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A collaborative process to strengthen the rollout of Benin’s health insurance scheme

Conrad Tonoukouen, Léandre Hounhoui, Romaric Houessou, Venant Quenum, Seyni Mbaye, Keith Mangam, Cicely Thomas, Cheickna Toure, Allison Kelley   |   March 25, 2021   |   Comments

In French.

In an effort to boost Benin’s socio-economic growth to lift as much of its population out of poverty as possible, the Government of Benin has set up the Insurance for Strengthening Human Capital (ARCH) project. The ARCH project focuses on four major reforms, including health nsurance to achieve universal health Coverage (UHC). The African Collaborative for Health Financing Solutions  (ACS) supports the Government of Benin in its quest for UHC through the deployment of the Health Insurance-ARCH (AM-ARCH) component. The ultimate goal is to provide high quality health coverage to the entire Benin population. AM-ARCH is currently in its pilot phase and offers free health insurance to a part of the population, characterized as being extremely poor in three health zones (figure pictured below): Abomey-Calai-Sô Ava, Dassa-Glazoué, and Djougou-Copargo-Ouaké.

Benin AM-ARCH Pilot Health Zones

To ensure the successful implementation of the AM-ARCH pilot, ACS has supported a participatory and inclusive approach to help the Government of Benin achieve the pilot’s intended objectives. To this end, ACS supported the Government of Benin to develop a learning agenda for the AM-ARCH pilot, with the participation of key stakeholders. The purpose was to strengthen collaboration between key partners and create an environment for all stakeholders to contribute to learning by holding a learning agenda collaborative workshop in 2019.

Forging a common vision and developing a learning agenda

The development of a learning agenda for the AM-ARCH program was the first opportunity to bring policymakers [Unité de Gestion du projet ARCH (UGP-ARCH), Ministry of Social Affairs and Microfinance, Ministry of Health], sub-national providers (Social Promotion Centres, Health Zones), and community leaders together in a dialogue about the implementation of AM-ARCH. The ACS team supported a collaborative approach to the learning agenda development to ensure that each stakeholder could share their expectations for the pilot implementation.

This process started with the ACS Benin team facilitating individual outreach via phone calls, google surveys, and some in-person discussions to solicit individual stakeholders’ perspectives on the main questions around how to successfully scale-up the AM-ARCH pilot program. With this information in mind, the facilitators better tailored the flow of the learning agenda workshop and were better able to tease out the hidden meaning or unspoken concerns during workshop discussions.

The workshop began with a presentation on a “learning agenda,” which is “a set of questions addressing critical knowledge gaps preventing informed decision-making regarding the design and implementation of a reform or new policy. The answers to these questions allow a government or committee to work in a more efficient manner.” The workshop, which was rolled out over two days, incorporated several facilitation approaches such as breakout group work and plenary exchanges supported by presentations on learning methods that demonstrated the various ways learning could be paired with the overall implementation plan.

While stakeholders’ challenges about AM-ARCH were not entirely aligned at first, this collaborative process allowed them to harmonize their perspectives and concerns. From this work, stakeholders prioritized three main focus areas, which they believed must be studied during the pilot phase to ensure successful scale-up. These included: 1) the provision of quality health services, 2) timely reimbursement of health services by ANAM (the National Agency for Health Insurance), and 3) an effective communication strategy that would allow AM-ARCH beneficiaries to understand what health services they are entitled to.

These priorities were used to form the backbone of the learning agenda. The ACS team supported the stakeholders to identify the following learning questions based on their discussions on the main questions regarding bringing the AM-ARCH pilot to scale:

  1. What are the key methods and strategies for designing and managing a successful complaints management system for AM-ARCH beneficiaries?
  2. What mechanisms should be put in place to better assess the quality of the health system?
  3. What are the strengths and weaknesses of the health service reimbursement mechanism?
  4. What is the impact of the communication plan on beneficiaries’ understanding of the health benefits package?

Indeed, the process of conception of the AM-ARCH learning agenda was a success because of the methods ACS used to make sure people felt like their voices were heard, everyone’s ideas were put on the table and the group collectively prioritized these learning questions. By going through the process of group ideation/brainstorming and then allowing the group to vote for which of the many ideas should be prioritized people were engaged and can see their questions/ideas reflected in the final set of questions that are now being pursued.

Good practices and lessons learned

The importance of advance preparation and fostering an open and inclusive working environment

The UGP’s leadership and ACS collaboration in preparing for and fostering an inclusive working environment (with support from the ACS project) contributed to the success of the learning agenda workshop. Before the event, ACS as a neutral facilitator, administered a questionnaire (by phone, Google form, and in-person) to all stakeholders to understand their expectations for the workshop. This preparation ensured that stakeholders’ expectations were incorporated into the design of the workshop, as demonstrated by:

  • Stakeholders having time in advance of the workshop to reflect on the lessons learned from the past as well as the expectations and challenges of the pilot phase and were then prepared to share this information during the workshop.
  • Those who did not feel comfortable speaking in public (fear of authority, for example) could give their opinion freely in advance.
  • Allow the facilitation team to make a pre-synthesis and make methodological guidance.

Convincing results for a first multi-sector consultation experiment on AM-ARCH

The AM-ARCH pilot learning agenda workshop brought together key health system stakeholders across the health system. In the past, these stakeholders often worked in isolation with some of the key actors unable to contribute. This was the first time that UGP met with many of the implementation actors allowing the UGP leadership to understand concerns, answer questions about the scheme’s pilot phase, and develop points of agreement across the stakeholder groups. Key achievements of this first workshop include collaborative identification of anticipated pilot phase challenges, recognition by decision-makers of the usefulness of collaborating with a diverse group of health system stakeholders including providers, and the distribution of responsibilities among actors.

Participants completed a satisfaction questionnaire at the end of the workshop finding that 93% of participants were very satisfied with the way the workshop was conducted as well as its achievements. They appreciated the fact that “ACS as a project did not come with a preconceived work plan and the usual conventional project indicators.” ACS started its interventions “without preconceived notions and created an environment in which every voice was valued and taken into account. The decision-makers sat down and listened. Other stakeholders also shared their views without fear.

Defining learning or evaluation questions early in the implementation of the pilot phase has allowed UGP to prepare for forward-looking follow-ups that take into consideration stakeholders’ concerns, The answers to these questions would allow UGP to work more efficiently in AM-ARCH pilot phase implementation and scaling up. This first workshop laid out the foundations for an endogenous learning culture that could allow the actors themselves to learn lessons and good practices.

Furthermore, ACS provided participants with a set of learning methods that allow for various levels of rigor appropriate for each question and the timeline of the overall pilot. This workshop built a learning approach that differs from a conventional M&E approach in that it allows for not just periodic assessments to be conducted but also continuous lessons to be shared in real-time for more adaptive management and the use of evidence translation to support broader learning from contexts outside of Benin to further improve activity design. Thus, at the end of the workshop, participants identified and assigned each learning question a specific method of learning that was appropriate for the type of answers they sought. For example, methods such as “lean testing” and “rapid feedback evaluation” were chosen to evaluate, respectively, the implementation of a management system and the communication plan.

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