Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo

BackgroundIn 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.MethodsIn 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.ResultsAll 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.ConclusionOn 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.【背景】为实现优质医疗卫生服务的可及性提升，互助医疗组织（mutual health organisations, MHOs）的业务范畴并非仅限于提供健康保险。作为由会员民主管理的组织，MHOs的宗旨是保障民众的诉求得以传达。在国家层面，它们致力于参与社会保障政策的制定；在地方层面，则旨在提升医疗卫生服务对会员需求与期望的响应性。 【方法】本质性研究旨在探究刚果民主共和国（Democratic Republic of Congo, DRC）的MHOs能否通过提升医疗质量并控制开支，切实维护会员权益。本研究的数据源自2016年在刚果民主共和国开展的一项针对13家MHOs运营表现的深度调研，我们对该现有数据集进行了二次分析，并基于赫希曼退出-呼吁理论（Hirschman’s exit-voice theory）构建分析框架，重点探究MHOs为提升会员所享医疗服务的质量与可负担性所采取的各项行动。该框架将MHO会员影响医疗服务供给方的四种机制划分为：(1) "退出"或"用脚投票"；(2) "构建长效诉求渠道"或通过战略采购制定规则；(3) "守护问责制下的长效诉求渠道"或督促监管机构落实监管职责；(4) 通过改善医患互动场景中的权力失衡状况，"强化短期诉求渠道"。 【结果】所有被调研的MHOs均采用了上述四种机制来优化医疗服务供给，但绝大多数医疗服务供给方并不认可其履职权限。在刚果民主共和国，医疗卫生质量与可负担性的管控被普遍视为卫生主管部门的职责，但相关部门仅极少履行此项职能。在当前环境下，刚果民主共和国的MHOs在提升医疗服务质量与可负担性方面的影响力较为薄弱。 【结论】仅靠刚果民主共和国的互助医疗组织，并无足够影响力来改变医疗服务供给方的运营行为。若要提升医疗卫生服务对MHO会员的响应性，需所有参与医疗服务供给的主体开展协作，共同营造能够让维护民众权益的诉求得以被倾听的有利环境。