hlsp consulting have been asked by DFID to do an assignment in
Malawi on Health Insurance. They are looking for an MSc / PhD student
(current or just graduated) to do 10 days worth of desk work for them in
the UK supervised by Alan Maynard.
> TORs are pasted below.
>
If you are intersted, please contact Suzanne Law:
[log in to unmask]
Draft Terms of Reference
Ministry of Health and Population, Republic of Malawi
May 2001
Designing the introduction of a
Formal Sector Health Insurance Scheme in Malawi
1. The consultancy team is to supply the services below to the Ministry
of Health and Population (MoHP) and partners.
2. Background
2.1 The Fourth National Health Plan (4th NHP) was launched in June 1999
and outlines the Government of Malawi's strategies to achieve a sound health
care delivery system by 2004. Successful implementation of the plan is
crucially dependent on the availability of resources. Analysis of current
financial sources and expenditure flows (for instance in the forthcoming
National Health Accounts) reveal a large resource gap in meeting the planned
activities of the 4th NHP. Moreover, private household expenditure on health
care incurred in circumventing access or quality constraints actually
exceeds recurrent government health expenditure. Sustainably filling this
resource gap and harnessing private sector health expenditure in a more
efficient manner requires new financing mechanisms over and above
traditional government and donor inputs and free service delivery. Several
potential mechanisms exist, including:
- Strengthening existing payment systems in government
facilities (such as
OPD1s)
- Introduction of user fees (at some point along the
cost sharing -recovery spectrum) in a wider range of health facilities, with
appropriate exemption mechanisms
- Contracting between health care providers to
increase access to health facilities and enhance efficiency
- Strengthening and extending Drug Revolving Funds
(DRFs)
- Introduction of a health insurance scheme for the
formal sector
2.2 Some of these financing options were assessed in a series of reports
by Liverpool Associates in Tropical Health (LATH) in 1999. The LATH June
1999 report, at the MoHP's request, concentrated on user fees and health
insurance schemes. The report outlines possible steps leading up to
implementation of these financing mechanisms. In a later September 1999
report, these steps are spread over an indicative 5-year timetable.
2.3 The Ministry/Donor financing sub-committee feels much of the work
towards introducing and expanding user fee schemes and strengthening
existing payment schemes is achievable "in-house". Some of the steps
outlined in the LATH reports are already underway (e.g. National Health
Accounts/ Household Expenditure Survey, evaluation of existing user fee
schemes) or can slot neatly into specific consultancies (e.g. design of fee
exemption mechanism). In contrast, none of the steps outlined by LATH
towards an insurance scheme have been undertaken. At the Ministry/Donor
meeting of 29th November 2000, the financing group made clear that capacity
within the ministry is insufficient to move forward simultaneously with both
user fee and health insurance schemes.
2.4 The financing group has recommended that an external consultancy be
commissioned to carry out some of the activities envisaged in moving towards
a health insurance scheme for the formal sector in Malawi. This was endorsed
by the Minister at the Ministry/Donor meeting on the 7th March 2001. These
activities roughly divide into two sequential areas. The first area is to
conduct an analysis of a range of different insurance package options and
their implications for the health sector. This will feed into a
recommendation from the MoHP to Cabinet for decision. The second area
follows the selection by Cabinet of a particular insurance package from the
range of options. It will design in detail the operationalization of the
health insurance scheme, probably in the form of a business plan. It will
focus on providing terms of reference for a Health Insurance Team (HIT) to
oversee implementation of the insurance scheme, and on the capitalization
requirements of providers in the insurance scheme. These are the dual aims
of the proposed consultancy.
2.5 The selection of the successful consultancy team will be made by MoHP
and DfID.
3. Purpose
To assist MoHP and its partners in launching the movement towards
implementing a formal sector health insurance scheme in Malawi.
