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Innovations in mutuality: challenges and learnings for the Universal Health Insurance Plan in Mali
  1. Laurence Touré1,
  2. Pauline Boivin1,
  3. Yacouba Diarra1,
  4. Seydou Diabaté1,
  5. Valéry Ridde2,3
  1. 1Miseli, Bamako, Mali
  2. 2Ceped, Université Paris Cité, IRD, Paris, France
  3. 3Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
  1. Correspondence to Professor Valéry Ridde; valery.ridde{at}ird.fr

Abstract

Background Many Sahel countries in Africa are looking for solutions for universal health coverage (UHC). Mali is in the process of adopting the Universal Health Insurance Plan, which allows for the mutualisation of existing schemes. Its operationalisation requires numerous adjustments to the current mutualist proposal and innovations in the system. The study focuses on innovations experienced in mutuality and their conditions of scale for UHC in Mali.

Methods This is qualitative research by multiple case studies. It is based on the collection of data by interviews (n=136), at a national and local level, on the analysis of documents (n=42) and a long field observation (7 months). The analytical framework concerns the dissemination and maintenance of health innovations (Greenhalgh et al, 2004).

Result The analysis of this innovation shows an interest in the technical and institutional viability that determines its performance and scale-up. The procrastination and scepticism displayed at the highest level of the state and the international level, the reluctance, both financial and ideological, to renew the old mutualist proposal, penalise this Malian experiment.

Conclusion This innovation is a decisive step in ensuring the health coverage of Mali’s agricultural and informal sectors. The reform will need to be amplified and supported in the future to expect the scale-up of a cheaper, technically and institutionally more efficient system. Without a political intention to mobilise national resources and accept a fundamental paradigm shift in health financing, the search for the financial viability of mutuality may, again, be at the expense of the performance.

  • health insurance
  • health systems

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2022-011055

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Community-based health insurance (CBHI) has failed to protect populations in the Sahel’s agricultural and informal sectors.

    • The Sahel countries are reforming their mutualist proposal from the perspective of UHC.

    WHAT THIS STUDY ADDS

    • The experimental conditions of the pilot CBHI reform programme are the main obstacles to the system’s innovation.

    • The financial viability of an attractive CBHI scheme for the target population requires optimising the technical reform, organisation and institutional commitment.

    • The non-systemic approach and the lack of communication, collaboration, and involvement between national and local actors hamper the development of a performative mutualist system.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • The pilot project, freed from CBHI principles and in a region disturbed by insecurity, could lay the foundations for an effective and sustainable system for health coverage in the informal and agricultural sectors.

    • The national Universal Health Insurance Plan must provide a framework to initiate a reflection on the reform of mutuality and the health system.

    Introduction

    In addition to the security challenges, Mali has faced over the past decade and which have had a significant impact on its health system,1 it faces many obstacles in finding solutions to strengthen its health system and universal health coverage (UHC).

    However, various sociohealth reforms have been driven and encouraged by international technical and financial partners.2 3 In the 1970s, Mali introduced primary healthcare. In the 1980s, the country generalised direct payment in community-run health centres,4 such as Benin, Guinea or Niger.5 While this policy has ensured better geographical availability of essential generic medicines, it has yet to be able to improve access to care.6 In the 2000s, Mali embarked on reforms focused on the demand for care by organising payment exemption policies.6 7 The effectiveness of these policies in West Africa varied greatly6 with notable successes in Burkina Faso,8 failures in Niger9 and challenges in Mali.7

    The Universal Health Insurance Plan (UHIP,RAMU in french) is the latest and arguably the most ambitious social reform proposed. It requires the merging of the various social protection systems against sickness (Compulsory Medical Insurance: AMO), Mutuality (community-based health insurance: CBHI), Medical Assistance Scheme (for the poorest: RAMED), User-fees exemption policies) under the aegis of a single para-public body, CANAM (National Health Insurance Fund). The aim is to pool resources and risks through concerted intervention management and a reduction in transaction costs.

