Making health insurance responsive to citizens: the management of members’ complaints by mutual health organisations in Kinshasa, Democratic Republic of Congo

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.

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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:

1. What are the MHO processes to manage and respond to member complaints and grievances?

2. 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?

3. What are some of the factors that influence their knowledge?

Study design and setting

To address the questions above we examined three MHOs (Mutuelle de santé des Enseignants de l’Enseignement Primaire, Secondaire et Professionnel (MESP) Kinshasa, MHO La Borne and MHO Lisanga) within four administrative districts of Kinshasa city where the three MHOs are located.

The MESP (MHO for Primary, Secondary and Vocational Teachers) in Kinshasa is a non-profit organisation that was launched in 2011. Enrolment into this MHO is mandatory for government employees (teachers and civil servants) working in the primary and secondary education system. In 2012, the government and the teachers’ labour union, established an agreement requiring a monthly premium contribution of FC9200 (~US$10) to be paid to the MESP for each employee covering a maximum of five household members. Half of this is to be deducted directly from employee payroll and the remaining half subsidised by the government.

The Centre de Gestion de risque et d’Accompagnement Technique (CGAT in English: Risk Management and Technical Support Centre) was created in 2010.30 It is a Congolese, non-profit, apolitical, non-religious and autonomous civil society umbrella organisation that provides managerial, technical and financial support to CBHIs offering voluntary-membership. MHOs La Borne and Lisanga are both community-based MHOs and operate under the CGAT umbrella and mentorship. In theory, the unit of enrolment is the entire household, but some exceptions are permitted. The annual standard premium contribution in these MHOs is US$55 (FC110 000 in 2021) per household, whether in the informal or formal sector. Although no government subsidy is offered to these MHOs, some financial support for operating costs is provided by international donor agencies through the CGAT. For the purpose of this paper, we pooled the data of these two MHOs, since both of them operate under the same CGAT umbrella.

Data collection and analysis

Using a sequential mixed-methods approach, the study comprised four types of sources: document review, in-depth interviews (IDIs), household surveys and focus group discussions (FGDs), as presented in the figure 2 below on data collection and analysis pathways.

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Qualitative data collection

Qualitative data analysis

The IDIs and documentary reviews allowed us to identify all of the practices applied by MHOs to gather and address grievances. These practices were categorised along the lines of the institutional arrangements presented in the conceptual framework shown in figure 1.

We applied both inductive and deductive analyses of the qualitative data to generate thematic codes and subcodes. These were used to create a comprehensive codebook. Coding was done using ATLAS.ti. Responses from the IDIs informed the household survey.

Quantitative data collection and analysis

FGD respondent selection and data analysis

FGDs with MHO members were conducted from 12 June 2021 to 21 July 2021 after a pretest on 1 June 2021 and 2 June 2021. This was timed with the aim to contextualise the information from the survey which occurred in the months prior. Questions revolved around understanding why some measures or decisions related to the institutional arrangements were not well known despite MHO managers’ declarations that they used specific channels to provide information and to collect claims. Those who participated in the survey were excluded from the FGDs. The final selection of participants was based on two key criteria: the availability of the targeted member and as much as possible, consideration of gender. The study included a total of 153 participants in 15 FGDs distributed as follows: 8 for the MESP and 7 for the CGAT (4 for Lisanga and 3 for La borne). FGDs were conducted in French or the local language (Lingala with a translated guide) by five experienced moderators, including members of our research team. Participants provided written consent. FGDs lasted between 1.5 and 2 hours, were audio recorded and complemented by written notes. Recordings were then transcribed and translated into French when necessary.

Patient and public involvement statement

There were no patients involved in this study. Participants were members of the MHOs as described above. A consent form was presented and explained by team members prior to each IDI, survey and FGD. Each participant was required to sign the forms to indicate informed consent. The results of the study will be disseminated to participants through workshops for validation of results for the concerned MHOs, the development of policy briefs for decision makers and dialogues for the MHO platforms.

Processes for grievance redressal

We found limited information on institutional arrangements, implementation measures or management of member complaints in the document review. However, IDIs with MHO managers confirmed the presence of five institutional arrangements presented in the conceptual framework in figure 1. Our study focused on one institutional arrangement measure, which is the ‘procedure of the management of member complaints’. This arrangement was selected as it is probably the most used by MHO members.

According to the MHO managers, all members are informed about the processes for registering and addressing complaints. MHO managers indicated that MHOs have instituted several mechanisms to channel member concerns and complaints. These include complaint books to register verbal member claims and claim letters, suggestion boxes in the MHO offices and in the contracted health facilities, telephone calls, face-to-face meetings between MHO brokers and members, the MHO’ General assembly and occasional member surveys. In the absence of a policy or guidance to address a particular type of complaint, MHO brokers escalate the case successively to the MHO Committee Board, its general assembly, or the MHO platform.

Of all these channels, MHO managers indicated complaints by phone was most common likely due to the faster response times.

Complaints during face-to-face contact are supposed to be addressed by MHO brokers at the health facility level for MESP members, and in some cases at the level of MHO headquarters for all of the MHOs. At the health facility level, direct contact is the most frequently used channel, much more than the registration book of complaints. In some instances, members channelled their concerns to the MHO via health providers.

