Exploring social accountability and responsiveness procedures of Community-based Health Insurance in Kinshasa, Democratic Republic of Congo, using qualitative approach research

Exploring social accountability and responsiveness procedures of Community-based Health Insurance in Kinshasa, Democratic Republic of Congo, using qualitative approach research | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring social accountability and responsiveness procedures of Community-based Health Insurance in Kinshasa, Democratic Republic of Congo, using qualitative approach research Dosithee Ngo-Bebe, Fulbert Nappa Kwilu, Arlette Kilonga Mavila, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8005371/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background For community health insurance (CHI), building a trustful relationship with affiliates is a major challenge. In the absence of national health insurance, mutual health organizations (MHOs) are functioning as community-based health insurance (CBHIs). MHOs have been considered as one of the building blocks of the financial mechanisms to access quality health care. This study intended to explore procedures used by MHOs to enhance their social accountability and responsiveness. Methods We conducted a qualitative case study to investigate institutional arrangements and its implementing measures. Data were collected through a documentary review of more than 50 local related documents, 34 in-depth interviews with MHO and health facility managers, and 15 focus group discussions with MHO members. We focused on identifying and analyzing the existing institutional arrangements, their implementation, and their perceived effectiveness. Results We distinguished five institutional arrangements with 35 related measures for implementing these arrangements. MHO managers perceived them to be successful, while their members disagreed, and most of them did not have good knowledge of these implementing measures. For MHO managers, potential contributing factors to this perceived success were the coaching from MHO platforms, the 2017 law regulating MHOs, the inclusion of MHOs in the national UHC strategy, the nature of membership affiliation, and MHO managerial capacities. Conclusion To build trustful relationships and to engage into an effective dialogue between MHO managers and members, MHOs should build their internal capacities in implementing key institutional arrangements and related measures to improve their social accountability and responsiveness. Community-based health insurance mutual health organization health financing system accountability and responsiveness Democratic Republic of Congo Figures Figure 1 Key Message Implication for policy makers Availability of a set of implementation measures of key institutional arrangements that aim to enhance Mutual Health Organization (MHO) social accountability and responsiveness. Controversial perceptions of the effectiveness of MHO procedures to operate relationships with their members are of high importance for policymakers in guiding MHOs’ management. Toward universal health coverage (UHC), implementing measures of institutional arrangements need to be converted into standards operating procedures (SOPs), as a way of improving MHOs’ internal managerial capacities. Implication for the public Empowering MHO members to improve their knowledge on their rights and obligations for better and effective use of their entitlements to obtain appropriate health care, is a must. The need to engage in much more effective communication between MHOs and their members emerges as a way forward to establishing a trustful relationship. This will then reverse the doubtful of members on the knowledge and effectiveness of the MHOs’ institutional arrangements and their implementation procedures, which would lead to improve it penetration in the country. It is noted that in the DRC context, MHOs will remain as building blocks of the upcoming health insurance, toward achieving UHC. Background This study attempts to contributing to the global debate on Community health insurance (CHI) accountability and responsiveness. CHI aims to provide financial protection from the cost of seeking healthcare through voluntary prepayment by community members. In most low and middle-income countries (LMICs), CHIs are viewed as one of the key mechanisms toward achieving universal health coverage (UHC). In the global perspective of health systems, social accountability is critical to empower CHI enrollees to better understanding and participating in decisions concerning the provision of quality healthcare, procedures to access them, costs that are required and other benefits that CHI members should know and request in seeking healthcare services. Empowered CHI members can contribute to improving service efficiency and quality [ 1 , 2 ]. At community level, CHIs are mainly organized as community-based health insurances (CBHIs), which schemes are active but face low enrollment, organizational challenges, and sustainability issues, but they increase service utilization and provide uneven financial protection against health expenditure shocks [ 2 – 4 ]. In the case of the Democratic Republic of Congo (DRC), where there is no yet national health insurance, mutual health organizations (MHOs) are considered as one of the cornerstones of the edifice of financial protection at community level. They are private, but socially oriented initiatives structured mainly as community-based organizations (CBO), built around the principles of solidarity and risk-sharing to facilitate access to health care for their members [ 3 ]. Two schemes of MHOs can be distinguished: corporate MHOs, with compulsory contributions and which are aligned to CHI, and strictly community-based MHOs, with voluntary affiliation and contributions which are aligned to CBHI [ 3 ]. However, their penetration is still embryonic, around 3–5%, an illustrative figure with clear limitations and large local variations, such as the spatial variations of the health insurance ownership between Bandundu & Kasaï Oriental (1.2%) and Kinshasa (15.5%). [ 4 – 7 ]. The absence of national health insurance and the very low penetration of MHOs explain why out of pocket payments are the first funding source for the health system in DRC (43%) [ 8 ]. In this context, user fees, unfortunately remain the rule, and effective financial protection the exception, despite some rare specific cases [ 9 – 12 ]. The UHC strategic plan 2020–2030 has defined strategies that include the extension of financial protection to people who work in the informal sector and mandatory protection for those who work in the formal sector, as stated in the Law No 17/002/2017 establishing the fundamental principles of MHOs in DRC [ 13 , 14 ]. However, problems in the design and operation of MHOs impair their social accountability and responsiveness and are at odds with a harmonious and trustful relationship with their members [ 12 , 15 , 16 ]. These problems are mainly: (i) Poor participation of MHO members in decision-making bodies and in oversight organs; (ii) Weakness of enrollment initiatives; (iii) Registered members taken as a given; and (iv) An unfulfilled role of MHO brokers, i.e., medical advisors and MHO delegates in the health facilities. These weaknesses trickle down in the internal management of MHOs [ 12 ]. Even with coaching by technical structures or support centers, most MHOs remain small-scaled and poorly professionalized organizations with limited coverage [ 10 , 15 ], and in contrast with the way forward as set in the 2017 law on MHOs [ 14 ]. Considering the important role of MHOs in the health system financing, the issue of their social accountability and responsiveness to members needs are central in establishing trustful relationships with their members, in increasing their penetration, and in bringing effective financial coverage to people toward the achievement of UHC; all in a context of deep poverty and challenging social, institutional, and political environment [ 2 , 9 , 15 ]. In such a difficult context, it is of paramount importance to explore to what extent, and via what institutional arrangements and related procedures, MHOs are accountable to their members and responsive to their needs. This article follows a previous one, which focused on the management of members’ complaints by mutual health organizations in Kinshasa [ 17 ]. It aimed to identify the various measures implemented by MHOs to enhance social accountability and responsiveness. We further strived to investigate and map the perceptions of both MHO managers and MHO members regarding the relevance and effectiveness of these measures. The research questions were the following: (1) What are the institutional arrangements and related measures set up by MHOs; (2) How do MHO managers perceive the effectiveness of these measures; (3) How do MHO members perceive the effectiveness of these measures; (4) What potential factors are influencing the implementation of these institutional arrangements. Methods Study design and approaches The study consists of an in-depth investigation of a broad range of implementing measures of institutional arrangements designed to enhance social accountability and responsiveness of MHOs vis-à-vis their members. Qualitative methods were used for this study, with three main approaches: (i) documentary review to map the various institutional arrangements implemented in each selected MHO; (ii) in-depth interviews with MHO managers; and (iii) focus group discussions with MHO members. Study sites The study was conducted in three MHOs, representing two distinct health insurance schemes. The first scheme comprises two MHOs, Lisanga and La Borne , that operate under the same platform umbrella, named “ Centre de Gestion de risque et d’Accompagnement Technique ” (CGAT). These two MHOs are designed as a community-based scheme in which people living in a given geographical area join the MHO on a voluntary basis, regardless of whether they work in the formal or informal sector. This scheme of MHO is in most instances launched by a nonprofit community organization with the objective of facilitating health care access to the affiliated members [ 3 , 16 ]. Of the two mentioned MHOs, the Lisanga MHO has been operational since 2014 and covered 4570 households in 2018. The La Borne MHO started providing its services in 2017, serving 3201 households in 2018. For these two MHOs, the package offered to the affiliated members consists of primary care, laboratory or radiology outsourcing examinations, hospital care, and reimbursement of some specialized medicines. The two MHOs are quite similar in terms of organizational structure, management tools, and technical guidance and backstop support from the CGAT, an umbrella platform which accounted for a total of 20,236 households in 2018. We therefore merged their data sets, henceforth, both are designated as “CGAT MHOs” in this study. The second scheme of MHO investigated is the MESP [Mutuelle de santé des enseignants de l’enseignement primaire, secondaire et professionnel] , which covered 41,220 households in 2018 in Kinshasa. MESP is based on a compulsory affiliation of teachers in government primary and secondary schools. The MESP resembles a social health insurance based on a public nonprofit rationale, in which the contribution is a function of the individual income of civil servants (teachers in public schools) with mandatory affiliation [ 3 ]. Apart from contributions deducted from the members’ salaries, the MESP receives a subvention from the government. Compared with the CGAT MHOs, the MESP offers a more comprehensive health services package, aligned to the different levels of health facilities, including hospitalization at second-level health care facilities when needed. Both schemes of MHOs are built on risk-sharing mechanisms and target risk reduction by pooling prepaid contributions meant to cover the health care expenses of their affiliated members [ 3 , 16 ]. Data collection Data were collected from 17 December 2020 to 15 March 2021, by our DRC research team, who have at least a master's degree in public health and who are co-authors of this paper. The field work was covered with an authorization of the Kinshasa School of Public Health, used to introduce them to the participants on a face-to-face approach. All the team members are university teachers and researchers. The guidelines of the IDIs and FG were pretested with the support of the CGAT in another MHO not part of the research. Desk review More than 50 local working documents were consulted using a content analysis approach, searching for information mainly on institutional arrangements and related operating measures. Documents explored were related to the creation of the MHOs, their status, enrollment conditions, agreements with health facilities, established communication channels, administrative decisions files, and many other managerial documents, such as annual reports, operational plans and MHO member databases. We also accessed lists of schools per administrative district of Kinshasa City. Other contents of interest were about policy reference documents such as National Laws on MHOs, National Health Development Plan, National Strategic Plan on UHC, and National health account reports. Most of them were official documents, but part of the grey literature. Documents were requested and reviewed mainly during our visits in MHO offices respecting the privacy of the MHOs. In-depth interviews In-depth interviews were held with MHO managers at their headquarters location and with those working within health facilities. For the CGAT, the interviewed staff included the team that ensures coordination and technical support and local managers of the Lisanga and La Borne MHOs. For the MESP, staff at headquarters and delegates who operate in the contracted health facilities were interviewed. Guides for in-depth interviews were established in French and administered during appointments with identified MHO managers in their workplace. All in-depth interviews were audio recorded with the approval of respondents and handwritten notes were also taken. The duration of the interviews took a maximum of 2 hours. In total, 34 in-depth interviews were conducted, including 12 women, from 18 February to 10 August 2020, under the difficult conditions of the COVID-19 pandemic. We used a targeted sampling strategy with the goal of capturing as much as possible the relevant information we sought. For this process, key staff members were identified with names and positions before we requested an appointment. We intended to reach out to different categories of respondents to generate an overview of their experiences or their perceptions of MHO services. The list of respondents included the Chief Executive Officers (CEOs), executive managers, delegates, medical advisers (14 for MESP and 11 for CGAT), and 9 health facilities managers. The exclusion criteria were the