An in-depth investigation of the causes of persistent low membership of community-based health insurance: a case study of the mutual health organisation of Dar Naïm, Mauritania

Abstract

BackgroundPersistent low membership is observed in many community-based health insurance (CBHI) schemes in Africa. Causes for low membership have been identified and solutions suggested, but this did not result in increased membership. In this case study of the mutual health organisation of Dar Naïm in Mauritania we explore the underlying drivers that may explain why membership continued to stagnate although several plans for change had been designed.MethodsWe used a systems approach focussed on processes, underlying dynamics and complex interactions that produce the outcomes, to delve into 10 years of data collected between 2003 and 2012. We used qualitative research methods to analyse the data and interpret patterns.ResultsDirect causes of stagnation and possible solutions had been identified in the early years of operations, but most of the possible solutions were not implemented. A combination of reasons explains why consecutive action plans were not put into practice, showing the complexity of implementation and the considerable management capacity required, as well as the challenges of integrating a novel organisational structure into exiting social structures.ConclusionsFor any CBHI project aiming at high membership, skilled professional management seems essential, with capacity to question and adapt routine procedures and interpret interactions within the wider society. Countries that include community-based health insurance in their strategic plan towards universal coverage will have to pay more attention to management capacity and the minutiae of implementation.

Assessing out-of-pocket expenditures for primary health care: how responsive is the Democratic Republic of Congo health system to providing financial risk protection?

“…Price discrimination practices may occur to overcome the absence of nation-wide cross-subsidization from wealth to poor (income) [ 41 ]. On the other hand, coping with relatively ineffective ‘EXIT and VOICE strategies [ 42 ]’ as ultimate mechanisms to enhance providers’ responsiveness may also exacerbate the burden [ 43 ]. In several respects, the situation is distressing and would require a superior focus on tackling health system failures that create the economic burden of illness.…”

Time to abandon amateurism and volunteerism: addressing tensions between the Alma-Ata principle of community participation and the effectiveness of community-based health insurance in Africa

“…In Africa, the development of community-based health insurance (CBHI: autonomous, not-for-profit, voluntary member-based organisations based on solidarity3) is, along with primary health centre management committees, a core component of this participation strategy. Indeed, a key characteristic of CBHI is that ‘the community is involved in driving its setup and in its management.’4 Yet despite a momentum observed in the development of CBHI schemes nearly three decades ago5 6—generally referred to as health mutuals (mutuelles de santé) in francophone countries—numerous studies have highlighted the difficulties encountered in actually implementing user participation: the low contributive capacity of populations, resulting in low enrolment rates and a very limited amount of premiums; very unequal consideration of the needs of beneficiaries (variability in the package of care covered, insufficient quality of care, tensions between CBHI schemes and health service providers); limited benefits for the poorest, who are not involved and the voluntary nature of enrolment and amateurism of management 7–11…”

Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo

“…These findings are consistent with previous study results highlighting the weak bargaining power of MHOs in their relationship with providers. Reasons evoked in this earlier work are their relative insignificance for hospital finances [23], a position of monopoly of providers in rural areas [24], and power imbalances [25,26].…”