Table 3

Summary of empirical results

External contextThe international and national contexts are a barrier to the scale-up : (1) ambiguous positioning on the strategy to be prioritised in order to achieve UHC, (2) insufficient technical and financial support for reforming dynamics.
Sector context and system preparation for innovationsAfter a long period of ideological and technical immobilism, the mutualist system begins a prudent reform. The recurrent underfunding of the sector is fueling tensions and a brake on accompanying UHC reforms.
Agents of changeThe group of experts responsible for the operationalisation of RAMU is the first agent of change, imposing certain innovations in mutuality. The second player, PADSS2, implemented this reform with an innovative pilot programme. But these two actors fail to evolve in a synergy of reflection and action.
Features of the innovative schemeMost of the features of the experienced mutualist system are in favour of national adoption in the perspective of UHC. The transferability of the model and its financial viability are compromised by a lack of ambition of the content of the innovations and their articulation.
Formulation and implementation processThe low-system, reflexive and iterative intervention strategy limits the pilot’s scope and compromises his chances of scaling. The potential remains partly unexplored.
  • PADSS2, Programme of Support for Socio-Health Development, Phase 2; RAMU, Universal Health Insurance Plan; UHC, universal health coverage.