unavailability of the targeted respondent, and we used a replacement approach by a colleague with the same profile. Focus Group Discussion Focus Group Discussions (FGDs) were organized with MHO members collecting information related to the MHO members’ points of view on their knowledge and perceived effectiveness of the measures put in place by the MHOs to improve social accountability and responsiveness. Fifteen FGDs with a total of 153 participants were conducted and distributed as follows: 8 for the MESP and 7 for the CGAT (4 for Lisanga and 3 for La Borne). The inclusion criteria were the availability of the targeted members and gender considerations, which led to mixed compositions of the groups. FGDs were conducted in French, the official language in DRC, used by most of literate people in Kinshasa. All the sessions were audio-recorded and transcripts generated. Through verbatims, some specific opinions and responses were captured to illustrate personal experiences. With a maximum of 2 hours, discussions took place either in the community for CGAT members, and in their school places for MESP members. Data analysis The analysis firstly consisted of an inventory and classification of arrangements and measures established in each of the two schemes of MHOs. The classification was conducted with the help of a guiding framework, explained and discussed with interviewees [ 18 – 20 ]. The analysis further explored whether MHO managers themselves were satisfied with the various arrangements introduced, and which factors managers identified as contributing to success, or lack of it. Secondly, the analysis looked into the perception of the members themselves. To analyze the content of the IDIs and FGDs, we used a qualitative analysis software, ATLAS.Ti, with an interactive inductive process, using a thematic content analysis approach. All transcripts were coded by two experienced researchers from the Department of social science, Kinshasa University, including one from our team. Some codes were added in an emerging process, whenever necessary [ 21 ]. Matrices were generated to identify themes and sub-themes emerging from the data, illustrated with relevant quotes and text results. According to the coding, MHO members were more willing to seek healthcare, once they were informed about the accountability and responsiveness measures associated with the five institutional arrangements. Conceptual framework of the institutional arrangements for MHOs in the DRC The conceptual framework is a generic framework situating the institutional arrangements and their implementing measures aiming to enhance MHO social accountability and responsiveness, as mentioned in Fig. 1 below. Source Adapted from Goetz and Gaventa (2001) and Molyneux (2012) [ 19 , 20 ] The framework presents a synthesis of documented institutional arrangements, with their potential and respective key implementation measures toward empowered members trough better knowledge and use of the measures, leading to satisfaction of members with quality healthcare in health facilities. Results Identified institutional arrangements and implementation measures We identified 35 social accountability and responsiveness promotion measures that were distributed into the following five institutional arrangements irrespective of the MHO scheme: (1) information provision; (2) navigation mechanisms; (3) grievance and redressal mechanisms; (4) oversight arrangements; and (5) participation in decision-making [ 19 , 20 ]. Among the 35 measures, 18 were common to both MHO schemes, 10 specifics to the MESP, and 7 specifics to the CGAT MHOs, as presented in Table 1 below. Table 1 Variation in measures implemented by MESP and CGAT MHOs for each institutional arrangement MEASURES COMMON TO BOTH MHOs MESP-SPECIFIC MEASURES CGAT-SPECIFIC MEASURES Information provision - Information campaign and enrollment process - Access through a set of phone numbers and/or hotline - Information sharing on decisions taken by the General Assembly - Display of press releases for member information - Information by peers: empowered members to inform other affiliates - Sharing information or concerns through social media Navigation mechanisms - Brokers’ orientation and follow-up of members in health facilities - Prior approval by medical advisor for navigation - Prior approval by medical advisor for any diagnostic voucher - Costs review of alternative health care - Case-by-case management for emergency and/or specialized exams - Special authorization to health facility access in favor of members living outside the MESP coverage areas Grievance and redressal mechanisms - Brokers to capture and manage members’ complaints - Feedback provided through General Assembly meetings and media supports - Case-by-case management for the reimbursement process - Case-by-case management for provision of non-covered specialized health care - Decentralization of administrative services to local offices closer to member households - Partnership agreements signed with pharmacies to provide medicines not available in the health facilities - Direct provision of medicines to members by CGAT avoiding members’ complaints Oversight arrangements - Prior approval by medical adviser of non-generic medicines - Use of individual biometric membership cards - Checking the membership status at the health facility - Approval of the bill by the medical advisor - Disciplinary measures to encourage health facilities to respect the clauses of contracts - MHO oversight committees or inspectors for periodic review of the technical plateau for health care - Checking the quality of affiliation by the health facility using updated lists - Double checking of the health care bills by the inspector - Prohibition of paying cash to members for prompt health care access or specialized examinations - Rapid survey (via phone) on conformity of health care management protocols on sample of consumers on the basis of existing patient protocols Participation in decision-making - MHO members’ right to substitute or to add a beneficiary member - MHO members’ right to change a first-line health facility up to three times - Invitation to members to join the General Assembly using letters, phone calls, and SMS reminders - Payment of 50% of the bill by the MHO member beyond the deductible amount - Involvement of members in the new member enrollment process - Incentives to members for participation in General Assembly Implementation of the institutional arrangements The description of the implementation of the five institutional arrangements was mainly captured through the IDIs conducted with the all the selected MHO managers. Provision of information For both schemes of MHOs, the provision of information is taking place through several communication channels, including (1) phone calls, text messages (SMS), and messages through WhatsApp groups; (2) interpersonal communication during meetings with managers and delegates in health facilities; (3) workplace meetings, mainly with members of the CGAT MHOs; (4) letters to MHOs; (5) press releases; (6) websites; (7) complaint books; and (8) suggestion boxes. The three main issues addressed by MHOs were the limited knowledge of members about the benefit package, the new measures introduced by the MHOs, and the limited contact with MHO managers in case of need. Respondents reported that the phone call is one of the most used and effective communication tools because it is the most direct way of getting information or feedback, or resolving a problematic situation. Another quality of the phone call is the speed and flexibility with which a member’s question can be answered directly and a solution found to satisfy his request. MHO managers phone numbers are written on membership cards. However, essential information is most often provided to members at the enrollment stage for both MHO schemes. The package of information given to members about members’ rights includes access to a health care package and a list of contracted health facilities. Navigation mechanisms Our working definition of navigation has been contextualized as the range of mechanisms put in place to guiding MHO members in the local health system, in particular when it comes to refer patients to more specialized outsourcing clinics and services such as general referral hospital, laboratory or X-rays services. The purpose is to overcome challenges related to (1) bypassing of first-line health services to access second-line health care, possibly leading to overuse of specialized care and exams; (2) lack of harmonizing of billing costs between providers for the provision of a similar item of healthcare; and (3) specifically for MESP, the need to rationalize the referral process to health facilities within the geographical area covered by the MHO. In both MHOs, medical advisors play a key role in the navigation mechanisms. In addition, MESP has posted their delegates in the contracted health facilities in order to facilitate health system navigation of their members. Members can present themselves to the medical advisors with transfer documents, including transfer notes, laboratory examination vouchers, requests for a specialist consultation, or requests for more specialized medicines. According to the therapeutic protocol, the medical advisor examines the relevance of each document for referral to a second or third-line clinic while taking precautions to avoid overconsumption and overbilling. As one of the interviewed reported: “ My role is to process members’ files as appropriate, starting with checking the membership, because each file must be checked in my office, with the member’s card. I also check whether it is an entitlement covered by the MHO, and if so, I then sign to direct the member to the referral hospital or clinic. ” (CGAT medical advisor Lisanga). As for the MESP delegates, in addition to facilitating referral processes of members from one health facility to another, or for a given medical service to another within the same health facility. They welcome members, check for their membership, navigate them to the appropriate services and ensure the control of the health facility billing. Grievance and redressal mechanisms Grievance and redressal mechanisms consist of a set of procedures that allow members to submit their complaints or suggestions to the MHO. The main issues were poor responsiveness in processing mail traffic and claims coming from members, addressing bottlenecks in the gathering of members at the MHO headquarters, and long waiting times to receive medicines from a drugstore or health facility. Face-to-face meetings with medical advisors, use of phone calls and suggestion boxes at the health facilities were common procedures used by both MHO schemes. The most frequently reported types of complaints were related to (1) poor quality of health care; (2) unavailability of good quality medicines; (3) long procedures, with multiple back-and-forth traveling between the MHO office and the health facilities; (4) delays in delivering the membership cards; (5) delays in getting answers from the MHOs; and more in general, (6) poor communication between MHOs and members. A specific complaint addressed to the MESP was the absenteeism of the MHO delegates in the health facilities, which leads to delays in accessing healthcare. As for CGAT, the specific complaints were related to (1) non-compliance with the agreed co-payment user fees; (2) non-reimbursement of invoices for expenses incurred by the members themselves; (3) non-compliance with therapeutic protocols; (4) unavailability of managers in the MHO office and/or inability to reach them by phone; and (5) increase in co-payment fees within a same year. All interviewees stated that interpersonal communication during face-to-face meeting is very much appreciated, as for members, it is the best means of communication toward solving their problems without any delay. For the two schemes, MHO brokers are committed to help improving health care provision to members, so as to comply with the content of the contracts signed with the providers. They use the same procedures: reminder letters about compliance with the terms of the contract; invalidation of acts that do not comply with the agreements; non-payment of overbilling invoices; and meetings with health facility officials to come up with consensus on some of the members’ claims. On this specific institutional arrangement, a comprehensive analysis has been already published [ 17 ]. Oversight arrangements The supervisory board for MHO activities mentioned by respondents is the control or monitoring committee that reports to the management committee. However, respondents pointed out that participation of MHO members in this board is not effective in the two schemes of MHOs, and the functioning of such a committee is questionable in some ways. This is the case for CGAT MHOs, where the CGAT accountant acts as a controller on behalf of the MHOs. Control is also exercised by MHO delegates in health facilities. In the particular case of the MESP, the delegates work is supported by the pricing committee, which crosschecks with the health facility agreements to verify the quality of health care offered to members. This committee also examines the relationship and interactions between delegates and members. Committee members report all weaknesses found in the field to the MHO management, so that managers can provide useful answers and allow health facilities and delegates to properly meet member expectations. Several issues were pointed out to be covered by oversight mechanisms: complaints about quality of care; member fraud in use of health care through substitution of a non-beneficiary for a member; overuse of a collective household card; and overcharging bills by contracted health facilities. In the case of MESP, respondents recognized the need to strengthen supervision of health facilities to compensate the relative lack of delegates. Indeed, only one delegate is supervising two to three health facilities. The control exercised by both MHOs in health facilities improves the technical threshold and the quality of health care provided. Member satisfaction is a necessary condition for the renewal of a contract. Similarly, control in health facilities minimizes overbilling and overconsumption of care and prevents fraud in the identity of membership card users. In addition, financial control guarantees the traceability of service provider invoicing and MHO payments. Participation in decision-making MHO managers noted that most members do not have full control over their rights and duties vis-à-vis the MHO. This lack of control is greater among dependents, including family members and other individuals related to the members, who are often absent during the membership processes and briefing sessions. In fact, the main issue at stake was that representative of members were not involved in the decision-making organs, such as General Assembly. MHO managers