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Article Excerpt
Une traduction en francais de ce resume figure a la fin de l'article. Al final del articulo se facilita una traduccion el espanol.
Introduction
In most African countries, including the low-income, landlocked Sahelian nation of Mali, poor and rural populations have low utilization and coverage rates for key preventive and primary curative interventions. Because of their poverty, these populations tend to suffer more health problems; because of their health problems, they tend to be poorer. (1) There are many reasons for low utilization of priority health services in Africa, including poor physical and financial access to care, socioeconomic factors, cultural factors and perceptions about the quality of care. (2-9)
In western Africa, mutual health organizations (MHO) have sprung up with amazing speed. (10,11) MHOs are voluntary organizations that provide health insurance services to their members and they are usually owned, designed and managed by the communities they serve. Member households pay an enrolment fee and then regular premiums to cover a membership-defined benefits package. After a waiting period, the MHOs reimburse providers of care for the services used by beneficiaries in the member households, with users making a small co-payment. MHOs are not for profit and are based on ethical principles of mutual aid and social solidarity. (10) The rise in popularity of MHOs reflects a need in communities to address the difficulty of paying for health tare when care is required. The government of Mali recognized the potential of MHOs in its 1997 10-year health and social sector development plan. (12)
Promoted as a solution to many health system problems, MHOs can provide additional avenues of resource mobilization and financial protection against devastating health-care expenditures, increase financial access to care, promote equity through risk-pooling as well as strengthen community solidarity and demand for quality care. (13-15) At a minimum, MHOs should contribute to increased use of effective and needed health services (16) and serve as a proxy for improved health.
Although there is enthusiasm and consensus on the worthiness of the principles and concepts behind the MHO movement, (17) concerns exist about their ability to meet all expectations. There is still little robust evidence of MHO cost-effectiveness, of their ability to cover significant portions of the population, or of the sustainability or effectiveness in increasing access to care and financial protection. Recent broad reviews of the MHO literature (16,18) found few studies that measure the effects of MHOs on health care utilization and even fewer that used econometric regression analysis. (18)
What is known from the few studies that have rigorously investigated the effects of MHOs is that: (i) there is an ever-growing demand for such financial protection mechanisms; (ii) MHOs seem able to enrol individuals from a variety of socioeconomic strata, although perhaps not the very poor; (19-21) (iii) members tend to have lower out-of-pocket expenditures than do non-members; (19,20,22) and (iv) members tend to use health services more when needed than do people not enrolled in MHOs. (19,23,24) The literature also highlights that MHOs require technical support to attain functionality, that they still tend to be small, and that they will be only one of many mechanisms for financing the health sector. (13,16,17)
In this paper we examine the effects of a community-based MHO intervention on the use of curative, maternal and child health inventions; inclusiveness of MHO membership, and MHOs' ability to provide financial protection in a rural and urban setting in Mall
Methods
Setting
Four MHOs were developed by the Ministry of Health of Mali and the USAID-funded Partners for Health Reform project (25) as part of a pilot programme to improve financial access to health services. A steering committee chaired by the Mall Ministry of Health selected four MHO pilot sites for the study: two in the rural district of Bla (BlaVille and Kemeni) and two in the urban commune of Sikasso (Wayerma and Bougoula). These sites were selected for their representativeness of the socioeconomic conditions faced by a large portion of Mall's population.
The USAID-funded Partners for Health Reform and Partners for Health Reformplus projects provided funding and technical assistance for MHO development and evaluation design. To ensure the sustainability of the organizations, no direct financial support was provided for the ongoing operation of the MHOs. At the start of the MHO intervention, a baseline household survey revealed low levels of coverage for antenatal care (57%); assisted deliveries (26%); child immunizations (29%); and treatment of child diarrhoea with oral rehydration therapy (30%). Utilization of curative services ranged from 0.24-0.30 visits per person per year. (26,27) In Bla district, roads are few and there is no ambulance service.
MHO intervention and study design
Table 1 presents descriptive information for the four pilot MHOs. Member households paid a once-off enrolment fee and a monthly or annual premium (based on the number of beneficiaries). On joining, members committed to make use of preventive services, such as immunizations, prenatal care and insecticide-treated mosquito nets. The MHOs signed agreements with local primary health-care centres and referral health centres (where available). When members or their beneficiaries needed curative or maternal care and were up to date on their premium payments, they paid a portion of charges (usually 20-25%) at the time of service, and the MHO covered the larger remaining portion.
Using a case--control design, we sought to answer three major research questions:
1. Does MHO membership affect utilization of priority health services such as modern treatment for fever and diarrhoea (in children), prenatal care and assisted deliveries, childhood immunizations, vitamin A supplementation, and use of insecticide-treated...
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