    Given the low coverage of public health insurance in Africa, international partners began testing the organisation of community-based health insurance (CBHI) as early as the 1990s. Despite some relative successes for their (rare) beneficiaries in Benin,10 for example, they remained on a small scale, protecting only a tiny proportion of the population.11 Today, 9% of the people in Kenya and 5% in Senegal are members of a CBHI,12 13 despite an ambitious policy of UHC for the past 10 years.14 15 Thus, in their initial form of voluntary membership and community management, CBHI failed to deliver on their promises.11

    Several countries are currently trying to innovate and change how they operate. Research has shown that the presence of professional managers is a factor in the performance of CBHI.14 Work in the Democratic Republic of Congo in the 1990s prompted the creation of larger-scale CBHI, particularly that of the health district.16 However, only some countries have embarked on this dissemination. Senegal has transformed from communal CBHI to departmental CBHI. This transformation has proven to be effective in increasing coverage.17 In Rwanda, local CBHI moved to a national network in 2006 with a complete operation change. Membership in CBHI is not compulsory. However, it is mandatory to be insured by one of the existing schemes, which represents a solid constraint for membership. The professional management of CBHI is under centralised governance.18 But they still face equity challenges, especially in protecting the poorest despite membership subsidies.19

    While research on CBHI and insurance systems in Africa has focused heavily on the determinants of membership or how they operate,20–22 more work needs to be taken to understand current innovations (larger-scale structuring, professionalisation, incentive/obligation to membership, etc). Although since Rogers’ proposals,23 there have been numerous analyses of health innovations, such as Greenhalgh et al’s famous meta-analysis,24 studies in West Africa on social25 innovations in health systems remain rare26–28 unlike technological innovations.29

    This study aims to understand the conditions for experimentation and possible scale-up of innovations in the field of a CBHI proposal in Mali in the context of UHIP.

    Methods

    Study setting

    The Malian state has renewed its trust in CBHI to cover 78% of the population, despite a low performance and lack of alternatives deemed acceptable. Meeting this challenge, therefore, required tackling both the problems of operationalising this policy and the low attractiveness of the mutualist package proposed since the 1990s. The national strategy for extending health coverage to agricultural and informal sectors by CBHI laid30 down the principles of this reform in 2010. The Health Financing Strategy for UHC will be developed in 201331 and the RAMU law in 2018.

    In the context of the slow maturation of RAMU, in 2015, a pilot experiment was initiated as part of the Programme of Support for Socio-Health Development, Phase 2 (PADSS2), funded by the French Development Agency. It incorporates a large number of proposals from the Strategy. It provides attractive membership conditions and offers, professionalisation of the service and deployment of CBHI on a broader scale (table 1).

    View this table:
    Table 1

    Presentation of the experienced mutualist system and offer in Mali (in italics the innovations)

    Study design

    This study is qualitative research by multiple case studies with several levels of analysis. The cases are the CBHI, MICBA (Interprofessional CBHI of the Bandiagara district) and MICMO (Interprofessional CBHI of the Mopti district), which implement the innovations. They are implemented in two circles in the same region of Mopti: Bandiagara and Mopti. The analysis levels correspond to the conceptual framework’s geographical scales and dimensions. Mali is organised administratively into regions, cercles and communes.

    Conceptual approach

    We used the conceptual framework of Greenhalgh et al24 for disseminating and maintaining health innovations adapted to the purpose of our research (figure 1). The authors point to the fact that many promising innovations in the field of health have resulted in unsuccessful attempts to scale up. They produced a framework for analysing the dissemination and maintenance of inventions, helping to predict and evaluate their success, taking into account different dimensions to be studied (box 1).

    Box 1

    Adaptation of the conceptual framework to the context of the study

    The external context is the international, national or local influences exerted on the experiment and may impact its scale-up. The internal context is the sociohealth sector. It includes the history of the mutualist system in terms of innovation, the institutions that constitute it, the interactions between actors/institutions, their responsiveness to change and the state of preparation of the sociohealth system for innovations. The actors of change are the two actors that have pushed for innovation and enabled it to materialise: (1) a group of experts responsible for the operationalisation of RAMU and (2) Programme of Support for Socio-Health Development, Phase 2 (PADSS2). The characteristics of the innovations are those of the innovative mutualist system experienced in the PADSS2 and able to influence its adoption. Formulation and implementation are the actions undertaken during the stages and activities of this mutualist programme.

    Figure 1
    Figure 1

    Analytical framework.

    Sampling and data sources

    The surveys were conducted from October 2019 to December 2021, and several data collection methods were used (table 2).