underlined the necessity of raising awareness of all members by giving them all relevant information needed to exercise their rights and obtain their benefits from MHO services. A respondent reported that “ there are many members’ complaints that could be explained by the fact that members are unaware of the concept of solidarity in the functioning of MHO, as they are not really participating in the life of the MHO.” (Medical adviser La Borne). In the case of the MESP, however, the MHO management provides members with agendas to participate in the ad-hoc committees set up for well-defined purposes or in meetings with trade unionists. With regard to the participation in the MHO General Assembly meetings, MHO managers stated that, according to the rules of the CGAT MHOs, participation is open to any member. Invitation letters are sent to some members to attend the General Assembly meetings. Other communication channels such as SMS messages or press releases, are also used to remind them to attend meetings. For MESP, only the delegates of the teacher’s trade union are invited to the General Assembly. As an incentive, a small financial token is given to them at the end of the meeting. Perceptions of the effectiveness of implementation measures by MHO managers Our understanding of the effectiveness of these measures was based on their ability to adequately address the issues raised. Of the 16 concerns, four were not effective, despite nuanced declarations of all the MHO managers. They were related to: (i) persistent bottlenecks in the members request to meet the MHO top management, leading to a situation of members gathering at headquarters for both MHO schemes; (ii) delays in the reimbursement of self-purchased medicines in the case of CGAT; (iii) complaints from MESP members about limitations on the number of beneficiaries of a health care package per household; (iv) complaints from CGAT members about the limitations on the number of sickness episodes, as well as the number of days in hospitals. The respondents offered more details, as described below. Points of views of MHO managers were also globally shared by health facility managers. On information sharing , in order to overcome the challenges of providing information to members, MHO managers shared a number of novel actions. Both MHOs designed an information kit shared with new members about the health package and displayed a press release for self-access to MHO information. Health facilities are also used as a channel of information dissemination. However, one of the respondents recognized that despite all the information channels, “ members are still not mastering their health care package and when requesting appointments are rerouted to medical advisors or delegates in health facilities ” (MESP Delegate, Limete). For CGAT MHOs specifically, efforts were taken to make better use of information campaigns during the enrollment process, to invite members to share information with peers about membership rights and benefits, and to improve the use of phone calls and social media. In both MHOs, managers described the recruitment process, phone calls and social media as the most effective ways to reach members with critical information. With regard to navigation mechanisms , both MESP and CGAT MHO managers emphasized the successful role of MHO brokers in health facilities, leading a drop in cost of laboratory examinations and other specialized services. Navigation mechanisms were used to rationalize health care, avoiding bypassing of first-line health services to access second-line care. Overall, it appeared that the different measures put in place to facilitate patient navigation were seen as satisfactory in both MHO schemes. Concerning grievance and redressal mechanisms , MESP managers perceived most of them to be effective. Better access to health facilities, provision of appropriate health care and improvements in the provision of specialized medicines and health care were reported. CGAT managers felt to be successful in improving member satisfaction about the way how complaints were addressed, including improved access to health facilities and provision of specialized health care in particular for members most in need. MESP managers were very often lagging behind because of restrictive procedures, such as delays in reimbursement of self-purchased medications and other services. With regard to the Oversight mechanisms , managers of both MHO schemes seemed satisfied with the effectiveness of the measures put in place to minimize complaints about health care quality, to reduce fraud by both members and non-beneficiaries, to decrease overbilling by health providers, and to improve adequacy and traceability between the invoice received and a member’s use of health care. MESP managers however expressed being more austere in their approach, even in delaying payment of the health facility bills. On the participation of MHO members in decision-making , only the CGAT managers’ respondents reported an effective representation of members in General Assembly meetings. MESP managers did not confirm this practice. Overall, most of the MHO managers recognized that institutional arrangements and their implementation measures are tools that govern relationships between MHOs and their members. These measures address concerns expressed by members on all matters related to the functioning of the MHO. However, MHO managers also argue that most of the arrangement measures do not yet have a formal regulatory status. When comparing the two MHO schemes, CGAT appears to be more effective in the use of combined channels to reach their members, limiting the delay in handling complaints from their members and getting members to participate in the General Assembly meetings. Perceptions of the effectiveness of implementation measures by MHO members The perceptions of the MHO members on the measures put in place, and their effectiveness, were captured through FGDs organized for members of the two MHOs. Their points of views are summarized below. Virtually, all participants in the FGD felt the communication systems to lack effectiveness. They expressed dissatisfaction in their attempts to communicate with their MHOs. Most of them recognized the existence of a number of communication channels such as phone calls, suggestion boxes, and direct contact with MHO brokers, but expressed the difficulties they encounter in trying to reach either MHO managers or brokers in the health facilities. MESP members reported that contact with the medical advisor and delegates was very often difficult, even impossible. In many cases, members of both MHOs stated not to have proper information on the health care package they are entitled to. More fundamentally, MESP participants challenged the mandatory nature of their affiliation: “We did not voluntarily or freely subscribe to this mutual insurance. They should have come to us to inform us about the existence of a mutual health insurance organization and then ask who wants to join or become a member. After the compulsory membership, we were left to our own devices, we didn’t even have any information about the functioning of the MHO”. (MESP FGD SAINT AUGUSTIN). On the navigation mechanisms , MHO members recognized the key role played by MHO brokers either for MESP or CGAT members. However, they did not agree that the main issues targeted by the navigation mechanism were sorted-out. For example, the basic principles and criteria for selecting contracted health facilities were not known. In addition, in the absence of MHO brokers who have to approve of the transfer vouchers, patients were left on their own and could not benefit from a transfer for care at a higher level in the health system. In fact, this referral process takes a lot of time since contacts were not taken on the very same day: "This can take days or even weeks with all the negative implications, notably the aggravation of the illness as well as the increase in transport costs due to the back and forth that the process generates”. (FGD MESP EP6 NGIRI-NGIRI). With regard to the grievance and redressal mechanisms , members of both MHOs acknowledged that they could introduce claims to their MHOs. However, they also stated that when confronted with problems of reimbursement of pre-funded expenses, poor quality of health care or any other problem, they were often unable to submit their complaints to the MHO. In addition, they said not to know on the basis of which criteria these complaints were eventually selected and treated. Sometimes, members were repetitively seeking for feedback while not receiving any answer from the MHOs [ 17 ]. The implementation of the oversight mechanisms is an area where MHO members appear to have been completely left-out. MHOs did not allow members to participate in their oversight process, even in the case of CGAT MHOs which are community-based organizations. Similarly, members were not involved in the control of the contracted health facilities with regard to possible overbillings. From the point of view of members of both MHOs, this was a reason why, in their view, the management of MHOs remained opaque. The effective participation of MHO members in decision-making was mainly captured through members’ participation in the General Assembly meetings. The majority of participants in the FGDs recognized the importance of member participation in the GA meetings: "It is during these meetings that the stakeholders discuss the functioning of the MHOs, i.e., on the mode of taking care of illnesses, the members' premium, and other necessary entitlements. It is therefore together that they should decide what can be done to meet the needs of all stakeholders”. (FGD La Borne). But only the CGAT MHOs organized General Assembly (GA) meetings and in principle invited member representatives to participate. In the case of the MESP, only delegates of the teachers Union were allowed to participate in the General Assembly meetings. Overall, it appeared that CGAT members were “closer” to their MHOs than those of the MESP. All along the FGDs, MESP members reflected on the lack of transparency in the management of their MHO. They complained not to receive adequate information about the functioning of their MHO and were struggling to reach MHO brokers at health facility level. On top of this, MESP members resented the heavy administrative restrictions in the organization and the functioning of their MHO. Potential factors influencing the implementation of institutional arrangements Support to MHOs The documentary review and IDIs confirmed that a limited number of MHOs benefit from government support and oversight of the national program of promoting MHOs. MESP receives financial support from government for healthcare provision and functioning of the MHO, while CGAT MHOs receives only technical support via MHO platforms and services provided by medical advisors who are civil servants paid by the government. Concurrently, others technical centers, including those under the CGAT umbrella, are being sponsored by donor organizations through international cooperation but also via local platforms of MHOs, which do have legal recognition. This variety of sources of support contributes to shape the context in which MHOs have to operate. Factors internal to the functioning of MHOs Positive factors include experiences of members who share their satisfaction about the benefits of an MHO: lower user fees (10%), avoidance of unpredictable health care expenditures, guarantee of receiving at least basic healthcare at any point in time, and corporate affiliation of small and medium-sized companies. For both MHO schemes, negative factors include shortages of medicines in health facilities, failure to maintain effective communication with members, and a lack of performant monitoring and evaluation systems of new measures or procedures that are implemented. For CGAT MHOs, an important limitation are the limited funds available for operations covering MHO management including the operation of websites, but also limitations in the package of care contracted for its members and insufficient outsourcing of some services, such as laboratory and pharmacies. The difference in the nature of membership affiliation (mandatory versus voluntary) affects the management of the two MHO schemes. Whereas MESP can deal with monthly contributions derived directly from the payroll, the CGAT MHOs must use complex mechanisms to raise member contributions. Most of the time, a two to three months renewal period of subscription is offered to households to allow them saving money to pay for the annual premium contribution. In addition, a large part of the CGAT membership comes from the formal sector, being enrolled by their employers from private companies. MHO internal capacities There are three major points to consider: the expertise of the managers, the availability of resources, and the work structure [ 22 , 23 ]. With respect to training, each staff member is required to undergo training, and most stated that they indeed had received training. Others benefited from the mentorship of more senior colleagues or via self-learning. In terms of resources, respondents emphasized the lack of resources. They especially mentioned office equipment, computer facilities, supplies, and work premises. MESP benefits from some government support for premises and funding, while CGAT MHOs have to rent infrastructure. In terms of internal organization, each agent has clear job description, with explicit standards and guidelines. Most agents have signed employment contracts. According to the MHO platform (POMUCO) 1 and the national support structures (i.e., PNPS 2 , PNPMS 3 ), their support consists of conducting feasibility studies, defining the level of the premium, training of managers and medical advisers, and advocacy at the level of government authorities. The latter eventually contributed to passing of the law on MHOs. In the case of CGAT, platforms largely depend from external donor funding paying salaries of MHO managers, providing additional financial incentives to medical advisers, and covering other managerial operations expenses, including communication. This dependency from external support obviously affects their sustainability. DISCUSSION The primary reason of conducting this study was that, during preliminary contacts with MHO support organizations, it was unclear whether MHOs implement and document the various institutional arrangements and its implementing measures that are part of their managerial procedures, and that are key for they social accountability and responsiveness. The first findings revealed that, concurrently, the measures taken to improve accountability and responsiveness appear to be largely similar for both MHO schemes, inspired by support platforms supported by foreign MHOs such as Belgian mutual health organizations. These measures however need to be further consolidated as standard operating procedures (SOPs) with