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  • 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

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Commentary
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
  1. Valéry Ridde1,2,
  2. Abena Asomaning Antwi3,
  3. Bruno Boidin4,
  4. Benjamin Chemouni5,
  5. Fatoumata Hane6,
  6. Laurence Touré7
  1. 1 IRD (French Institute for Research on Sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Montreal, Canada
  2. 2 University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
  3. 3 Centre lillois d'études et de recherches sociologiques et économiques (Clersé), Université de Lille, Lille, France
  4. 4 Centre lillois d'études et de recherches sociologiques et économiques (Clersé), Université de Lille, Lille, France
  5. 5 Department of International Development, London School of Economics and Political Science, London, UK
  6. 6 Département de sociologie, Université Assane Seck de Ziguinchor, Ziguinchor, Sénégal
  7. 7 Miseli, Bamako, Mali
  1. Correspondence to Professor Valéry Ridde; valery.ridde{at}ird.fr

https://doi.org/10.1136/bmjgh-2018-001056

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    Summary box

    • Forty years after the 1978 Alma-Ata declaration, the second international conference on primary health care in October 2018 is expected to reaffirm the place of communities in health systems management and governance.

    • In parts of Africa, community-based health insurance (CBHI)—with communities at the centre—is still seen as a strategy for achieving universal health coverage (UHC)—but there are tensions between the Alma-Ata principle of community participation, as currently interpreted, and CBHI.

    • The tension relates particularly to the community’s role in terms of the voluntary nature of CBHI membership and volunteer involvement of the community in governance andmanagement—this tension requires a rethink of the role of communities in CBHI.

    • We use examples of Rwanda, Ghana, Mali and Senegal to demonstrate the challenges associated with the place of communities in CBHI, and the need to reduce the role of community volunteers in CBHI and instead focus on professionalising management.

    • Countries that still wish to rely on CBHIs for UHC must find ways to make populations enrolment compulsory, and strengthen the professionalisation of CBHI management, while also ensuring that communities continue to have a place in CBHI governance.

    Introduction

    The 1978 Alma-Ata declaration asserted that primary healthcare ‘requires and promotes maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary healthcare.’1 It enshrined community participation in health management. Thirty years on, however, WHO’s 2008 report on primary healthcare2 noted the weak progress in this area and reaffirmed the need to mobilise people’s participation. The declaration formulated in anticipation of the second international conference on primary healthcare, slated for October 2018 (Kazakhstan), reiterates these principles by promoting community participation in healthcare governance, management and funding and by considering populations to be coproducers of health.

    In Africa, the development of community-based health insurance (CBHI: autonomous, not-for-profit, voluntary member-based organisations …

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