Provider payment in community-based health insurance schemes in developing countries: a systematic review
In 1998, a Mutual Health Organization (MHO) was created in the region of Guinee forestiere in Guinea-Conakry, West Africa, in the context of the action-research project PRIMA (Projet de recherche sur le partage du risque maladie). The aim of the project was to test whether, and under which conditions, an MHO can improve the access to quality health care. The specificity of the model is double-sided: on the one hand, the wish to integrate the organization into the local health system through a partnership between MHO and health services; on the other hand, the systematic efforts by the local research team to involve health professionals, at both the operational and managerial level of the system, in the planning and implementation of the MHO. We present the results of a study that investigates the health professionals' perception of this model. In April 2000, semi-structured interviews were held with 16 health professionals working at the different operational, managerial and administrative levels of the Guinean health system. The professionals perceive the MHO as an effective strategy to overcome financial accessibility problems. However, the interviews highlight the uncertainties and worries of the health professionals, their lack of understanding of the model, their reluctance even to fully accept it. The partnership approach was not internalized. They understand the technical instrument, but are confused and uncomfortable in their dialogue with the population. This study illustrates the difficulties of establishing a real partnership between population and health services, as well as the need for proper training and coaching of the health workers in the set-up of MHOs. The importance of this aspect was insufficiently recognized by the research team, despite its good intentions and its huge investment in organizing exchange between stakeholders. An important lesson of this experience is the need for promoters to conceive and operate MHO systems in which the expectations and fears of the health care providers are better identified and better taken into account.