specific instructions and be integrated into the set of internal rules of MHOs. Overall, managers of both MHO schemes were positive about the measures put in place. MHO members however did not share this positive view. This contrast in perception definitely should benefit from further investigations. Our study confirms the key role played by MHO brokers (medical advisors, MHO delegates or any other MHO representative) in the implementation of arrangements, at least through the provision of information, the orientation of patients in the complex health care circuit, and the handling of member complaints. Not all MHO brokers are “independent” as some of them are themselves MHO staff. Medical advisors, on the other hand, are supposedly independent civil servants at the service of MHOs [ 14 ]. MHO managers as well as health facility managers recognized that many MHO members in both MHO schemes are ill-informed about the contents of the health care package, have limited knowledge about risk sharing in general, and face multiple needs in a context of limited purchasing power [ 12 , 18 , 22 ]. This situation explains why, in many instances, households did not enroll all members [ 15 ]. Thus, they still face substantial out-of-pocket health costs for the other household members, leading to an inequitable form of healthcare financing, with catastrophic and impoverishing effects on their living standards [ 23 – 27 ]. However, in any case, the correct implementation of the contract signed between MHOs and health facilities is critical for accountability and community satisfaction with service delivery [ 28 ]. For the navigation mechanisms to work, MHOs have contracted with government, private, and faith-based health facilities, even if they apply different levels of fees. The use of the curative consultation at the level of first-line health facilities is mandatory for MHO members who are using them frequently (rate of 30% to 40%) to seek for health care [ 13 ]. The referral second-line health facilities are less used by MHO members as subject to MHO brokers approval under navigation procedures [ 18 , 29 , 30 ]. Similar results have been reported in another study conducted in Kinshasa [ 15 ]. For both MHO schemes, the grievances reported in this study are predictors of MHO members’ dissatisfaction [ 17 , 31 ]. But in certain circumstances, the MHO’s responsiveness may go beyond the initially agreed health package. A medical advisor stated that “ with respect to this limitation, we are trying to grant grace or special agreement, after reviewing the member’s situation. For example, when a member brings an unregistered child in critical condition, we are quick to grant a pardon, because children are the most privileged.” (CGAT medical advisor, La Borne). Fraud and breach of trust are observed among household members, health workers, and MHO employees [ 12 ]. Previous billings towards MHOs have shown that, without a review of member consumption, health facility managers tend to abuse the process in trying to get more money [ 25 ]. To prevent fraud and abuse, the use of individual biometric cards associated with the presence of MHO brokers in health facility seems to be effective. All MHO managers recognized the traceability of health care bills by MHO brokers. Regarding participation of MHO members in decision-making organs, measures to allow such processes were seen to be weak. We found that the mechanisms put in place were not very effective, even in the case of CGAT, despite the fact that the invitation to members to attend the General Assembly included reimbursement of transportation costs, a practice also mentioned in other studies [ 18 ]. The lack of participation could be seen as a lack of community engagement, which are rooted in interactions that are relatively responsive, respectful and that bring tangible related benefits [ 32 ]. MHOs have limited internal capacities because they are understaffed and they are very dependent on donor support in case of CGAT, and on the administration of the supervisory Ministry for MESP. MHO managers are overloaded with administrative tasks, which reduces their availability to respond to member requests [ 18 , 31 ]. Overall, measures taken to implement the various institutional arrangements to enhance MHOs social accountability and responsiveness are more a reflection of a set of ad hoc practices than standardized decisions documented and incorporated into end-to-end processes such as SOPs for MHO management. Managers are organizing the day-to-day management process, without however having expert administrative support in terms of decisions or written guidance. In fact, as part of the social accountability mechanisms, the weakness in implementing these measures include lack of capacity, poor commitment and insufficient participatory governance structures capable of strengthening the trust and commitment of members, as also reported in other countries, such as Ethiopia [ 33 – 35 ]. However, the proposed conceptual framework could be used by MHOs as a tool that may guide the formal setting of procedures suitable for MHO managers to enhance MHO accountability and responsiveness. Such kind of framework have also been proposed as theories of change underpinning social accountability [ 36 ]. MHOs operate in a context of poorly regulated health care provision of poor quality, little or no public funding, and lack of trust in MHO governance, which have led to high rates of membership dropout in Ethiopia, for example [ 37 ]. Similarly, it has been reported that the low responsiveness of community health insurance schemes is a major obstacle to their adoption in sub-Saharan Africa, confirming that social accountability mechanisms are crucial to the sustainability of such systems, knowing that in DRC, MHOs struggle to survive financially [ 2 , 12 , 38 ]. One of the ways forward is for MHOs to gain and deserve people’s trust. In that respect, more transparency and adequate responses to members needs and expectations is crucial. This includes promoting trust in members and their community and reverse the negative perception of members in the management of MHOs and in the quality and accessibility of health care and services [ 39 ]. MHOs need to better inform people on the benefits they offer in terms of accessing health care and securing members rights, which should be part of an honest implementation of social accountability procedures [ 16 , 40 ]. More accountability and better responsiveness of MHOs are one step in expanding membership, knowing that vulnerable households covered by CBHI make more use of health services, than those without insurance [ 34 ]. Study limitations One limitation is the fact that views of MHO managers and of MHO members were collected separately without any subsequent “confrontation” of the two views. A mixed group discussion would have been useful in bridging some of the gaps between the optimistic points of views of MHOs managers and the sometimes-harsh critique of MHO members. Another limitation is that our findings pertain to the specific situation of a very limited number of MHOs operating in the huge Kinshasa metropole and may therefore not be generalizable to MHOs throughout the DRC. CONCLUSION The conceptual framework underlying this study was instrumental in capturing the building blocks and related pathways in assessing the effectiveness and impact of the various institutional arrangements and related implementing measures to improve social accountability and responsiveness of MHOs. The implementation of these measures led to a range of outcomes perceived as satisfactory by the MHO managers in terms of empowering MHO members to improve their knowledge regarding the effective use of their entitlements to obtain appropriate health care. However, this positive perspective was largely contradicted by MHO members who were often unaware of most of the measures put in place and doubtful on their effectiveness. The challenges and hurdles to be taken are plentiful, but one of the most important ways forward that emerges from our research is the need to engage into a much more effective dialogue between MHO managers and members. Abbreviations DRC Democratic Republic of Congo CHI Community Health Insurance CBHI Community Based Health Insurance MHO Mutual Health Organization UHC Universal Health Coverage LMIC Low and Middle Income Country CBO Community based Organization CGAT Risk Management and Technical Support Center MESP Health insurance for primary, secondary, and vocational school teachers FGD Focus group discussion IDI In depth Interview. Declarations Acknowledgement and funding This study was part of a global investigation of health insurance accountability and responsiveness initiated and funded by the Global Alliance for Health Policy and System Research (AHPSR) and the World Health Organization [grant No WHO 2019/960869-0]. Conflict of interest The authors had no conflicts of interest to declare. Ethical statement The research protocol received the approval of the Kinshasa School of Public Health Ethics Review Committee under registration No: ESP/CE/004/2020. According to the Helsinki declaration, the protection of participants was respected under anonymous and COVID 19 protection measures, such as the use of masks and appropriate distancing. For the IDIs with managers, a written informed consent form was presented and explained, and each interviewee signed it before the interview. For FGDs, each member of the group was invited to express consent before participation. Consent for participation and publication All person interviewed signed a written informed consent to participate in the study and agreed for the publication of the results. All co-authors have reviewed the paper and agreed to have it submitted for review and publication. Co-authors gender, credentials and email addresses Mr Dosithee Ngo-Bebe, PhD ; Mr Fulbert Nappa Kwilu, PhD ; Mrs Arlette Kilonga Mavila, MD, MPH ; Mr Serge Kule Kapanga, Advanced Studies Degree in social science ; Mr Bart Criel, PhD Author Contribution DNB, FNK and BC developed the protocol; FNK, AKM and SKK conducted the IDIs and the FGDs; FNK, SKK and DNB conducted the analysis; DNB, FNK, and BC conducted the writing process; BC reviewed the manuscript. All authors red, commented and approved the manuscript. Data Availability The authors confirm that all pertinent data are contained within this document. However, additional data can be made available upon request. References World Health Organization. Neglected health systems research: governance and accountability. Research issues 3. Alliance for health policy and systems research. World Health Organ. 2008. https://www.who.int/alliance-hpsr/AllianceHPSR Criel B, Waelkens M-P, Kwilu NF, Coppieters Y, Laokri S. 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Footnotes POMUCO : Platform of mutual health organizations in Congo ( Plateforme des organisations des mutuelles de santé du Congo) PNPS : National Social Protection Support Program ( Programme National d’appui à la Protection Sociale) PNPMS : National Program for promoting mutual health organizations ( Programme National de Promotion des Mutuels de Santé) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 12 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Editor invited by journal 17 Nov, 2025 Submission checks completed at journal 15 Nov, 2025 First submitted to journal 15 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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12:29:49","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":150895,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8005371/v1/0e0c4b5194bc09e6c822ec09.html"},{"id":98752230,"identity":"770336e4-12d8-45f2-930d-c8bdb6439e4d","added_by":"auto","created_at":"2025-12-22 09:15:22","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":661563,"visible":true,"origin":"","legend":"\u003cp\u003eFramework of the implementation of MHO institutional arrangements in Kinshasa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource:\u003c/strong\u003eAdapted from Goetz and Gaventa (2001) and Molyneux (2012) [19,20]\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8005371/v1/e261433d08fb78a91129bfde.jpeg"},{"id":98785449,"identity":"876102ad-15d8-42de-86bc-801da34455ca","added_by":"auto","created_at":"2025-12-22 12:43:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1971585,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8005371/v1/d34d9ffa-8549-4aa3-af72-705b6787cfd4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring social accountability and responsiveness procedures of Community-based Health Insurance in Kinshasa, Democratic Republic of Congo, using qualitative approach research","fulltext":[{"header":"Key Message","content":"\u003cp\u003e\u003cstrong\u003eImplication for policy makers\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAvailability of a set of implementation measures of key institutional arrangements that aim to enhance Mutual Health Organization (MHO) social accountability and responsiveness.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eControversial perceptions of the effectiveness of MHO procedures to operate relationships with their members are of high importance for policymakers in guiding MHOs’ management.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eToward universal health coverage (UHC), implementing measures of institutional arrangements need to be converted into standards operating procedures (SOPs), as a way of improving MHOs’ internal managerial capacities. \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eImplication for the public\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmpowering MHO members to improve their knowledge on their rights and obligations for better and effective use of their entitlements to obtain appropriate health care, is a must. The need to engage in much more effective communication between MHOs and their members emerges as a way forward to establishing a trustful relationship. This will then reverse the doubtful of members on the knowledge and effectiveness of the MHOs’ institutional arrangements and their implementation procedures, which would lead to improve it penetration in the country. It is noted that in the DRC context, MHOs will remain as building blocks of the upcoming health insurance, toward achieving UHC.