4. Objectives
The consultancy has two main objectives that correspond to the two stages of
the consultancy:
4.1 To prepare a selection of health insurance options that the Ministry
can present and recommend via the Office of the President and Cabinet for a
firm policy decision by Cabinet. These options should adjust parameters such
as target populations (just public sector or full formal sector),
compulsory/voluntary insurance, and extent of insurance coverage (e.g.
inpatient (emergency) coverage or comprehensive (including outpatient)
coverage etc.) and indicative contributory levels. The legislative/legal
implications of certain packages (i.e. introduction of compulsory insurance
for the entire private sector) should be investigated. Advantages and
disadvantages of each policy package should be assessed.
4.2 After Cabinet has decided on one health insurance package, a
fully-costed business plan detailing the operationalization of this package
should be prepared. This plan should be easily adaptable into a funding
proposal. A large component of this plan will be the terms of reference for
a Health Insurance Team (HIT) to oversee the implementation of the chosen
health insurance scheme. The human, information and financial requirements
of these ToRs need to be calculated. Another important component will be the
capitalization requirements of health service providers in the insurance
scheme.
5. Tasks
5.1 Collate and evaluate seminal and recent literature relevant to
introducing a health insurance scheme in developing economies, and write a
synopsis of this literature to be made available to key stakeholders upon
arrival in-country. This should draw on plenty of empirical examples of
health insurance schemes, e.g. in the Philippines, Vietnam, Bangladesh and
so forth.
5.2 Be briefed at MoHP upon arrival. The consultants are to impartially
recommend any adjustment in these terms of reference as they feel
appropriate.
5.3 Meet relevant stakeholders such as the Medical Aid Society of Malawi
(MASM), important private sector companies, civil society groups and the
Department for Human Resources, Management and Development of the Government
of Malawi.
5.4 Evaluate why progress towards a health insurance scheme has not
progressed since 1999, and draw lessons. This task should focus on an
evaluation of the steps towards implementing a health insurance scheme as
detailed in the 1999 LATH reports, in light of interim developments and
information on the Malawian health sector.
5.5 Describe a series of options for the health insurance package, to be
included in a report after stage one of the consultancy. The parameters that
should be examined include:
- The total target population for the health insurance
scheme, and the number of employees within this population (e.g. just public
sector or full formal sector, compulsory/voluntary insurance).
- Whether insurance is to be compulsory or voluntary
and the varying legal implications of these different options.
- The package of benefits to be available under health
insurance, and the approximate utilization and provision cost of this
benefit package (e.g. different coverage scenarios: just impatient
(emergency) or including outpatient (comprehensive).
- Approximate contribution rates, collection of
contributions and provider payment mechanisms.
- Payment exemptions, if any (based on assessments of
affordability and willingness to pay).
- The level of entry point into the insured health
system: i.e. OPD 1 wards at district/central hospitals, possible specialist
insurance wards, private providers.
- The required capacity of different health care
providers to meet each package, and existing gap in meeting this capacity.
- Methods of accrediting providers, and awarding,
monitoring and auditing contracts.
- The regulatory environment in which the health
insurance scheme will operate (i.e. if the health insurance scheme is
ultimately run privately, the insurance market is likely to be a
monopolistic), and the legislative implications of this.
5.6 In the second stage of the consultancy, write the business plan for
operationalizing the health insurance package chosen by Cabinet. This should
focus on two areas:
- Detailed ToRs/mandates for a Health Insurance Team
(HIT) that will oversee implementation of the chosen health insurance
package. These ToRs will include:
o the management structure of the HIT,
its human resource requirements (drawing members from the ministry, donor
community, NGOs and other stakeholders), and its information requirements.
o an assessment of the financial
implications of the creation of the HIT and how seed monies can be raised to
finance the team's activities (e.g. salaries, office, equipment, research)
and/or contracts with providers until operational revenues begin to flow
steadily.
o an assessment of the institutional
structure (private firm, agency or etc) and arrangements likely to work
best. A plan for the transition process of moving from the HIT to the
desired structure once operational revenues are flowing should also be
investigated.
o an assessment of the relationship of
the HIT vis-à-vis other players in the health insurance market (e.g. MASM).