    View this table:
    Table 2

    Data collection methods

    Supplemental material

    Interview sampling strategy

    At the national level, we interviewed the leading executives involved in mutuality, the RAMU and the PADSS2 programme. At the level of the circle, we met with the actors involved in the reference health centre (district hospitals), the boards of administration of CBHI, and the Technical Union of Mutuality (UTM) regional coordinators.

    At the local level, we selected six municipalities, three per circle. These are the municipalities of Mopti, Sio and Socoura in the circle of Mopti and the municipalities of Bandiagara, Dourou and Soroly in the circle of Bandiagara. These municipalities were chosen to vary the contexts: performance of the communal section of the CBHI (membership rate), the performance of the Community Health Centre (CSCom, primary health centre) (frequency) and the urban or rural character of the municipality. The insecurity factor forced us to exclude some of the municipalities initially retained. In these six municipalities, our interlocutors were the mayors, the elected representatives of the six communal CBHIt sections, effectively involved in the activities of the CBHI society, the health professionals of the CSCom and the mutualist members. The sample of mutualists was randomly selected from the membership base of CBHI by telephone.

    The observation phases were organised in the same municipalities and at the level of the regional coordination of the UTM. We have chosen to follow in their activities the main professional actors recruited by the UTM at the rate of one whole week per observation post: six managers, three development assistants, two medical advisers, the coordinator and the central manager. We also observed 1 week in each of the six health centres in the selected municipalities. Finally, at the end of 2019, two assistants followed the week of intensifying awareness-raising activities and enlisting CBHI to observe the interactions between elected mutualists and CBHI professionals. Systematic and daily notetaking of all these observations was made.

    Analysis

    We fully transcribed all the interviews in French and entered observation notes. Those data were analysed manually in light of the dimensions of the conceptual framework.32 The authors’ reflexivity statement has been added as online supplemental appendix 2.

    Supplemental material

    Results

    We will present the results for each dimension of the conceptual framework. Table 3 gives the overall summary of the analysis.

    View this table:
    Table 3

    Summary of empirical results

    External context

    UN organisations have long resisted implementing social policies.33 As part of the promotion of UHC, from 2010 onwards, they declared themselves in favour of social protection and promoting health insurance in the countries of the South.

    However, there are divergent views within the international community on the policies to be prioritised to achieve UHC.34 International partners encourage health and social policies that often compete.35 Sceptical about the capacity of CBHI to cover the informal and agricultural sectors, external support tends to focus on strengthening health supply rather than organising demand for care.

    International mutualist networks, including that of UEMOA (West African Economic and Monetary Union), have contributed to adopting regulations and social legislation. They are essential meeting and advocacy frameworks (Abidjan, Lomé, etc). They now place ‘the development of CBHI from an ‘ecosystem’ perspective and seek to promote the mutualist model as a lever for UHC.36

    Our documentation review and interviews with various national stakeholders and partners showed that the Malian state reproduces its partners’ ambiguous and ambivalent positioning on achieving UHC. In recent years, the inconsistency of policy directives has resulted in a stack of policies that need to be revised. The government’s position on the direction to be prioritised to achieve UHC remains somewhat disconcerting and unilinear. The absence of arbitration at the highest level of the state, even though health funding from the state budget does not reach 6%,37 fuels scepticism about the state’s ability to achieve its commitments:

    We have a governance problem related to people’s issues too. The RAMU depends on three departments without a level above, which is a problem. A minister cannot hold another minister accountable at the same level as the minister. The one in charge of the file must inform and involve others. What he doesn't always want to do to keep his hand on the file. However, for a long time, no one has followed this issue in primacy. — Civil Society and Partners, 2

    Finally, the political security context is worrying. The Mopti region, where innovation is taking place, is symptomatic of this climate of insecurity and the resulting consequences in terms of the growing vulnerability of populations and the health system breakdown.

    Sector context and system preparation for innovations

    Institutions and their interactions

    The social sector was built in Mali in the budget shadow and the indifference of health actors. This lack of synergy translates into weak intersectionality in the debates and favours partisan positions at the expense of the system. Inconsistencies within the state encourage and reinforce historically constituted intrasectoral divisions and tensions. Beyond consensus on the need to move towards UHC, the divergence of approach between health and social development is recurrent.35 38 39

    There are few actors involved in mutuality. They are essentially the regulatory and supervisory structures and a flagship structure belonging to civil society, the UTM (Union technique de la Mutualité), which provides authentic leadership, thanks to its experience and technical expertise, unparalleled in Mali (figure 2).

