Will Maldives health insurance scheme succeed?

Maldives yesterday launched its second social health insurance scheme in as many years. Will the scheme be second time lucky and succeed? Success of course depends entirely on how one defines success. If by success one means that those who are lucky enough to get enrolled into the scheme get the limited package of benefits that it promises, without bankrupting the scheme, there is a fair chance of success. However if by success one means that all citizens will get access to effective health care by paying an affordable premium, the story may be different.

Maldives is certainly not the first country to attempt "universal coverage" of social health insurance. So it is worthwhile to learn from the experiences of other countries. Fortunately for us such experience has been summarized by Guy Carrin in a brilliant meta-analytic article ("Guy Carrin, Social health insurance in developing countries: a continuing challenge, International Social Security Review, p57-69, Vol.55, 2/2002".)

According to Carrin some of the difficulties faced by countries include the following:

1. Inadequate or ineffective health care provided to the insured members: This implies that the general or special health care services provided to insured members are part of the basic benefit package that may already exist or be created by the SHI schemes. If the existing health care system is not able to provide the essential health care package, it makes little sense to start a SHI scheme. It is painfully obvious that the Maldives health system is far short of providing even a semblance of adequate health care. Just look at the thousands of Maldivians travelling abroad for treatment.
   
2. Lack of managerial or administrative capacity to organize a nation-wide SHI scheme, that make inadequate collection or reimbursements, inefficient management of revenues and assets collected, or lack of monitoring the necessary health and financial information: With little experience in handling any sort of insurance, let alone health insurance, Maldives is far from meeting the managerial criteria for organizing an effective health insurance scheme.
   
3. Poor political stability usually linked with economic insecurity and also lack of policy debates among high-level policy makers and beneficiaries: The Maldivian economy currently faces a crisis. Further, no open debate has ever been conducted among the stakeholders.
   

 

The ingredients of successful social health insurance have also been identified by the author. They include:

1. Level of income: Once general population has better income, they tend to make higher health insurance contributions. No country (with the exception of Haiti) with per capita GDP below $ 3000 has succeeded in implementing social health insurance. While the Maldives GDP approaches this figure, income inequalities are likely to hamper insurance.
   
2. Relative size of informal and formal sectors: The larger the informal sector, the more difficult it is to manage the setting and collection of contributions and even reimbursement. In the Maldives fishermen and a wide range of other workers are in the informal sector. This will make the situation extremely complicated.
   
3. Time implications: Experience indicates that a few decades are needed to reach universal coverage. Appropriate strategic development plans are required; it is likely that Maldives will take at least several decades to achieve universal coverage.