanda.

Mutual health organizations, community based schemes, social health insurance systems, linked schemes, etc. can play an active part in reinforcing health systems and in fighting against HIV/AIDS since they create a solvent demand for health care services and contribute positively to increasing the quality and availability of health care. Strategies targeted at reinforcing health systems (in the vein of the diagonal approach) could channel the resources of various global vertical funds (Global Fund, GAVI, UNITAID, etc.) into support for the development of health insurance mechanisms, notably in the context of the HIV/AIDS epidemic.

For more information about the diagonal approach, please read the 4th issue of the G-News page 25, visit the wiki on linkages  and the Country Page on Rwanda on the GESS platform.

• The example of Cambodia: The initiative of GRET, a French NGO
  

GRET is a French NGO which has been active in Cambodia since the late 1980s, and which launched in 1991 a microfinance program called AMRET. GRET learned that health insurance would be an appropriate means of protection for the poor households: several studies confirmed that health risks are a leading predictor of poverty for rural households in Cambodia, a country where health conditions are among the worst and families invest the most in care. GRET launched an experimental rural health insurance program in 1998 to enable families to cover health care costs without risking impoverishment. The program is called “SKY”, a Khmer acronym of "Sokhapheap Krousar Yeung", “Health for Our Families.”

SKY signed a partnership agreement with Khemara, a local NGO working for families affected by HIV/AIDS. This agreement enables to cover some health care services, including possible opportunistic diseases, but doesn’t cover the monthly consultation or the ARVs that are provided for free by the state. SKY and Khemara facilitate both the access for their community networks to the health insurance scheme and the personal support of the families, and organize information and prevention campaigns.

To learn more about the SKY microinsurance scheme, please visit www.sky-cambodia.org and read the AMIN Infosheet of GRET-SKY and the Country Page on Cambodia on the GESS platform.

For more information, please read Community social protection and income security for households experiencing major illnesses including HIV/AIDS in selected communities around Phnom Penh, Men Chean R, ILO, Center for Advanced Study (CAS) Phnom Penh. This document deals with the partnership agreement between the SKY-GRET microinsurance scheme and Khemara, an NGO working for families affected by HIV/AIDS.

• Example of a Life insurance scheme:

ICMIF (International Cooperative and Mutual Insurance Federation), as a cooperative insurance company, now has a life policy including persons with HIV/AIDS, covering a total of 118,200 people for policies with loans, savings, collective life and funeral plans.

For more information, please read the 4th issue of Prosper, the ICMIF newsletter page 13.

• Examples of Health insurance schemes:
  

Microcare Health Limited in Uganda is one example of a regulated insurer that targets both low-income and corporate clients and integrates prevention, testing and counseling services of HIV/AIDS within its comprehensive health package as a risk-reduction strategy. They have recently been able to include treatment of first-line anti-retroviral drugs in their community schemes by linking with the public delivery channels, a benefit that was only accessible to corporate clients in the past.

For more information, please read Microfinance and HIV/AIDS NOTE #3 “Microinsurance for Markets Affected by HIV/AIDS”, USAIDS, 2008

Orissa: PREM’s Health Micro-Insurance Scheme India: PREM’s initiated special programmes addressing malaria prevention and control, early childhood care & stimulation, safe motherhood, HIV/AIDS prevention and control, promotion of village medicine depot, supply of emergency medicines and assistance to members in need of health care services both at the local and district level through a social protection component.

For more information, please read the AMIN Infosheet on PREM.

In India, Jeevodhayam is a microinsurance project of mutual participation, devised by the non-governmental organisation Project Concern International (PCI) and Care India. Jeevodhayam is important for financing the mortgage of Persons Living with HIV and AIDS (PLHAs). The project is a pilot programme thus insuring the lives of PLHAs through a micro Insurance programme with a mutual model.

For more information, please read the article from The Hindus and a detailed description in this article.

Karuna Trust, in India, together with the United Nations Development Programme (UNDP), plans to introduce a pilot insurance for antiretroviral drugs for people who are HIV positive. Following a study conducted on behalf of UNDP, Karuna Trust’s insurance scheme is going to be one of the three field experiments for insuring HIV/AIDS. This benefit will be added to the package for all insured clients.

For more information, please read the Case Study of the CGAP working group on Karuna Trust, Karnataka, page 40.

• Example of a both Life and Health insurance scheme:
  

FINCA International (Foundation for International Community Assistance) has partnered with leading insurance companies to offer health and life insurance products, health care, and business-interruption coverage in response to the AIDS crisis occurring in Africa. FINCA Uganda, which is a world pioneer in microinsurance, has partnered with AIG to provide life insurance, to ensure that the death of a village bank member does not result in hardship for the other village bank members or the family of the deceased as the client's loan is paid off.

For more information, please read : http://en.wikipedia.org/wiki/FINCA_International and visit http://www.villagebanking.org.