Health Insurance Risk Management in the Comoros
1. Context
The Union of the Comoros (Comoros) has specific characteristics that impact the organization of health services, hospital services, and care pathways. Comoros is an archipelago with an estimated population of 909,529 inhabitants (2025), of which 45% live below the poverty line.
Concerned with accelerating progress towards achieving Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) by 2030, the Comorian government has made the implementation of Generalized Health Insurance (Assurance Maladie Généralisée “AMG”) one of its priorities. The AMG is defined as a basic medical coverage that should gradually benefit the entire Comorian population and, by extension, all Comorian residents. To make the AMG operational, the Comorian government receives funding from the French Development Agency (AFD) for a support project for the AMG, titled "PAAMG," under which technical assistance is provided by the AEDES-Swiss TPH consortium from July 2022 until the end of June 2027.
The UTGAM (Technical Unit for the Management of Generalized Health Insurance) is the pilot management body for the AMG. The enrollment process for insured individuals began in June 2025, and the coverage of health services was opened in December 2025, inaugurated by the President of the Union of the Comoros. The pilot zone covers 7 health districts across three islands, with a projected coverage of nearly 65%. The pre-registration phase recorded 160,386 potential insured individuals, of which 72% could benefit from government subsidies at various levels.
A detailed preparation phase for the AMG has focused on institutional, operational, and technical aspects, including regulations, contractual provisions, personnel mobilization, the definition of standard operating procedures, and the adjustment of the management information system.
The PAAMG, including the technical assistance it mobilizes, continues with the presence of two permanent technical assistants, experts in public health and health insurance, and a plan to mobilize short-term experts for specific institutional, organizational, and technical support needs, particularly related to the openIMIS information management system and the institutionalization of the AMG.
However, specific support is still needed to strengthen the capacities for managing risks related to health insurance, which cannot be covered by the current mandate of the AEDES-Swiss TPH consortium under the PAAMG. Indeed, managing health insurance requires techniques and knowledge, particularly to ensure the economic viability of the system. Once the scheme is in place, the main challenges consist of closely monitoring its operation and detecting anomalies such as low enrollment numbers, collection of contributions, or overconsumption of healthcare, which requires specific controls and guidance for decision-makers.
2. Objectives
The project aims to improve the performance of the health insurance scheme "AMG" through an actuarial and risk management approach that enhances efficiency and cost control, while ensuring equitable access to care for the population. This approach encompasses prevention, quality of care, accessibility, and combating the main risks associated with health insurance (moral hazard, fraud, waste, abuse, and cream-skimming).
Specifically, the project aims to achieve the following objectives:
A. Establish a digital solution to anticipate risks related to health insurance based on standard health insurance indicators, data shared by openIMIS (the information management system for insurance), and periodic collection of other necessary data (e.g., monthly administrative costs) from stakeholders to inform decision-makers.
B. Develop national capacities for managing risks related to health insurance within the technical management unit of the AMG, particularly for data management experts and actuaries.
3. Method/Approach
The project will be implemented in three phases over 18 months, including a preparatory phase of 3 months (needs assessment, IT development of the solution, training plan, etc.), a 12-month period corresponding to the annual cycle of the health insurance scheme, necessary for conducting a coherent data analysis (including training), and a capitalization phase.
4. Target Groups
The primary target group is the personnel of UTGAM, who will benefit from capacity building in risk management. More broadly, the beneficiaries of the AMG and the Comorian population will benefit from the improvements made to the AMG, leading to more reliable and accessible medical coverage.