    Figure 2
    Figure 2

    Actors involved in mutuality. UTM, Technical Union of Mutuality.

    History of change and receptivity to innovations

    The UTM developed a fairly reformative view of the coverage of the informal and agricultural sectors. However, it needs help to express it since it derives its legitimacy from the mutualist movement and suffers from the recurring underfunding of the sector. The arrival of a new player in 2019, the AMAMUS (Malian agency for social Mutuality), shakes the institutional head-to-head between the Malian state and the UTM without stimulating a real reform dynamic despite the substantial autonomy conferred on it by its status.

    Other national actors concerned with social protection remain on the margins of decisions on mutuality, in particular the Directorate General of Health, the National Health Insurance Fund and the National Medical Assistance Agency. Local actors need to be stronger involved due to reduced decentralisation of decisions and inefficient management of partnerships.

    Competition to access scarce social resources fuels institutional tensions that weaken it. Professional and bureaucratic culture (respect for hierarchy, vertical communication) generates weak collaborative dynamics and encourages routine behaviour:

    This lack of synergy, this notorious lack of collaboration between actors on the ground, is as if everyone is trying to draw the cover towards him by forgetting that, individually, no one will be able to have good results. With the momentum we are currently in the mutualist movement, I am not very optimistic for RAMU. State/expert group, 4

    In terms of ideas, a significant community ideology considers appropriate to the African context. Its use by the State has been reflected since the 1990s in creating multiple community entities, including community health associations (ASACO) that manage primary health centres and CBHI despite their ‘poor result’ (civil society and partners, 5).

    Voluntary lay management is often considered preferable to the risky dependence on state funding, which would compromise the autonomy of CBHI. Resistance to change is manifested by a weak consideration of the recommendations of studies which, for a long time, show structural weaknesses and propose solutions, including the professionalisation of management and broader portability of a more attractive product.16

    System readiness for change

    In 2015, we noted the beginning of a dynamic of change. It is a question of reducing the system for rapid national coverage and of carefully engaging in reflection on the limits of the original model of CBHI and the possibility of overcoming it:

    It is said at home that we must not see the clouds and empty the jar, so it is essential that we continue but keep the existing one. For the time being, it is the community mutuals but on a circle scale rather than a communal one. UTM, 8

    Agents of change

    Since 2015, the group of experts in charge of the operationalisation of the UHIP has given new impetus and the opportunity to make the reform a reality. This multidisciplinary group of experts, composed for the most of national executives, constitutes a unique framework for consultation and multisectoral reflection.

    By putting CBHI into perspective for the first time with the two other existing social protection systems (AMO and RAMED), it proposes a law that constitutes a reforming framework for mutuality. Many CBHI principles are thus called into question. The prescription of compulsory membership of the UHIP calls into question the principle of voluntary membership of CBHI, the management of risk by the CANAM and the significant involvement of the State (subsidisation of 50% of the amount of contributions), marking the end of the autonomy of CBHI. This perspective requires the professionalisation of the CBHI system. Finally, it suggests a streamlined structure at the level of the circle, offering national portability of an insurance product equivalent to other existing schemes.

    ‘Many questions remain to be solved because there are different mutualist principles incompatible with UHIP: voluntary membership, different contribution levels, harmonisation to be planned and probably difficult to do.’ State/Expert Group, 4

    Since the end of 2018, this group has been struggling to give actual content to the various decrees implementing the law to bring this mutuality reforming logic to fruition. In addition to the problems of political instability in recent years, the progress of the work has been hampered by its very inclusive operation. The National Committee for Reflection and Follow-up for the Operationalisation of the UHIP, whose function is precisely to validate and monitor the proposals of the group of experts and to open debates, has only met twice since its creation in 2015. The Civil Society Platform for UHIP is no longer held due to a lack of external funding. Finally, the expert group deplores the lack of quality studies to support the reflection, especially around the thorny issues of financing the scheme, while national technical expertise in the actuary field is still limited:

    Many questions remain to be resolved because there are different mutualist principles incompatible with RAMU: voluntary membership, different contribution levels, harmonisation to be foreseen and probably difficult to do. State/expert group, 4

    The PADSS2 occurs in this context. This programme presents the originality of a comprehensive approach (supply and demand) with the parallel implementation of three components. Component 1 focuses on strengthening the provision of maternal and child healthcare. Component 2 provides ‘the establishment of an innovative financing mechanism aimed at the accessibility of care and the sustainability of health facilities’.40 Ultimately, the development of CBHI is retained by the National Strategy. Component 3 aims to strengthen the capacity of ministries involved at a central level and deconcentrated in their planning and oversight missions.