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eThis study attempts to contributing to the global debate on Community health insurance (CHI) accountability and responsiveness. CHI aims to provide financial protection from the cost of seeking healthcare through voluntary prepayment by community members. In most low and middle-income countries (LMICs), CHIs are viewed as one of the key mechanisms toward achieving universal health coverage (UHC). In the global perspective of health systems, social accountability is critical to empower CHI enrollees to better understanding and participating in decisions concerning the provision of quality healthcare, procedures to access them, costs that are required and other benefits that CHI members should know and request in seeking healthcare services. Empowered CHI members can contribute to improving service efficiency and quality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt community level, CHIs are mainly organized as community-based health insurances (CBHIs), which schemes are active but face low enrollment, organizational challenges, and sustainability issues, but they increase service utilization and provide uneven financial protection against health expenditure shocks [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the case of the Democratic Republic of Congo (DRC), where there is no yet national health insurance, mutual health organizations (MHOs) are considered as one of the cornerstones of the edifice of financial protection at community level. They are private, but socially oriented initiatives structured mainly as community-based organizations (CBO), built around the principles of solidarity and risk-sharing to facilitate access to health care for their members [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo schemes of MHOs can be distinguished: corporate MHOs, with compulsory contributions and which are aligned to CHI, and strictly community-based MHOs, with voluntary affiliation and contributions which are aligned to CBHI [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, their penetration is still embryonic, around 3\u0026ndash;5%, an illustrative figure with clear limitations and large local variations, such as the spatial variations of the health insurance ownership between Bandundu \u0026amp; Kasa\u0026iuml; Oriental (1.2%) and Kinshasa (15.5%). [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The absence of national health insurance and the very low penetration of MHOs explain why out of pocket payments are the first funding source for the health system in DRC (43%) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this context, user fees, unfortunately remain the rule, and effective financial protection the exception, despite some rare specific cases [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe UHC strategic plan 2020\u0026ndash;2030 has defined strategies that include the extension of financial protection to people who work in the informal sector and mandatory protection for those who work in the formal sector, as stated in the Law No 17/002/2017 establishing the fundamental principles of MHOs in DRC [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, problems in the design and operation of MHOs impair their social accountability and responsiveness and are at odds with a harmonious and trustful relationship with their members [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These problems are mainly: (i) Poor participation of MHO members in decision-making bodies and in oversight organs; (ii) Weakness of enrollment initiatives; (iii) Registered members taken as a given; and (iv) An unfulfilled role of MHO brokers, i.e., medical advisors and MHO delegates in the health facilities.\u003c/p\u003e \u003cp\u003eThese weaknesses trickle down in the internal management of MHOs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Even with coaching by technical structures or support centers, most MHOs remain small-scaled and poorly professionalized organizations with limited coverage [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and in contrast with the way forward as set in the 2017 law on MHOs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsidering the important role of MHOs in the health system financing, the issue of their social accountability and responsiveness to members needs are central in establishing trustful relationships with their members, in increasing their penetration, and in bringing effective financial coverage to people toward the achievement of UHC; all in a context of deep poverty and challenging social, institutional, and political environment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In such a difficult context, it is of paramount importance to explore to what extent, and via what institutional arrangements and related procedures, MHOs are accountable to their members and responsive to their needs.\u003c/p\u003e \u003cp\u003eThis article follows a previous one, which focused on the management of members\u0026rsquo; complaints by mutual health organizations in Kinshasa [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. It aimed to identify the various measures implemented by MHOs to enhance social accountability and responsiveness. We further strived to investigate and map the perceptions of both MHO managers and MHO members regarding the relevance and effectiveness of these measures.\u003c/p\u003e \u003cp\u003eThe research questions were the following: (1) What are the institutional arrangements and related measures set up by MHOs; (2) How do MHO managers perceive the effectiveness of these measures; (3) How do MHO members perceive the effectiveness of these measures; (4) What potential factors are influencing the implementation of these institutional arrangements.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and approaches\u003c/h2\u003e \u003cp\u003eThe study consists of an in-depth investigation of a broad range of implementing measures of institutional arrangements designed to enhance social accountability and responsiveness of MHOs vis-\u0026agrave;-vis their members. Qualitative methods were used for this study, with three main approaches: (i) documentary review to map the various institutional arrangements implemented in each selected MHO; (ii) in-depth interviews with MHO managers; and (iii) focus group discussions with MHO members.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy sites\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in three MHOs, representing two distinct health insurance schemes. The first scheme comprises two MHOs, \u003cem\u003eLisanga\u003c/em\u003e and \u003cem\u003eLa Borne\u003c/em\u003e, that operate under the same platform umbrella, named \u0026ldquo;\u003cem\u003eCentre de Gestion de risque et d\u0026rsquo;Accompagnement Technique\u003c/em\u003e\u0026rdquo; (CGAT). These two MHOs are designed as a community-based scheme in which people living in a given geographical area join the MHO on a voluntary basis, regardless of whether they work in the formal or informal sector. This scheme of MHO is in most instances launched by a nonprofit community organization with the objective of facilitating health care access to the affiliated members [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf the two mentioned MHOs, the \u003cem\u003eLisanga\u003c/em\u003e MHO has been operational since 2014 and covered 4570 households in 2018. The \u003cem\u003eLa Borne\u003c/em\u003e MHO started providing its services in 2017, serving 3201 households in 2018. For these two MHOs, the package offered to the affiliated members consists of primary care, laboratory or radiology outsourcing examinations, hospital care, and reimbursement of some specialized medicines. The two MHOs are quite similar in terms of organizational structure, management tools, and technical guidance and backstop support from the CGAT, an umbrella platform which accounted for a total of 20,236 households in 2018. We therefore merged their data sets, henceforth, both are designated as \u0026ldquo;CGAT MHOs\u0026rdquo; in this study.\u003c/p\u003e \u003cp\u003eThe second scheme of MHO investigated is the MESP \u003cem\u003e[Mutuelle de sant\u0026eacute; des enseignants de l\u0026rsquo;enseignement primaire, secondaire et professionnel]\u003c/em\u003e, which covered 41,220 households in 2018 in Kinshasa. MESP is based on a compulsory affiliation of teachers in government primary and secondary schools. The MESP resembles a social health insurance based on a public nonprofit rationale, in which the contribution is a function of the individual income of civil servants (teachers in public schools) with mandatory affiliation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Apart from contributions deducted from the members\u0026rsquo; salaries, the MESP receives a subvention from the government.\u003c/p\u003e \u003cp\u003eCompared with the CGAT MHOs, the MESP offers a more comprehensive health services package, aligned to the different levels of health facilities, including hospitalization at second-level health care facilities when needed. Both schemes of MHOs are built on risk-sharing mechanisms and target risk reduction by pooling prepaid contributions meant to cover the health care expenses of their affiliated members [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected from 17 December 2020 to 15 March 2021, by our DRC research team, who have at least a master's degree in public health and who are co-authors of this paper. The field work was covered with an authorization of the Kinshasa School of Public Health, used to introduce them to the participants on a face-to-face approach. All the team members are university teachers and researchers. The guidelines of the IDIs and FG were pretested with the support of the CGAT in another MHO not part of the research.\u003c/p\u003e\n\u003ch3\u003eDesk review\u003c/h3\u003e\n\u003cp\u003eMore than 50 local working documents were consulted using a content analysis approach, searching for information mainly on institutional arrangements and related operating measures. Documents explored were related to the creation of the MHOs, their status, enrollment conditions, agreements with health facilities, established communication channels, administrative decisions files, and many other managerial documents, such as annual reports, operational plans and MHO member databases. We also accessed lists of schools per administrative district of Kinshasa City. Other contents of interest were about policy reference documents such as National Laws on MHOs, National Health Development Plan, National Strategic Plan on UHC, and National health account reports. Most of them were official documents, but part of the grey literature. Documents were requested and reviewed mainly during our visits in MHO offices respecting the privacy of the MHOs.\u003c/p\u003e\n\u003ch3\u003eIn-depth interviews\u003c/h3\u003e\n\u003cp\u003eIn-depth interviews were held with MHO managers at their headquarters location and with those working within health facilities. For the CGAT, the interviewed staff included the team that ensures coordination and technical support and local managers of the Lisanga and La Borne MHOs. For the MESP, staff at headquarters and delegates who operate in the contracted health facilities were interviewed.\u003c/p\u003e \u003cp\u003eGuides for in-depth interviews were established in French and administered during appointments with identified MHO managers in their workplace. All in-depth interviews were audio recorded with the approval of respondents and handwritten notes were also taken. The duration of the interviews took a maximum of 2 hours. In total, 34 in-depth interviews were conducted, including 12 women, from 18 February to 10 August 2020, under the difficult conditions of the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eWe used a targeted sampling strategy with the goal of capturing as much as possible the relevant information we sought. For this process, key staff members were identified with names and positions before we requested an appointment. We intended to reach out to different categories of respondents to generate an overview of their experiences or their perceptions of MHO services. The list of respondents included the Chief Executive Officers (CEOs), executive managers, delegates, medical advisers (14 for MESP and 11 for CGAT), and 9 health facilities managers. The exclusion criteria were the unavailability of the targeted respondent, and we used a replacement approach by a colleague with the same profile.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFocus Group Discussion\u003c/h2\u003e \u003cp\u003eFocus Group Discussions (FGDs) were organized with MHO members collecting information related to the MHO members\u0026rsquo; points of view on their knowledge and perceived effectiveness of the measures put in place by the MHOs to improve social accountability and responsiveness. Fifteen FGDs with a total of 153 participants were conducted and distributed as follows: 8 for the MESP and 7 for the CGAT (4 for Lisanga and 3 for La Borne). The inclusion criteria were the availability of the targeted members and gender considerations, which led to mixed compositions of the groups.\u003c/p\u003e \u003cp\u003eFGDs were conducted in French, the official language in DRC, used by most of literate people in Kinshasa. All the sessions were audio-recorded and transcripts generated. Through verbatims, some specific opinions and responses were captured to illustrate personal experiences. With a maximum of 2 hours, discussions took place either in the community for CGAT members, and in their school places for MESP members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe analysis firstly consisted of an inventory and classification of arrangements and measures established in each of the two schemes of MHOs. The classification was conducted with the help of a guiding framework, explained and discussed with interviewees [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The analysis further explored whether MHO managers themselves were satisfied with the various arrangements introduced, and which factors managers identified as contributing to success, or lack of it. Secondly, the analysis looked into the perception of the members themselves.\u003c/p\u003e \u003cp\u003eTo analyze the content of the IDIs and FGDs, we used a qualitative analysis software, ATLAS.Ti, with an interactive inductive process, using a thematic content analysis approach. All transcripts were coded by two experienced researchers from the Department of social science, Kinshasa University, including one from our team. Some codes were added in an emerging process, whenever necessary [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Matrices were generated to identify themes and sub-themes emerging from the data, illustrated with relevant quotes and text results. According to the coding, MHO members were more willing to seek healthcare, once they were informed about the accountability and responsiveness measures associated with the five institutional arrangements.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eConceptual framework of the institutional arrangements for MHOs in the DRC\u003c/h3\u003e\n\u003cp\u003eThe conceptual framework is a generic framework situating the institutional arrangements and their implementing measures aiming to enhance MHO social accountability and responsiveness, as mentioned in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSource\u003c/strong\u003e \u003cp\u003eAdapted from Goetz and Gaventa (2001) and Molyneux (2012) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe framework presents a synthesis of documented institutional arrangements, with their potential and respective key implementation measures toward empowered members trough better knowledge and use of the measures, leading to satisfaction of members with quality healthcare in health facilities.