In particular, the preferred health insurance market structure (e.g.
competitive or monopolistic) needs to be investigated in light of envisaged
market size and number of health insurance providers.
- Meeting the managerial and capitalization
requirements of providers in the health insurance scheme.
5.7 After the second stage, the consultants should attend a debriefing
meeting at MoHP.
5.8 After the second stage help organise and facilitate, a one-day
meeting with relevant stakeholders in order to:
- Present findings
- Present and discuss related implications and
recommendations
- Explore options for the way forward
5.10 Prepare two reports on a Malawian health insurance scheme (see
specifications below).
5.11 Perform other tasks as necessary.
6. Outputs
6.1 Distribute a synopsis of essential literature on the implementation
of health insurance schemes to key MoHP personnel.
6.2 Meeting with stakeholders held.
6.3 Within two weeks after the end of the first stage of the
consultancy, a technical report covering the relevant objectives and tasks
specified above will be produced. This report should include:
- Findings of why the process became stalled and how
to avoid this happening again
- Analysis of the points detailed under 5.5. This
report will form the basis of the Ministry's recommendation to Cabinet of
one health insurance package among several options.
Hard and electronic copies of the report should be provided
6.4 Within two weeks after the end of the second stage of the consultancy, a
business plan covering the relevant objectives and tasks specified above
will be produced.
- The ToRs for the HIT as described in 5.6.
- The managerial and capitalization requirements of
providers as described in 5.6
- Possible sources of financing the HIT explored
This report should be easily adaptable into a funding
proposal/business plan for the health insurance scheme. Hard and electronic
copies of the report should be provided
7. Timing
By its nature, this is a two-stage consultancy. The first stage of assessing
the options of insurance packages available to the Ministry is envisaged to
require around 20 consultancy days, including home desk collation and review
of essential literature. As this options package will then be prepared for a
decision by Cabinet, upon which the second stage of the consultancy will
build, the second stage could be up to 6 months later. The second stage is
envisaged to require at least 10 consultancy days.
8. Consultancy requirements and qualifications
An envisaged team of two senior consultants shall demonstrate:
* Top expertise in theory, design and implementation of health
insurance schemes in developing countries, with good experience in
microeconomics.
* Ability and track record in launching projects from a stationary
position. Ability to identify obstacles that have prevented any prior
movement in the project and creativity in circumventing these problems are
essential.
* There should be a strong bias towards specific practical experience
of creating health insurance schemes in developing countries.
* Impartial advice on further necessary technical assistance.
* Excellent communication skills.
Similar experience in the region shall be considered as an asset.
9. Reporting and working relationships
The consultants will work in close collaboration with MoHP officials
(especially the financing sub-committee) and stakeholders. Reporting will be
to the Secretary for Health and Population.
10. Consultants
CVs, together with a short statement of competency should be submitted to
DfID's Health and Population Adviser, Malawi. DfID and MoHP will then select
the consultants for the contract.
Prepared by
The JIP Financing Sub-Committee
Annex 1
Background Documentation
1. Malawi National Health Plan 1999-2004, Ministry of Health
and Population, May 1999
2. Draft Joint Implementation Plan for National Health
Priorities 2000-2001
3. DFID Support to Malawi National Health Plan, Final Report.
March 2000. LATH.
4. DFID Support to Malawi National Health Plan, Role of NGOs
and Private Providers in the Health Sector in Malawi, Final Report, October
1999, LATH
5. DFID Support to Malawi National Health Plan, Health Care
Financing Strategy, Visit Report, June 1999, LATH
6. DFID Support to Malawi National Health Plan, Implementation
of a Health Care Financing Strategy, Visit Report, September 1999, LATH
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