    Experienced in the only two circles of Mopti and Bandiagara (Mopti region) between 2017 and 2021, this programme is presented as a pilot from the perspective of RAMU. It considers the proposals for reforms contained in the strategic and planning documents for CBHI actors of the UHC.

    These two actors of change need to pursue the synergy of action and reflection envisaged in the formulation of the programme over the long term. The two processes, the pilot programme and the operationalisation of RAMU are evolving in parallel. The PADSS2 coordinator needs to participate in the expert group meetings as initially planned. The PADSS2 Steering Committee rarely meets. The progress of the pilot programme needs to be presented to the specialist group. The latter endorses certain decisions in the context of the implementing decrees of the RAMU Act without worrying about the results of the pilot experiment underway.

    Mopti’s experimentation was also very poorly known to the group of experts when this program was set up to experiment. We are moving forward without referring to what is being done in this experiment. State/expert group,6

    Features of the innovative scheme

    We note the compatibility of the experienced scheme with the new international creed and the national recommendations. It is also the expression of a largely endogenous dynamic. Both the actors of change and the drivers of the initiative are part of the sociohealth sector. Only funding is mainly external.

    This mutualist proposal has visible and observable advantages compared with community CBHI. There is a clear interest in the model from target populations and local partners. Professionalisation improved access to the CBHI service, the reliability of the management, thus the credibility and performance of the scheme:

    The role of salaried agents in the establishment of the section is enormous; they are like the engine of the CBHI; they are the ones who train us, they inform us, they show us the paths to follow, and they help us to sensitise people to join the mutual insurance company. (H, section social action secretary, Mopti circle)

    With the MICBA CBHI, the quality of the remedies is better with a technical and medical team that controls and monitors the products prescribed to patients. Whereas with the communal CBHI, there was no control over the quality of the products prescribed. (H, section secretary for external relations, Bandiagara circle)

    The attractiveness of the CBHI offer translates into a faster rate of penetration than that of previous schemes. In 2021, about 9% of the population of both circles were members of CBHI, while this rate was less than 1% in 2016, before the project.

    The experimental proposal is consistent in its innovative approach since it provides for complementary, organisational (professionalisation), technical (digitalisation), institutional (mutualist structuring on a circle scale) and financial innovations.

    However, the lack of formalisation of procedures makes the portability of the proposed model easier. Furthermore, modelling seems premature, as poor performance requires optimisation of the proposed institutional and technical framework.

    The validity of this innovative scheme is not optimal and could not be improved during implementation:

    As regards the institutional setup, implementation shows a practical simplification of the administrative procedure compared with the previous model. But the establishment of the various mutual bodies (mutuals and communal offices) takes time and requires a vital budget for the often-limited involvement of elected officials. Mutual authorities, aware of their limitations, are well accommodated from a management delegation to a team of professionals.

    Professionalisation has a certain degree of completeness, with that of human resources, material resources (provision of IT and logistics equipment) and activities (management activity in particular). On an unprecedented scale in Mali, it nevertheless shows some limitations:

    • Recruitment of qualified personnel in the absence of an actuary training structure.

    • The anticipation of the evolution of the workload defines the employee team profile.

    • Computerisation and automation of administrative and financial procedures.

    • The formalisation of team management tools, governance and internal management documents (modelling of the scheme).

    • Professionalisation of certain core activities: communication and management of partnerships. Health facilities need to be more involved in promoting mutuality or helping discourage mutualists.

    The risk of lack of financial viability of the experimented model is real since, at the end of the programme, the funds available can only cover expenditure up to 1 year, according to the regional coordinator of the UTM.

    Formulation and implementation process

    The programme’s ambitions are supported by substantial funding, and its 6-year duration, exceptional in support of mutuality, is a very positive factor.