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIdentified institutional arrangements and implementation measures\u003c/h2\u003e \u003cp\u003eWe identified 35 social accountability and responsiveness promotion measures that were distributed into the following five institutional arrangements irrespective of the MHO scheme: (1) information provision; (2) navigation mechanisms; (3) grievance and redressal mechanisms; (4) oversight arrangements; and (5) participation in decision-making [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Among the 35 measures, 18 were common to both MHO schemes, 10 specifics to the MESP, and 7 specifics to the CGAT MHOs, as presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVariation in measures implemented by MESP and CGAT MHOs for each institutional arrangement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMEASURES COMMON TO\u003c/p\u003e \u003cp\u003eBOTH MHOs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMESP-SPECIFIC MEASURES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCGAT-SPECIFIC MEASURES\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformation provision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Information campaign and enrollment process\u003c/p\u003e \u003cp\u003e- Access through a set of phone numbers and/or hotline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Information sharing on decisions taken by the General Assembly\u003c/p\u003e \u003cp\u003e- Display of press releases for member information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Information by peers: empowered members to inform other affiliates\u003c/p\u003e \u003cp\u003e- Sharing information or concerns through social media\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNavigation mechanisms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Brokers\u0026rsquo; orientation and follow-up of members in health facilities\u003c/p\u003e \u003cp\u003e- Prior approval by medical advisor for navigation\u003c/p\u003e \u003cp\u003e- Prior approval by medical advisor for any diagnostic voucher\u003c/p\u003e \u003cp\u003e- Costs review of alternative health care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Case-by-case management for emergency and/or specialized exams\u003c/p\u003e \u003cp\u003e- Special authorization to health facility access in favor of members living outside the MESP coverage areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrievance and redressal mechanisms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Brokers to capture and manage members\u0026rsquo; complaints\u003c/p\u003e \u003cp\u003e- Feedback provided through General Assembly meetings and media supports\u003c/p\u003e \u003cp\u003e- Case-by-case management for the reimbursement process\u003c/p\u003e \u003cp\u003e- Case-by-case management for provision of non-covered specialized health care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Decentralization of administrative services to local offices closer to member households\u003c/p\u003e \u003cp\u003e- Partnership agreements signed with pharmacies to provide medicines not available in the health facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Direct provision of medicines to members by CGAT avoiding members\u0026rsquo; complaints\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOversight arrangements\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Prior approval by medical adviser of non-generic medicines\u003c/p\u003e \u003cp\u003e- Use of individual biometric membership cards\u003c/p\u003e \u003cp\u003e- Checking the membership status at the health facility\u003c/p\u003e \u003cp\u003e- Approval of the bill by the medical advisor\u003c/p\u003e \u003cp\u003e- Disciplinary measures to encourage health facilities to respect the clauses of contracts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- MHO oversight committees or inspectors for periodic review of the technical plateau for health care\u003c/p\u003e \u003cp\u003e- Checking the quality of affiliation by the health facility using updated lists\u003c/p\u003e \u003cp\u003e- Double checking of the health care bills by the inspector\u003c/p\u003e \u003cp\u003e- Prohibition of paying cash to members for prompt health care access or specialized examinations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Rapid survey (via phone) on conformity of health care management protocols on sample of consumers on the basis of existing patient protocols\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParticipation in decision-making\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- MHO members\u0026rsquo; right to substitute or to add a beneficiary member\u003c/p\u003e \u003cp\u003e- MHO members\u0026rsquo; right to change a first-line health facility up to three times\u003c/p\u003e \u003cp\u003e- Invitation to members to join the General Assembly using letters, phone calls, and SMS reminders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Payment of 50% of the bill by the MHO member beyond the deductible amount\u003c/p\u003e \u003cp\u003e- Involvement of members in the new member enrollment process\u003c/p\u003e \u003cp\u003e- Incentives to members for participation in General Assembly\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of the institutional arrangements\u003c/h2\u003e \u003cp\u003eThe description of the implementation of the five institutional arrangements was mainly captured through the IDIs conducted with the all the selected MHO managers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eProvision of information\u003c/h2\u003e \u003cp\u003eFor both schemes of MHOs, the provision of information is taking place through several communication channels, including (1) phone calls, text messages (SMS), and messages through WhatsApp groups; (2) interpersonal communication during meetings with managers and delegates in health facilities; (3) workplace meetings, mainly with members of the CGAT MHOs; (4) letters to MHOs; (5) press releases; (6) websites; (7) complaint books; and (8) suggestion boxes.\u003c/p\u003e \u003cp\u003eThe three main issues addressed by MHOs were the limited knowledge of members about the benefit package, the new measures introduced by the MHOs, and the limited contact with MHO managers in case of need.\u003c/p\u003e \u003cp\u003eRespondents reported that the phone call is one of the most used and effective communication tools because it is the most direct way of getting information or feedback, or resolving a problematic situation. Another quality of the phone call is the speed and flexibility with which a member\u0026rsquo;s question can be answered directly and a solution found to satisfy his request. MHO managers phone numbers are written on membership cards.\u003c/p\u003e \u003cp\u003eHowever, essential information is most often provided to members at the enrollment stage for both MHO schemes. The package of information given to members about members\u0026rsquo; rights includes access to a health care package and a list of contracted health facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eNavigation mechanisms\u003c/h2\u003e \u003cp\u003eOur working definition of navigation has been contextualized as the range of mechanisms put in place to guiding MHO members in the local health system, in particular when it comes to refer patients to more specialized outsourcing clinics and services such as general referral hospital, laboratory or X-rays services. The purpose is to overcome challenges related to (1) bypassing of first-line health services to access second-line health care, possibly leading to overuse of specialized care and exams; (2) lack of harmonizing of billing costs between providers for the provision of a similar item of healthcare; and (3) specifically for MESP, the need to rationalize the referral process to health facilities within the geographical area covered by the MHO.\u003c/p\u003e \u003cp\u003eIn both MHOs, medical advisors play a key role in the navigation mechanisms. In addition, MESP has posted their delegates in the contracted health facilities in order to facilitate health system navigation of their members. Members can present themselves to the medical advisors with transfer documents, including transfer notes, laboratory examination vouchers, requests for a specialist consultation, or requests for more specialized medicines. According to the therapeutic protocol, the medical advisor examines the relevance of each document for referral to a second or third-line clinic while taking precautions to avoid overconsumption and overbilling.\u003c/p\u003e \u003cp\u003eAs one of the interviewed reported: \u0026ldquo;\u003cem\u003eMy role is to process members\u0026rsquo; files as appropriate, starting with checking the membership, because each file must be checked in my office, with the member\u0026rsquo;s card. I also check whether it is an entitlement covered by the MHO, and if so, I then sign to direct the member to the referral hospital or clinic.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(CGAT medical advisor Lisanga).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAs for the MESP delegates, in addition to facilitating referral processes of members from one health facility to another, or for a given medical service to another within the same health facility. They welcome members, check for their membership, navigate them to the appropriate services and ensure the control of the health facility billing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eGrievance and redressal mechanisms\u003c/h2\u003e \u003cp\u003eGrievance and redressal mechanisms consist of a set of procedures that allow members to submit their complaints or suggestions to the MHO. The main issues were poor responsiveness in processing mail traffic and claims coming from members, addressing bottlenecks in the gathering of members at the MHO headquarters, and long waiting times to receive medicines from a drugstore or health facility.\u003c/p\u003e \u003cp\u003eFace-to-face meetings with medical advisors, use of phone calls and suggestion boxes at the health facilities were common procedures used by both MHO schemes.\u003c/p\u003e \u003cp\u003eThe most frequently reported types of complaints were related to (1) poor quality of health care; (2) unavailability of good quality medicines; (3) long procedures, with multiple back-and-forth traveling between the MHO office and the health facilities; (4) delays in delivering the membership cards; (5) delays in getting answers from the MHOs; and more in general, (6) poor communication between MHOs and members. A specific complaint addressed to the MESP was the absenteeism of the MHO delegates in the health facilities, which leads to delays in accessing healthcare. As for CGAT, the specific complaints were related to (1) non-compliance with the agreed co-payment user fees; (2) non-reimbursement of invoices for expenses incurred by the members themselves; (3) non-compliance with therapeutic protocols; (4) unavailability of managers in the MHO office and/or inability to reach them by phone; and (5) increase in co-payment fees within a same year.\u003c/p\u003e \u003cp\u003eAll interviewees stated that interpersonal communication during face-to-face meeting is very much appreciated, as for members, it is the best means of communication toward solving their problems without any delay.\u003c/p\u003e \u003cp\u003eFor the two schemes, MHO brokers are committed to help improving health care provision to members, so as to comply with the content of the contracts signed with the providers. They use the same procedures: reminder letters about compliance with the terms of the contract; invalidation of acts that do not comply with the agreements; non-payment of overbilling invoices; and meetings with health facility officials to come up with consensus on some of the members\u0026rsquo; claims.\u003c/p\u003e \u003cp\u003eOn this specific institutional arrangement, a comprehensive analysis has been already published [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eOversight arrangements\u003c/h2\u003e \u003cp\u003eThe supervisory board for MHO activities mentioned by respondents is the control or monitoring committee that reports to the management committee. However, respondents pointed out that participation of MHO members in this board is not effective in the two schemes of MHOs, and the functioning of such a committee is questionable in some ways. This is the case for CGAT MHOs, where the CGAT accountant acts as a controller on behalf of the MHOs.\u003c/p\u003e \u003cp\u003eControl is also exercised by MHO delegates in health facilities. In the particular case of the MESP, the delegates work is supported by the pricing committee, which crosschecks with the health facility agreements to verify the quality of health care offered to members. This committee also examines the relationship and interactions between delegates and members. Committee members report all weaknesses found in the field to the MHO management, so that managers can provide useful answers and allow health facilities and delegates to properly meet member expectations.\u003c/p\u003e \u003cp\u003eSeveral issues were pointed out to be covered by oversight mechanisms: complaints about quality of care; member fraud in use of health care through substitution of a non-beneficiary for a member; overuse of a collective household card; and overcharging bills by contracted health facilities. In the case of MESP, respondents recognized the need to strengthen supervision of health facilities to compensate the relative lack of delegates. Indeed, only one delegate is supervising two to three health facilities.\u003c/p\u003e \u003cp\u003eThe control exercised by both MHOs in health facilities improves the technical threshold and the quality of health care provided. Member satisfaction is a necessary condition for the renewal of a contract. Similarly, control in health facilities minimizes overbilling and overconsumption of care and prevents fraud in the identity of membership card users. In addition, financial control guarantees the traceability of service provider invoicing and MHO payments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eParticipation in decision-making\u003c/h2\u003e \u003cp\u003eMHO managers noted that most members do not have full control over their rights and duties vis-\u0026agrave;-vis the MHO. This lack of control is greater among dependents, including family members and other individuals related to the members, who are often absent during the membership processes and briefing sessions. In fact, the main issue at stake was that representative of members were not involved in the decision-making organs, such as General Assembly.