Waelkens Maria-Pia, Coppieters Yves, Laokri Samia, Criel Bart
Université libre de Bruxelles (ULB), School of Public Health, 808 Route de Lennik, 1070, Brussels, Belgium.
Université libre de Bruxelles (ULB), School of Public Health, Health Policy and Systems - International Health, 808 Route de Lennik, 1070, Brussels, Belgium.
BMC Health Serv Res. 2017 Aug 7;17(1):535. doi: 10.1186/s12913-017-2419-5.
Persistent low membership is observed in many community-based health insurance (CBHI) schemes in Africa. Causes for low membership have been identified and solutions suggested, but this did not result in increased membership. In this case study of the mutual health organisation of Dar Naïm in Mauritania we explore the underlying drivers that may explain why membership continued to stagnate although several plans for change had been designed.
We used a systems approach focussed on processes, underlying dynamics and complex interactions that produce the outcomes, to delve into 10 years of data collected between 2003 and 2012. We used qualitative research methods to analyse the data and interpret patterns.
Direct causes of stagnation and possible solutions had been identified in the early years of operations, but most of the possible solutions were not implemented. A combination of reasons explains why consecutive action plans were not put into practice, showing the complexity of implementation and the considerable management capacity required, as well as the challenges of integrating a novel organisational structure into exiting social structures.
For any CBHI project aiming at high membership, skilled professional management seems essential, with capacity to question and adapt routine procedures and interpret interactions within the wider society. Countries that include community-based health insurance in their strategic plan towards universal coverage will have to pay more attention to management capacity and the minutiae of implementation.
在非洲，许多社区医疗保险（CBHI）计划的参保率持续低迷。导致参保率低的原因已被查明，解决方案也已提出，但这并未带来参保人数的增加。在对毛里塔尼亚达尔奈姆互助健康组织的本案例研究中，我们探究了可能解释尽管已制定多项变革计划但参保人数仍停滞不前的潜在驱动因素。
我们采用了一种系统方法，聚焦于产生结果的过程、潜在动态和复杂相互作用，深入研究了2003年至2012年期间收集的10年数据。我们使用定性研究方法来分析数据并解读模式。
在运营初期就已确定了停滞的直接原因和可能的解决方案，但大多数可能的解决方案并未得到实施。多种原因共同解释了为何连续的行动计划未得到执行，这表明了实施的复杂性以及所需的相当大的管理能力，以及将新型组织结构融入现有社会结构的挑战。
对于任何旨在实现高参保率的社区医疗保险项目而言，熟练的专业管理似乎至关重要，需要有能力质疑和调整常规程序，并解读更广泛社会中的相互作用。将社区医疗保险纳入其全民覆盖战略计划的国家将不得不更加关注管理能力和实施细节。