In general, MHO brokers at the health facility level are responsible for managing member complaints given their front-line access to members. They play an intermediary role between health facilities and MHO members to discuss members’ concerns and encourage MHO responsiveness. One IDI respondent stated that:

Members are free to make an appointment with a medical advisor on a daily basis. A member can come and tell us about his dissatisfaction with the healthcare or quality of care in a health facility. (CGAT MHO Medical advisor)

We found, however, that regardless of channel used, registration and archiving of member complaints and suggestions was not systematic and often absent. In addition, MHOs did not have adequate systems to track their responses to members as noted below by an MESP delegate:

All complaints received are not properly reported in our activity report book or in using the periodic reporting software (SKYNET)—mainly if we can deal with it directly without escalating the complaint to the MESP headquarters. (MESP delegate, CH Elykia / Kimbaseke)

MHO management and response to member complaints and grievances

MHO managers mentioned some limitations with managing complaints using the existing procedures. MHO managers in both schemes cited stock-outs of medicines in health facilities and inadequate procedures to improve patient navigation as recurring member complaints. In response, all MHOs have made provisions to offer medicines directly to their members in the case of health facility stockout. For navigation, member complaints are mostly related to delays in getting the approval from the broker to attend another health facility. Other claims include issues such as reimbursement for prepaid medicines by the members.

Managers from both MHO schemes said that they annually organise rapid member satisfaction surveys. The MESP does this through phone calls and CGAT through select household visits. These surveys allow them to address identified problems and prevent reoccurrence. Survey reports are usually presented at the general assembly.

Member knowledge of MHO institutional arrangements, use of the grievance processes and their satisfaction with it

Members overall opinions on relationships with MHOs

Majority of the FGD participants expressed their dissatisfaction with respect to relationships with their MHOs. The following complaints were highlighted when trying to take advantage of their MHO benefits: unavailability of drugs in health facilities, poor reception by healthcare providers, delay in the reimbursement of prepaid services or specialised medicines, poor quality of care and medication, and lack of permission to get healthcare via outsourcing or specialised healthcare and medicines.

For example, MESP members believe that the responsibility of their MHO is to ensure quality care, mainly the availability of quality medicines in the health facilities, which are not available all the time. With respect to the use of phone calls to complain, even in the absence of a clear understanding of whose phone number was on the membership card, most of the MESP participants claimed that:

Even if you call these numbers, it usually takes longer before someone picks up the phone. Most of the time, the phone call does not go through, and we give up calling. (FGD Bahumbu, MESP and others)

CGAT members were relatively positive and recognised the effectiveness of using different channels for making a claim:

Communication channels do exist, such as suggestion boxes or direct contact with MHO delegates. However, the main problem is that members do not know how their complaints and suggestions are being managed by the MHOs, and this is one of the reasons for their dissatisfaction. (FGD Eglise La Borne/ CGAT)

Although CGAT members recognised the effectiveness of using different channels for submitting claims, members of the MESP declared that submitting a claim is a challenge, as everything has been imposed on members with little flexibility. When they do try to make a claim, the process is frustrating:

In our MHO, it seems that there is no channel, no mechanism for recording and managing complaints. For those who also have the possibility to complain, their grievances seem to be completely ignored. Members do not know on what basis their claims are selected and handled, even how long this process is taking before receiving an acceptable answer, even if our subscriptions say that we are fully covered. (FGD Saint Theo de Lemba/MESP)

Similarly, members mentioned their dissatisfaction in terms of communication with MHOs. For most of them, communication systems put in place by the MHOs were lacking or suboptimal. The following declaration confirmed this position:

There is no real information that comes to us unless you have difficulties with one or more hospitals, so you can contact them to get information. Otherwise, there is no information, neither among us, nor with the hierarchy. (FGD Saint Theo de Lemba/MESP)

The poor effective communication was further elaborated by another member:

Members could only be satisfied whenever they are quickly receiving feedback on their complaints… when they themselves have purchased specialized medicine to start a treatment and get the reimbursement of the amount spent within the same period as the sickness. (FGD of Lisanga—MHO/CGAT)

However, CGAT members complained that their MHO offices were usually closed or the MHO managers were not present in their offices.

It appeared that members were generally interacting among themselves on grievance and redressal mechanisms when facing issues in accessing healthcare. The best-informed people were those who had previously experienced difficulties and had consulted with MHO brokers for solutions. This was then an opportunity for MHO brokers to share information regarding the existing measures and on how members should use them to claim their rights.

The majority of the MESP FGD participants declared that the procedure for delivering their membership card was poorly organised. Furthermore, access to healthcare at the designated facility was often denied when the MESP delegate/broker was not present to assist. This results in either the member having to return on another day or the health facility keeping the member’s card for presentation to the delegate (broker) at a later time. In the event of loss, the member is charged a replacement cost of approximately FC10 000 in 2021 (US$5), or else further access to the health facility is denied. As a school teacher said:

All the school teachers go at the same time to the ITI N’djili (decentralized MESP office) and they can spend 3 to 4 hours waiting. In my family, nobody has a card currently. Why can’t the MESP schedule the distribution of the cards by school and by specific day of the week for every school? Between MESP and us, the dialogue falls on deaf ears. (FGD Ndjili for MESP)

Study strengths and limitations

To our knowledge, this study is the first to explore the knowledge, use and satisfaction of grievance redressal mechanisms instituted by MHOs in the DRC. Our study comes at a critical time as DRC is considering strengthening its health financing reforms from a UHC perspective. The mixed-methods approach that we used provided multiple sources of information and contributed to enhancing the validity and reliability of our findings.

The study also comes with some limitations. It was conducted in the specific urbanised environment of Kinshasa, DRC’s capital city. This is not necessarily representative of the situation of MHO accountability and responsiveness in the rest of the country. Furthermore, the study also does not explore important intrahousehold dynamics. In addition, some social desirability bias linked to some variables were not taken into consideration. However, it should be noticed that the results obtained from the qualitative approach have provided similar results to the quantitative approach, thus minimising these limitations. Finally, the study does not gather qualitative information on the broader relationship between MHO managers and users in terms of locating this within the broader political economy of the DRC.