\u003c/p\u003e \u003cp\u003eMHO managers underlined the necessity of raising awareness of all members by giving them all relevant information needed to exercise their rights and obtain their benefits from MHO services. A respondent reported that \u0026ldquo;\u003cem\u003ethere are many members\u0026rsquo; complaints that could be explained by the fact that members are unaware of the concept of solidarity in the functioning of MHO, as they are not really participating in the life of the MHO.\u0026rdquo; (Medical adviser La Borne).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn the case of the MESP, however, the MHO management provides members with agendas to participate in the ad-hoc committees set up for well-defined purposes or in meetings with trade unionists.\u003c/p\u003e \u003cp\u003eWith regard to the participation in the MHO General Assembly meetings, MHO managers stated that, according to the rules of the CGAT MHOs, participation is open to any member. Invitation letters are sent to some members to attend the General Assembly meetings. Other communication channels such as SMS messages or press releases, are also used to remind them to attend meetings. For MESP, only the delegates of the teacher\u0026rsquo;s trade union are invited to the General Assembly. As an incentive, a small financial token is given to them at the end of the meeting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions of the effectiveness of implementation measures by MHO managers\u003c/h2\u003e \u003cp\u003eOur understanding of the effectiveness of these measures was based on their ability to adequately address the issues raised. Of the 16 concerns, four were not effective, despite nuanced declarations of all the MHO managers. They were related to: (i) persistent bottlenecks in the members request to meet the MHO top management, leading to a situation of members gathering at headquarters for both MHO schemes; (ii) delays in the reimbursement of self-purchased medicines in the case of CGAT; (iii) complaints from MESP members about limitations on the number of beneficiaries of a health care package per household; (iv) complaints from CGAT members about the limitations on the number of sickness episodes, as well as the number of days in hospitals. The respondents offered more details, as described below. Points of views of MHO managers were also globally shared by health facility managers.\u003c/p\u003e \u003cp\u003eOn \u003cb\u003einformation sharing\u003c/b\u003e, in order to overcome the challenges of providing information to members, MHO managers shared a number of novel actions. Both MHOs designed an information kit shared with new members about the health package and displayed a press release for self-access to MHO information. Health facilities are also used as a channel of information dissemination. However, one of the respondents recognized that despite all the information channels, \u0026ldquo;\u003cem\u003emembers are still not mastering their health care package and when requesting appointments are rerouted to medical advisors or delegates in health facilities\u003c/em\u003e\u0026rdquo; \u003cem\u003e(MESP Delegate, Limete).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFor CGAT MHOs specifically, efforts were taken to make better use of information campaigns during the enrollment process, to invite members to share information with peers about membership rights and benefits, and to improve the use of phone calls and social media. In both MHOs, managers described the recruitment process, phone calls and social media as the most effective ways to reach members with critical information.\u003c/p\u003e \u003cp\u003eWith regard to \u003cb\u003enavigation mechanisms\u003c/b\u003e, both MESP and CGAT MHO managers emphasized the successful role of MHO brokers in health facilities, leading a drop in cost of laboratory examinations and other specialized services. Navigation mechanisms were used to rationalize health care, avoiding bypassing of first-line health services to access second-line care. Overall, it appeared that the different measures put in place to facilitate patient navigation were seen as satisfactory in both MHO schemes.\u003c/p\u003e \u003cp\u003eConcerning \u003cb\u003egrievance and redressal mechanisms\u003c/b\u003e, MESP managers perceived most of them to be effective. Better access to health facilities, provision of appropriate health care and improvements in the provision of specialized medicines and health care were reported. CGAT managers felt to be successful in improving member satisfaction about the way how complaints were addressed, including improved access to health facilities and provision of specialized health care in particular for members most in need. MESP managers were very often lagging behind because of restrictive procedures, such as delays in reimbursement of self-purchased medications and other services.\u003c/p\u003e \u003cp\u003eWith regard to the \u003cb\u003eOversight mechanisms\u003c/b\u003e, managers of both MHO schemes seemed satisfied with the effectiveness of the measures put in place to minimize complaints about health care quality, to reduce fraud by both members and non-beneficiaries, to decrease overbilling by health providers, and to improve adequacy and traceability between the invoice received and a member\u0026rsquo;s use of health care. MESP managers however expressed being more austere in their approach, even in delaying payment of the health facility bills.\u003c/p\u003e \u003cp\u003eOn the \u003cb\u003eparticipation of MHO members in decision-making\u003c/b\u003e, only the CGAT managers\u0026rsquo; respondents reported an effective representation of members in General Assembly meetings. MESP managers did not confirm this practice.\u003c/p\u003e \u003cp\u003eOverall, most of the MHO managers recognized that institutional arrangements and their implementation measures are tools that govern relationships between MHOs and their members. These measures address concerns expressed by members on all matters related to the functioning of the MHO. However, MHO managers also argue that most of the arrangement measures do not yet have a formal regulatory status. When comparing the two MHO schemes, CGAT appears to be more effective in the use of combined channels to reach their members, limiting the delay in handling complaints from their members and getting members to participate in the General Assembly meetings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions of the effectiveness of implementation measures by MHO members\u003c/h2\u003e \u003cp\u003eThe perceptions of the MHO members on the measures put in place, and their effectiveness, were captured through FGDs organized for members of the two MHOs. Their points of views are summarized below.\u003c/p\u003e \u003cp\u003eVirtually, all participants in the FGD felt the \u003cb\u003ecommunication systems\u003c/b\u003e to lack effectiveness. They expressed dissatisfaction in their attempts to communicate with their MHOs. Most of them recognized the existence of a number of communication channels such as phone calls, suggestion boxes, and direct contact with MHO brokers, but expressed the difficulties they encounter in trying to reach either MHO managers or brokers in the health facilities. MESP members reported that contact with the medical advisor and delegates was very often difficult, even impossible. In many cases, members of both MHOs stated not to have proper information on the health care package they are entitled to.\u003c/p\u003e \u003cp\u003eMore fundamentally, MESP participants challenged the mandatory nature of their affiliation: \u003cem\u003e\u0026ldquo;We did not voluntarily or freely subscribe to this mutual insurance. They should have come to us to inform us about the existence of a mutual health insurance organization and then ask who wants to join or become a member. After the compulsory membership, we were left to our own devices, we didn\u0026rsquo;t even have any information about the functioning of the MHO\u0026rdquo;. (MESP FGD SAINT AUGUSTIN).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOn the \u003cb\u003enavigation mechanisms\u003c/b\u003e, MHO members recognized the key role played by MHO brokers either for MESP or CGAT members. However, they did not agree that the main issues targeted by the navigation mechanism were sorted-out. For example, the basic principles and criteria for selecting contracted health facilities were not known. In addition, in the absence of MHO brokers who have to approve of the transfer vouchers, patients were left on their own and could not benefit from a transfer for care at a higher level in the health system. In fact, this referral process takes a lot of time since contacts were not taken on the very same day: \u003cem\u003e\"This can take days or even weeks with all the negative implications, notably the aggravation of the illness as well as the increase in transport costs due to the back and forth that the process generates\u0026rdquo;. (FGD MESP EP6 NGIRI-NGIRI).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWith regard to the \u003cb\u003egrievance and redressal mechanisms\u003c/b\u003e, members of both MHOs acknowledged that they could introduce claims to their MHOs. However, they also stated that when confronted with problems of reimbursement of pre-funded expenses, poor quality of health care or any other problem, they were often unable to submit their complaints to the MHO. In addition, they said not to know on the basis of which criteria these complaints were eventually selected and treated. Sometimes, members were repetitively seeking for feedback while not receiving any answer from the MHOs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe implementation of the \u003cb\u003eoversight mechanisms\u003c/b\u003e is an area where MHO members appear to have been completely left-out. MHOs did not allow members to participate in their oversight process, even in the case of CGAT MHOs which are community-based organizations. Similarly, members were not involved in the control of the contracted health facilities with regard to possible overbillings. From the point of view of members of both MHOs, this was a reason why, in their view, the management of MHOs remained opaque.\u003c/p\u003e \u003cp\u003eThe effective \u003cb\u003eparticipation of MHO members in decision-making\u003c/b\u003e was mainly captured through members\u0026rsquo; participation in the General Assembly meetings. The majority of participants in the FGDs recognized the importance of member participation in the GA meetings: \u003cem\u003e\"It is during these meetings that the stakeholders discuss the functioning of the MHOs, i.e., on the mode of taking care of illnesses, the members' premium, and other necessary entitlements. It is therefore together that they should decide what can be done to meet the needs of all stakeholders\u0026rdquo;. (FGD La Borne).\u003c/em\u003e But only the CGAT MHOs organized General Assembly (GA) meetings and in principle invited member representatives to participate. In the case of the MESP, only delegates of the teachers Union were allowed to participate in the General Assembly meetings.\u003c/p\u003e \u003cp\u003eOverall, it appeared that CGAT members were \u0026ldquo;closer\u0026rdquo; to their MHOs than those of the MESP. All along the FGDs, MESP members reflected on the lack of transparency in the management of their MHO. They complained not to receive adequate information about the functioning of their MHO and were struggling to reach MHO brokers at health facility level. On top of this, MESP members resented the heavy administrative restrictions in the organization and the functioning of their MHO.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePotential factors influencing the implementation of institutional arrangements\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eSupport to MHOs\u003c/h2\u003e \u003cp\u003eThe documentary review and IDIs confirmed that a limited number of MHOs benefit from government support and oversight of the national program of promoting MHOs. MESP receives financial support from government for healthcare provision and functioning of the MHO, while CGAT MHOs receives only technical support via MHO platforms and services provided by medical advisors who are civil servants paid by the government. Concurrently, others technical centers, including those under the CGAT umbrella, are being sponsored by donor organizations through international cooperation but also via local platforms of MHOs, which do have legal recognition. This variety of sources of support contributes to shape the context in which MHOs have to operate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eFactors internal to the functioning of MHOs\u003c/h2\u003e \u003cp\u003ePositive factors include experiences of members who share their satisfaction about the benefits of an MHO: lower user fees (10%), avoidance of unpredictable health care expenditures, guarantee of receiving at least basic healthcare at any point in time, and corporate affiliation of small and medium-sized companies.\u003c/p\u003e \u003cp\u003eFor both MHO schemes, negative factors include shortages of medicines in health facilities, failure to maintain effective communication with members, and a lack of performant monitoring and evaluation systems of new measures or procedures that are implemented. For CGAT MHOs, an important limitation are the limited funds available for operations covering MHO management including the operation of websites, but also limitations in the package of care contracted for its members and insufficient outsourcing of some services, such as laboratory and pharmacies.\u003c/p\u003e \u003cp\u003eThe difference in the nature of membership affiliation (mandatory versus voluntary) affects the management of the two MHO schemes. Whereas MESP can deal with monthly contributions derived directly from the payroll, the CGAT MHOs must use complex mechanisms to raise member contributions. Most of the time, a two to three months renewal period of subscription is offered to households to allow them saving money to pay for the annual premium contribution. In addition, a large part of the CGAT membership comes from the formal sector, being enrolled by their employers from private companies.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eMHO internal capacities\u003c/h2\u003e \u003cp\u003eThere are three major points to consider: the expertise of the managers, the availability of resources, and the work structure [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. With respect to training, each staff member is required to undergo training, and most stated that they indeed had received training. Others benefited from the mentorship of more senior colleagues or via self-learning.