Ouimet Marie-Jo, Fournier Pierre, Diop Idrissa, Haddad Slim
Centre de recherche et de formation, CSSS de la Montagne, Montréal, QC.
Can J Public Health. 2007 Jul-Aug;98(4):341-6. doi: 10.1007/BF03405415.
Although community-based health insurance (CBHI) seemed promising to improve access to health care, its implementation has been slow and laborious. We hypothesize that the existing tension between the competing objectives of solidarity and financial sustainability that are pursued by CBHI may partly account for this. This paper aims to evaluate if there is a gap between CBHI subscribers' values and their promoters', and to determine which characteristics of subscribers and CBHIs are associated with their values.
A study of all Senegal CBHI organizations was undertaken in 2002. The analysis includes: 1) content of interviews with subscribers and promoters; and 2) multilevel logistical analysis of the links between characteristics of subscribers (n = 394) and organizations (n = 46) and composite indicators representing values (redistribution, solidarity when difficulties, solidarity between healthy and unhealthy).
Promoters emphasize financial sustainability; subscribers are split between financial sustainability and solidarity. Men, polygamous families and individuals with a lower socio-professional status are twice as likely to be in favour of redistribution; subscribers who participate in decision-making and those who think their CBHI is facing difficulties are less in favour of solidarity. At CBHI level, although the variance was significant, none of the variables were retained.
More attention should be given to reducing the gap between promoters' and subscribers' values, and to increasing member participation in the processes involved in implementing CBHI. This could help all actors involved to understand and improve determinants of enrolment in, and performance of CBHI, thus increasing access to health care for vulnerable populations in developing countries.
尽管基于社区的医疗保险（CBHI）似乎有望改善医疗服务的可及性，但其实施过程缓慢且艰巨。我们推测，CBHI所追求的团结与财务可持续性这两个相互竞争目标之间现有的紧张关系可能部分解释了这一现象。本文旨在评估CBHI参保者与推广者的价值观之间是否存在差距，并确定参保者和CBHI的哪些特征与其价值观相关。
2002年对塞内加尔所有CBHI组织进行了一项研究。分析包括：1）对参保者和推广者的访谈内容；2）对参保者（n = 394）和组织（n = 46）的特征与代表价值观的综合指标（再分配、困难时期的团结、健康与不健康者之间的团结）之间的联系进行多层次逻辑分析。
推广者强调财务可持续性；参保者在财务可持续性和团结之间存在分歧。男性、一夫多妻制家庭以及社会职业地位较低的个人支持再分配的可能性是其他人的两倍；参与决策的参保者以及认为其CBHI面临困难的参保者对团结的支持度较低。在CBHI层面，尽管差异显著，但没有变量被保留。
应更加关注缩小推广者和参保者价值观之间的差距，并增加成员对CBHI实施过程的参与度。这有助于所有相关行为者理解并改善CBHI参保率和绩效的决定因素，从而增加发展中国家弱势群体获得医疗服务的机会。
