Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium.
PLoS One. 2020 Apr 16;15(4):e0231660. doi: 10.1371/journal.pone.0231660. eCollection 2020.
In their mission to achieve better access to quality healthcare services, mutual health organisations (MHOs) are not limited to providing health insurance. As democratically controlled member organisations, MHOs aim to make people's voices heard. At national level, they seek involvement in the design of social protection policies; at local level, they seek to improve responsiveness of healthcare services to members' needs and expectations.
In this qualitative study, we investigated whether MHOs in the Democratic Republic of Congo (DRC) succeed in defending members' rights by improving healthcare quality while minimising expenses. The data originate from an earlier in-depth investigation conducted in the DRC in 2016 of the performance of 13 MHOs. We re-analysed this existing dataset and more specifically investigated actions that the MHOs undertook to improve quality and affordability of healthcare provision for their members, using a framework for analysis based on Hirschman's exit-voice theory. This framework distinguishes four mechanisms for MHO members to use in influencing providers: (1) 'exit' or 'voting with the feet'; (2) 'co-producing a long voice route' or imposing rules through strategic purchasing; (3) 'guarding over the long voice route of accountability' or pressuring authorities to regulate and enforce regulations; and (4) 'strengthening the short voice route' by transforming the power imbalance at the provider-patient interface.
All studied MHOs used these four mechanisms to improve healthcare provision. Most healthcare providers, however, did not recognise their authority to do so. In the DRC, controlling quality and affordability of healthcare is firmly seen as a role for the health authorities, but the authorities only marginally take up this role. Under current circumstances, the power of MHOs in the DRC to enhance quality and affordability of healthcare is weak.
On their own, mutual health organisations in the DRC do not have sufficient power to influence the practices of healthcare providers. Greater responsiveness of the health services to MHO members requires cooperation of all actors involved in healthcare delivery to create an enabling environment where voices defending people's rights are heard.
互助健康组织（MHO）的使命是实现更好地获得高质量医疗保健服务，其不仅限于提供健康保险。作为民主控制的成员组织，MHO 旨在让人们的声音被听到。在国家层面，他们寻求参与社会保护政策的制定；在地方层面，他们寻求提高医疗服务对成员需求和期望的响应能力。
在这项定性研究中，我们调查了刚果民主共和国（DRC）的 MHO 是否通过提高医疗质量同时最大限度地减少费用来成功捍卫成员的权利。这些数据源自于 2016 年在 DRC 进行的一项关于 13 个 MHO 绩效的深入调查。我们重新分析了这个现有的数据集，并特别研究了 MHO 为改善其成员提供的医疗服务的质量和负担能力而采取的行动，使用基于 Hirschman 的退出-声音理论的分析框架。该框架区分了 MHO 成员用来影响提供者的四种机制：（1）“退出”或“用脚投票”；（2）“共同生产长声音路线”或通过战略采购施加规则；（3）“长期监督问责制”或向当局施压以监管和执行法规；（4）“通过改变提供者-患者界面的权力失衡来加强短声音路线”。
所有研究的 MHO 都使用了这四种机制来改善医疗服务的提供。然而，大多数医疗服务提供者并没有认识到他们有这样做的权力。在 DRC，控制医疗质量和负担能力被坚决视为卫生当局的角色，但当局只略微承担了这一角色。在当前情况下，MHO 在 DRC 增强医疗质量和负担能力的权力较弱。
仅靠自己，DRC 的互助健康组织没有足够的权力来影响医疗服务提供者的做法。要使卫生服务对 MHO 成员更加响应，需要参与医疗保健提供的所有行为者合作，创造一个有利的环境，让捍卫人民权利的声音被听到。
