African Women's Health:
Why Mutual Health Organizations are Making a Difference
A new adaptation of the centuries-old tradition of mutual aid societies shows promise of improving access to healthcare and reducing unnecessary maternal and infant deaths in developing nations.
More than half a million women worldwide die from pregnancy-related causes each year, and most of those deaths are preventable, even in the poorest countries, according to the World Health Organization. The risk is highest for women in sub-Saharan Africa, whose lifetime chances are 1 in 16 of dying during pregnancy, childbirth, or post-partum.
An approach to health insurance arising from principles of solidarity and mutual assistance appears to offer an alternative to poor women and their families who cannot afford health services. Called Community-Based Health Financing (CBHF), the method encourages communities to share risks and pool funds in order to provide members with affordable coverage for some basic health needs. Its use has been supported and strengthened by funding from the US Agency for International Development.
Community-Based Health Financing, an approach to health insurance arising from principles of solidarity and mutual assistance, appears to offer an alternative to poor women and their families who cannot afford health services.
"This is very much a grassroots-driven movement," explains health financing specialist Allison Gamble Kelley of Abt Associates. "A lot of the initiators are women's associations and women's groups, and their top priority is maternal and child health."
Mutual Health Organizations are helping families in Ghana to cope more readily with health crises. A typical program in West Africa begins with a group of committed individuals who encourage others to join them in designing a program that requires monthly or semi-annual contributions (averaging about $8 per family per year) that are pooled to cover future expenses of its members. The groups affiliate with clinics and hospitals, using the bargaining power of their numbers to negotiate better rates for a predetermined set of health services.
Abt Associates has offered technical assistance to these groups in Ghana, Mali, Rwanda, and Senegal for several years under the auspices of Partners for Health Reformplus, the flagship health systems project of USAID. Known in West Africa as mutual health organizations (MHOs) or mututelles, their numbers have been growing impressively and attracting the attention of government and non-profit agencies.
Mali elders in Sikasso review information on the community's use of health services. Community-Based Health Financing provides ways for poor communities to fund health care.
In Rwanda, for example, 88,000 members enrolled in an MHO between 1999 and 2000, and membership reached 200,000 in 2003, according to health economist Pia Schneider of The World Bank, formerly of Abt Associates. All of those MHOs are organized and managed by their members, Schneider says, most of them farmers who serve without pay.
In part because women have been a major force in their development, most MHOs offer pre- and post-natal care, some cover normal deliveries, and many cover complicated deliveries, according to Kelley. Family planning is still an "outlier" service, unpopular in some areas due to religious and cultural beliefs, she adds. But reproductive health generally has become a prominent benefit. In addition, primary care, including treatment for malaria and other common ailments, is typically covered.
It is already clear that MHOs have an important advantage over healthcare initiatives designed and organized by governments or NGOs. They are viewed as legitimate because they are indigenous.
Results so far are encouraging. The majority of MHOs are less than three years old and tend to be "financially fragile" for at least five years, Kelley says, but Abt Associates research shows that they are increasing access to healthcare services in poor countries. Families that rarely sought help from health professionals are now more likely to do so when the need arises because they do not have to scrape together fees in an emergency. Many West African women have died during complicated deliveries because their families could not pay for an ambulance, according to Schneider.
In recent Abt Associates surveys, pregnant women in Rwanda who were MHO members were up to 65 percent more likely to visit modern healthcare providers than pregnant non-members. Non-members were almost twice as likely as members to deliver babies without assistance.
Staff and consultants to USAID's PHRplus program strategize on how to provide technical assistance to Mutual Health Organizations in Africa.
In Senegal, a new national strategic plan to expand MHOs nationwide has recently been developed with assistance from Abt Associates. The plan not only increases but also coordinates the involvement of the government, donors, and non-governmental organizations (NGOs) whose support is critical to the survival of young MHOs, Kelley said.
Long-term sustainability is still a looming question. Unsurprisingly, problems such as low collection rates for premiums, unwieldy record-keeping as MHOs grow, and a lack of administrative experience all challenge the survival of these homegrown organizations.
But Kelley believes that MHOs can provide at least part of the solution to meeting reproductive healthcare needs in developing countries. To gain more insight, Abt Associates plans to use the results from recently conducted household studies in Senegal, Mali, and Ghana to document the impact of membership in an MHO on the use of family planning and reproductive health services.
Families that rarely sought help from health professionals are now more likely to do so when the need arises because they do not have to scrape together fees in an emergency.
It is already clear that MHOs have an important advantage over healthcare initiatives designed and organized by governments or NGOs. They are, Kelly says, viewed as "completely legitimate" because they are indigenous. "[MHOs] stem from existing solidarity links, organizations such as women's trade associations that already exist and are happening even in the absence of technical assistance from outsiders," Kelly observes. "The people themselves have decided this is how they want to access care.
"It's a movement that's growing by leaps and bounds, exponentially, every year. And why not take advantage of it? Let's use it to get kids immunized, provide pre-natal care, preventive care. It's a tool that can be quite useful."