    On the other hand, the choice of a region exposed to different hazards (one of the poorest, weak health indicators, context of insecurity) could be more conducive to a pilot programme. Thus, nearly half of the 57 communes of the two circles were under total jihadist occupation during the programme period, with most other municipalities being partially occupied.

    In addition, component 1 is neither in the context of innovation nor in the interests of the sustainability of the acquis. The contribution to establishing the accreditation process at a national and regional level is envisaged but without linking with component 2, and ultimately abandoned.

    The experienced mutualist system is separate from the systemic approach initially planned. From the moment of formulation, the activities are envisaged without consultation or coordination between the actors of components 1 and 2 of the PADSS2. Their implementation is done without synchronisation due to various administrative and bureaucratic constraints, both on the part of the state and the lessor. Scepticism, manifested openly against mutuality by the two successive PADSS2 coordinators, does not facilitate the understanding of the stakes of this pilot programme or the articulation of the two components. The two schemes coexist without actually collaborating.

    Finally, the UTM is selected as the lead operator, foreshadowing the delegated managing body (OGD) role it is called on to play in the context of the RAMU. This is a significant asset. Despite its strong expertise, it remains pretty new to the scale of innovations to be tested and articulated. It should be able to position itself as a learning structure, with technical support and continuous capitalisation, which is not foreseen in the programme. Indeed, the reflexive approach inherent in any pilot is limited during implementation. The technical management of the UTM is almost the only accountant of the outcome of this innovative experiment. Anxious to show its capacity to deal with rather than its doubts or the inevitable limits of the initial institutional and technical arrangements, and with little room for manoeuvring to make changes, it is limited to exciting adjustments but to the margin. The state is associated with the framework of a steering committee, but it remains in poor capacity for proposals and support for this local experience.

    Discussion

    For the first time in Mali, given the challenges of RAMU, a scheme with many innovations has been tested over a long period. It has characteristics that make it attractive to the population, more reliable and efficient, with a professionalised management allowing to consider the integration of mutuality in the RAMU to cover the informal and agricultural sectors. The penetration rate of 7% of the two CBHI in 2021 in a few years of implementation41 exceed the results achieved by CBHI over the past 30 years. However, they still need to be improved to ensure their viability and sustainability.

    The analysis of the contexts and the implementation process, usually overlooked,27 makes it possible to show that the conditions for implementing this experiment have reproduced, at the programme level, the main obstacles to innovation that have always been exerted against the mutualist project. Thus, strategic thinking and reforming ambition have been constrained by the actors' ineffective communication and consultation capacity and a certain ideological conservatism. This has played a negative role in communication around this pilot project and on the operator’s ability to convince in a local context of experimentation characterised by a strong scepticism of the partners and heavily impacted by insecurity. The deficit in the financial viability of CBHI is the result. However, it risks fuelling the very consensual chilliness of its designers and even more of its critics for fear of the consequences of adopting these innovations for RAMU. Finally, with some repercussions on a technical ‘design’ of CBHI possibly reduced, and an institutional status quo, even though innovations remain to be found to reduce costs and to build a new way of thinking about the health coverage of the agricultural and informal sectors.

    Senegal, which launched 2014 similar innovations through two departmental health insurance units (UDAM), is in this perspective. The context is relatively identical: the same international and national ambiguity for UHC, even a long history of an inefficient community mutuality and even the need to renew this proposal. In addition, the technical proposals come together: structuring at the level of the circle/department, professionalisation and subsidising of the state. But the Senegalese model has specificities. It renews the community approach by replacing it with decentralised citizenship. It also demonstrates the benefits of a systemic approach because, in parallel with the organisation of demand, the programme has intervened to reform supply.42 Several studies have presented the sustainability and resilience of these UDAMs43 and confirmed the fundamental role of professionalisation for the performance of CBHI in Senegal.14 In September 2022, the National Agency of the CMU of Senegal decided to transform all communal community CBHI into 46 departmental CBHI. The experienced schemes, therefore, seems to have borne fruit and influenced this decision-making of a scale-up.

