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.

Autor: Waelkens MP; Université libre de Bruxelles (ULB), School of Public Health, 808 Route de Lennik, 1070, Brussels, Belgium. Maria-Pia.Waelkens@ulb.ac.be., Coppieters Y; Université libre de Bruxelles (ULB), School of Public Health, Health Policy and Systems - International Health, 808 Route de Lennik, 1070, Brussels, Belgium., Laokri S; Université libre de Bruxelles (ULB), School of Public Health, Health Policy and Systems - International Health, 808 Route de Lennik, 1070, Brussels, Belgium.; Tulane University, School of Public Health and Tropical Medicine, Global Community Health and Behavioral Sciences, 1440 Canal Street, New Orleans, LA, 70112, USA., Criel B; Department of Public Health - Equity & Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
Jazyk: angličtina
Zdroj: BMC health services research [BMC Health Serv Res] 2017 Aug 07; Vol. 17 (1), pp. 535. Date of Electronic Publication: 2017 Aug 07.
DOI: 10.1186/s12913-017-2419-5
Abstrakt: Background: Persistent 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.
Methods: We 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.
Results: Direct 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.
Conclusions: For 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.
Databáze: MEDLINE
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