Background
The evolution of community-based health insurance schemes to move towards universal health coverage
Health services are underused in several low-income and middle-income countries (LMICs). This is due to a wide range of factors, including poor availability, accessibility and affordability of quality healthcare. Given that insufficient public revenues fail to adequately fund the health system, health services often resort to a cost-recovery strategy funded through direct payment of care by households at the point of delivery, in other words out-of-pocket payments (OOP).1–3 OOP payment constitutes the predominant form of healthcare financing in several LMICs, and funding generated through it often serves to complement salaries and the operational costs of health facilities.2 4–6
In line with the WHO’s guidance related to universal health coverage (UHC)7 in the context of limited capacity to finance sustainable social protection, several governments in LMICs have instituted national health financing reforms. Such reforms seek to enhance household protection against catastrophic health expenditures. They address public expectations through strategies to remove financial barriers to healthcare access.6 8 To this end, many countries have opted to promote the use of community-based health insurance (CBHI) as one such strategy.8 CBHI is a financing mechanism characterised by community solidarity, participatory decision-making and management, and a non-profit policy. Other characteristics include affordable premium contributions, financial transparency, fair regulation in the provision of healthcare and adequate funding mechanisms.9–11 Through CBHI, households can reduce OOP payments which are significant financial barriers to accessing healthcare.1 12–17
The management of CBHIs relies considerably on community participation.2 9 18–21 CBHIs use social accountability mechanisms that require public participation to recognising failures in the delivery of healthcare services and, consequently, can apply pressure on providers for improvement, reform, and accountability to the community.15 22
Low awareness on community-based insurance principles among enrollees is a major challenge for CBHIs.23 This is often on account of poor provision of information around CBHIs as well as broader political economy factors that reinforce power asymmetries between users of health services and providers and government officials, with the latter group not feeling the need to communicate clearly with users of services.23 The lack of information coupled with inadequate accountability, transparency, trust and poor responsiveness of CBHI constitute barriers to enrolment; thus, compromising progress towards UHC.3 6 24
CBHIs in the Democratic Republic of Congo
In the Democratic Republic of Congo (DRC), there is no national social health insurance scheme or programme. In this setting, CBHI is implemented by ‘Mutuelles de santé’ (mutual health organisations—MHOs). MHOs appeared in the 1990s as healthcare financing and pooling mechanisms to bridge the health financing gap.25 However, MHO penetration in the country remains low, representing 7% of household payments on health in 2015.26 In 2017, DRC finally passed a law organising MHOs and published a social protection policy document.27 28 Both documents described MHOs as a critical health financing mechanism. Employees in the formal sector are enrolled according to the DRC labour law (Loi organique No 17/002) which states that, an employee and his/her family members are entitled to be supported for healthcare by his/her employer.27 In DRC, some small-sized and medium-sized enterprises rely on CBHI to provide financial healthcare access to their employees, in the geographical area where they are implemented, leading to a kind of group enrolment in a CBHI. Two schemes of MHOs appear in these documents: one for employees in the formal sector with compulsory enrolment and premium contributions deducted from salaries. The second scheme, more organised as a typical CBHI scheme, is mainly intended for workers in the informal sector where the enrolment and premium contributions are individually and voluntary based. In all MHO schemes, healthcare services are offered by private or publicly contracted primary health centres and general referral hospitals based on their locations across the 24 municipalities of the city of Kinshasa. Healthcare services offered at hospital level are accessible only with referral from health centre and approval by an MHO broker, except in case of emergency and life-threatening conditions.
The extension and professionalisation of MHOs are reflected in DRC’s UHC strategic plan 2020–2030 which strives to enhance social protection for the citizens.19 28–30 The extension of social protection through high coverage rate of CBHIs as expected from the strategic plan relies on trusted relationships between MHOs and their members and high satisfaction with services which would facilitate increased penetration.
MHO accountability and responsiveness mechanisms in DRC
Inappropriate MHO delivery service discourages members and they often fail to renew their membership in CBHI schemes, or even, to turn into automedication, therefore increasing OOP.3 MHO schemes have, therefore, instituted several mechanisms to enhance accountability and responsiveness to member needs and expectations, including information provision, navigation mechanisms and grievance redressal mechanisms. Despite oversight arrangements and members participation in decision-making as two other mechanisms to enhance accountability and responsiveness to member needs, few steps have been taken by MHOs to implement these arrangements.15 31 All the mechanisms mentioned above were brought together in a generic framework describing the institutional arrangements aimed to enhance MHO accountability and responsiveness (figure 1). More details on figure 1 are provided later in this section.
With respect to the provision of information and assisting with navigation, MHOs in DRC provide documentation to members, create channels of communication (phone or face to face), and avail procedures of grievance reporting. These are intended to be accessible to members, MHO brokers and health facility managers. Documents (letters, registration books, survey reports, general assembly reports), emails, phone calls, WhatsApp and face-to-face visits are used to register and track members, as well as record members’ complaints and suggestions. In case members are unable to navigate the various processes, they can consult with MHO brokers who are either MHO employees delegated at the health facility or MHO medical advisors. MHO brokers play an intermediary role between providers in health facilities and MHO members in order to address member concerns and to assist them in navigating between health facilities.
With respect to grievances and complaints, MHO members can contact an MHO broker in person or by phone. The MHO brokers are then required to apply the necessary processes. Should this fail, brokers can escalate member complaints to the MHO Committee Board or to its general assembly.
Though MHOs intend to reduce household OOP expenditures, their effectiveness is hindered by a lack of financial support from the government, extreme poverty within the population, provision of poor-quality healthcare, adverse selection of individuals with a history of chronic disease, a history of distrustful relationships with a community and low enrolment rate.6 32 33 Furthermore, there is a knowledge gap related to the effectiveness of the various processes instituted by the MHO to provide information, sensitise community members and manage the relationships with different partners in the DRC. Thus, it is important to understand how best to enhance the effectiveness of the MHOs accountability and responsiveness toward their members, as MHOs are very suitable organisations that could reach people in their specific communities, even in the remote risky areas throughout the country, including the ones in war-torn North Kivu and Ituri, mineral-rich Haut Katanga and remote Bas Uélé provinces. This would consequently enhance MHO penetration as well as improve their overall functioning,
Figure 1 is adapted from a framework by Goetz and Gaventa31 and Molyneux et al15 to depict the links we sought to explore. The extent of member empowerment and MHO responsiveness are interlinked and dependent on member participation organisational accountability to the population being served.3 34 Increased member knowledge and improved social protection through grievance redressal mechanisms are rooted in the ability of MHOs to empower their members.35 36
Study aims
The DRC context is characterised by an insufficiently regulated health system, and by political, economic and social factors that play a major role in influencing how initiatives at the community level translate into empowered MHO members and MHO responsiveness. When preparing tools for data collection and analysis, the framework informed how the interview guides were structured and data analysis planned.
In response to the knowledge gaps and dissatisfaction highlighted above, the study assessed grievance redressal mechanisms that are used by MHOs to manage member complaints (highlighted in grey in figure 1). The study explored three main questions:
What are the MHO processes to manage and respond to member complaints and grievances?
To what extent are the members knowledgeable about the MHO institutional arrangements, their use of existing grievance processes and their satisfaction with the MHO response?
What are some of the factors that influence their knowledge?