    The paralleling of these two programmes, in perspective with other experiences in Rwanda, Ghana, Ethiopia44 45 and soon in Benin, to better integrate mutuality into a broader national health financing mechanism, shows that technical and institutional solutions exist and are proven. In Ghana, the NHIS (National Health Insurance Scheme) programme ‘was the subject of a presidential review in 2017. The recommendations made increasingly distance the system from any Community responsibility for the governance of health insurance’.45 In Rwanda, the success of mutuals in terms of membership rate was achieved at the expense of the initial commitment to community participation and management. The CBHI deployment has been accompanied by a significant involvement of the government and its donors in funding health.18 45

    Mali could build on these initiatives and continue its efforts to achieve sufficient institutional, organisational and technical sustainability conditions to consider its scale-up without diminishing its scope.

    Establishing a social protection system against the disease has a political significance that justifies the substantial financial effort it entails. Some sub-Saharan countries have understood this and have been able to find ways to finance it.18 45 The Malian State could unambiguously embark on this path and admit the full potential of this mutualist reform, previously perceived as an outsized expenditure item. Especially since Mali, notwithstanding the current crisis, can find the means of its policy. Many international reports or studies have shown this.38 42 46 The mining sector represents a unique opportunity for national and sustainable UHC funding to limit healthcare reliance on external funding sources. It is, therefore, essential ‘to articulate the objective of maximising mining revenues, as defined in the National Policy for the Development of the Mining and Petroleum Sectors and the 2019 Mining Code, with the financing needs of key utilities.’47

    Limitations of the study

    The number of interviews conducted and the inclusion of a wide range of actors, from the national to the very local level, the cross-referencing of these interview data with each other and with the extensive documentation used (data triangulation), reinforces the credibility and reliability of the results presented. In addition, colleagues from the relevant organisations have validated the analyses in this article. The fact that the context of the experiment studied is very specific in terms of security, limits the scope of the innovations implemented, but does not influence the transferability of the results presented here.

    Conclusion

    Like most countries, Mali has long stumbled against the idea that social protection is a luxury that African states cannot offer their people. Acceptance of this finding was facilitated by the solidarity and community organisation of their populations. It is in this context that mutuality has developed, on a very local scale and with autonomous and community functioning. The lack of state involvement and the low contribution capacity of the informal and agricultural sectors have limited the ambitions of this scheme. After more than thirty years of experimentation, it is still unattractive and underperforming. The idea that universal health insurance is possible in low-income countries, particularly for informal and agricultural groups, has come a long way. With the promotion of UHC, some countries have demonstrated that it is technically and socially feasible to meet the challenge. One of the conditions is to stand out from the original CBHI model whose principles are a barrier to its success. The study of the experimentation of an innovative CBHI programme in the Mopti region shows that Mali has committed itself timidly to this path. Successful experiences in a growing number of sub-Saharan countries must be a source of inspiration and lead to push this reform momentum further.

    The operationalisation of RAMU in Mali and the synergy of its various regimes should facilitate this awareness. This could materialise the scaling up of innovations to disseminate a successful insurance product for the informal and agricultural sectors. Otherwise, the risk of a scale-up from a model to a discount in the name of cultural and social realism or of a financial inability of the state is not to be ruled out. In the absence of a strong will on the part of the state to impose a recast of mutuality from a global perspective, including supply and demand, to finance it, and to think of technical, institutional, and financial viability without opposing them, it is to be feared that the measures adopted will not allow the scheme to gain credibility. It will not be able to make the difference with competing travelling models, promoted with the force of international technical and financial support.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The Ethics Committee authorised this research by Decision No 34/2018/CE-INRSP of 26 December 2018. All individuals were informed of the ethical issues and were allowed to withdraw from the study at any time. They all agreed to participate through verbal informed consent.

    Acknowledgments

    The authors are indebted to the staff of the mutuals and UTM for their support throughout the study. We want to thank Heather Hickey for their English editing.

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    Footnotes

    • Handling editor Seye Abimbola

    • Twitter @ValeryRidde

    • Contributors LT, PB and VR defined the research questions and corresponding study design. LT, PB, SD and YD acquired the data and prepared them for analysis. LT and PB performed the investigation with support from all authors. All authors contributed to the interpretation of the results. LT drafted the manuscript with the help of all authors. All authors read and approved the final manuscript.

      LT act as guarantor.

    • Funding This research is part of the Unissahel program (Universal Health Coverage in Sahel), funded by the Agence Française de Développement (AFD).

    • Disclaimer The opinions expressed are exclusive of the authors and do not reflect the official position of the Agence Française de Développement.

    • Competing interests None

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Author note The reflexivity statement for this paper is linked as an online supplemental file 2.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.