\u003c/p\u003e \u003cp\u003eIn terms of resources, respondents emphasized the lack of resources. They especially mentioned office equipment, computer facilities, supplies, and work premises. MESP benefits from some government support for premises and funding, while CGAT MHOs have to rent infrastructure.\u003c/p\u003e \u003cp\u003e In terms of internal organization, each agent has clear job description, with explicit standards and guidelines. Most agents have signed employment contracts.\u003c/p\u003e \u003cp\u003eAccording to the MHO platform (POMUCO)\u003csup\u003e1\u003c/sup\u003e and the national support structures (i.e., PNPS\u003csup\u003e2\u003c/sup\u003e, PNPMS\u003csup\u003e3\u003c/sup\u003e), their support consists of conducting feasibility studies, defining the level of the premium, training of managers and medical advisers, and advocacy at the level of government authorities. The latter eventually contributed to passing of the law on MHOs.\u003c/p\u003e \u003cp\u003eIn the case of CGAT, platforms largely depend from external donor funding paying salaries of MHO managers, providing additional financial incentives to medical advisers, and covering other managerial operations expenses, including communication. This dependency from external support obviously affects their sustainability.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe primary reason of conducting this study was that, during preliminary contacts with MHO support organizations, it was unclear whether MHOs implement and document the various institutional arrangements and its implementing measures that are part of their managerial procedures, and that are key for they social accountability and responsiveness.\u003c/p\u003e \u003cp\u003eThe first findings revealed that, concurrently, the measures taken to improve accountability and responsiveness appear to be largely similar for both MHO schemes, inspired by support platforms supported by foreign MHOs such as Belgian mutual health organizations. These measures however need to be further consolidated as standard operating procedures (SOPs) with specific instructions and be integrated into the set of internal rules of MHOs. Overall, managers of both MHO schemes were positive about the measures put in place. MHO members however did not share this positive view. This contrast in perception definitely should benefit from further investigations.\u003c/p\u003e \u003cp\u003eOur study confirms the key role played by MHO brokers (medical advisors, MHO delegates or any other MHO representative) in the implementation of arrangements, at least through the provision of information, the orientation of patients in the complex health care circuit, and the handling of member complaints. Not all MHO brokers are \u0026ldquo;independent\u0026rdquo; as some of them are themselves MHO staff. Medical advisors, on the other hand, are supposedly independent civil servants at the service of MHOs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMHO managers as well as health facility managers recognized that many MHO members in both MHO schemes are ill-informed about the contents of the health care package, have limited knowledge about risk sharing in general, and face multiple needs in a context of limited purchasing power [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This situation explains why, in many instances, households did not enroll all members [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Thus, they still face substantial out-of-pocket health costs for the other household members, leading to an inequitable form of healthcare financing, with catastrophic and impoverishing effects on their living standards [\u003cspan additionalcitationids=\"CR24 CR25 CR26\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, in any case, the correct implementation of the contract signed between MHOs and health facilities is critical for accountability and community satisfaction with service delivery [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the navigation mechanisms to work, MHOs have contracted with government, private, and faith-based health facilities, even if they apply different levels of fees. The use of the curative consultation at the level of first-line health facilities is mandatory for MHO members who are using them frequently (rate of 30% to 40%) to seek for health care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The referral second-line health facilities are less used by MHO members as subject to MHO brokers approval under navigation procedures [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Similar results have been reported in another study conducted in Kinshasa [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor both MHO schemes, the grievances reported in this study are predictors of MHO members\u0026rsquo; dissatisfaction [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. But in certain circumstances, the MHO\u0026rsquo;s responsiveness may go beyond the initially agreed health package. A medical advisor stated that \u0026ldquo;\u003cem\u003ewith respect to this limitation, we are trying to grant grace or special agreement, after reviewing the member\u0026rsquo;s situation. For example, when a member brings an unregistered child in critical condition, we are quick to grant a pardon, because children are the most privileged.\u0026rdquo; (CGAT medical advisor, La Borne).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFraud and breach of trust are observed among household members, health workers, and MHO employees [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Previous billings towards MHOs have shown that, without a review of member consumption, health facility managers tend to abuse the process in trying to get more money [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To prevent fraud and abuse, the use of individual biometric cards associated with the presence of MHO brokers in health facility seems to be effective. All MHO managers recognized the traceability of health care bills by MHO brokers.\u003c/p\u003e \u003cp\u003eRegarding participation of MHO members in decision-making organs, measures to allow such processes were seen to be weak. We found that the mechanisms put in place were not very effective, even in the case of CGAT, despite the fact that the invitation to members to attend the General Assembly included reimbursement of transportation costs, a practice also mentioned in other studies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The lack of participation could be seen as a lack of community engagement, which are rooted in interactions that are relatively responsive, respectful and that bring tangible related benefits [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMHOs have limited internal capacities because they are understaffed and they are very dependent on donor support in case of CGAT, and on the administration of the supervisory Ministry for MESP. MHO managers are overloaded with administrative tasks, which reduces their availability to respond to member requests [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, measures taken to implement the various institutional arrangements to enhance MHOs social accountability and responsiveness are more a reflection of a set of \u003cem\u003ead hoc\u003c/em\u003e practices than standardized decisions documented and incorporated into end-to-end processes such as SOPs for MHO management. Managers are organizing the day-to-day management process, without however having expert administrative support in terms of decisions or written guidance. In fact, as part of the social accountability mechanisms, the weakness in implementing these measures include lack of capacity, poor commitment and insufficient participatory governance structures capable of strengthening the trust and commitment of members, as also reported in other countries, such as Ethiopia [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the proposed conceptual framework could be used by MHOs as a tool that may guide the formal setting of procedures suitable for MHO managers to enhance MHO accountability and responsiveness. Such kind of framework have also been proposed as theories of change underpinning social accountability [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMHOs operate in a context of poorly regulated health care provision of poor quality, little or no public funding, and lack of trust in MHO governance, which have led to high rates of membership dropout in Ethiopia, for example [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Similarly, it has been reported that the low responsiveness of community health insurance schemes is a major obstacle to their adoption in sub-Saharan Africa, confirming that social accountability mechanisms are crucial to the sustainability of such systems, knowing that in DRC, MHOs struggle to survive financially [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the ways forward is for MHOs to gain and deserve people\u0026rsquo;s trust. In that respect, more transparency and adequate responses to members needs and expectations is crucial. This includes promoting trust in members and their community and reverse the negative perception of members in the management of MHOs and in the quality and accessibility of health care and services [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. MHOs need to better inform people on the benefits they offer in terms of accessing health care and securing members rights, which should be part of an honest implementation of social accountability procedures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. More accountability and better responsiveness of MHOs are one step in expanding membership, knowing that vulnerable households covered by CBHI make more use of health services, than those without insurance [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eOne limitation is the fact that views of MHO managers and of MHO members were collected separately without any subsequent \u0026ldquo;confrontation\u0026rdquo; of the two views. A mixed group discussion would have been useful in bridging some of the gaps between the optimistic points of views of MHOs managers and the sometimes-harsh critique of MHO members. Another limitation is that our findings pertain to the specific situation of a very limited number of MHOs operating in the huge Kinshasa metropole and may therefore not be generalizable to MHOs throughout the DRC.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe conceptual framework underlying this study was instrumental in capturing the building blocks and related pathways in assessing the effectiveness and impact of the various institutional arrangements and related implementing measures to improve social accountability and responsiveness of MHOs.\u003c/p\u003e \u003cp\u003eThe implementation of these measures led to a range of outcomes perceived as satisfactory by the MHO managers in terms of empowering MHO members to improve their knowledge regarding the effective use of their entitlements to obtain appropriate health care. However, this positive perspective was largely contradicted by MHO members who were often unaware of most of the measures put in place and doubtful on their effectiveness. The challenges and hurdles to be taken are plentiful, but one of the most important ways forward that emerges from our research is the need to engage into a much more effective dialogue between MHO managers and members.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDRC Democratic Republic of Congo\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHI Community Health Insurance\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBHI Community\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBased Health Insurance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMHO Mutual Health Organization\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUHC Universal Health Coverage\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC Low and Middle\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIncome Country\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBO Community\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebased Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCGAT Risk Management and Technical Support Center\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMESP Health insurance for primary, secondary, and vocational school teachers\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD Focus group discussion\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI In\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edepth Interview.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eAcknowledgement and funding\u003c/h2\u003e \u003cp\u003eThis study was part of a global investigation of health insurance accountability and responsiveness initiated and funded by the Global Alliance for Health Policy and System Research (AHPSR) and the World Health Organization [grant No WHO 2019/960869-0].\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe authors had no conflicts of interest to declare.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthical statement\u003c/h2\u003e \u003cp\u003e The research protocol received the approval of the Kinshasa School of Public Health Ethics Review Committee under registration No: ESP/CE/004/2020. According to the Helsinki declaration, the protection of participants was respected under anonymous and COVID 19 protection measures, such as the use of masks and appropriate distancing. For the IDIs with managers, a written informed consent form was presented and explained, and each interviewee signed it before the interview. For FGDs, each member of the group was invited to express consent before participation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for participation and publication\u003c/strong\u003e \u003cp\u003e All person interviewed signed a written informed consent to participate in the study and agreed for the publication of the results. All co-authors have reviewed the paper and agreed to have it submitted for review and publication.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCo-authors gender, credentials and email addresses\u003c/h2\u003e \u003cp\u003eMr Dosithee Ngo-Bebe, PhD\u0026thinsp;\u0026lt;\u0026thinsp;[email protected]\u0026gt;; Mr Fulbert Nappa Kwilu, PhD\u0026thinsp;\u0026lt;\u0026thinsp;[email protected]\u0026gt;; Mrs Arlette Kilonga Mavila, MD, MPH\u0026thinsp;\u0026lt;\u0026thinsp;[email protected]\u0026gt;; Mr Serge Kule Kapanga, Advanced Studies Degree in social science\u0026thinsp;\u0026lt;\u0026thinsp;[email protected]\u0026gt;; Mr Bart Criel, PhD\u0026thinsp;\u0026lt;\u0026thinsp;[email protected]\u0026gt;\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDNB, FNK and BC developed the protocol; FNK, AKM and SKK conducted the IDIs and the FGDs; FNK, SKK and DNB conducted the analysis; DNB, FNK, and BC conducted the writing process; BC reviewed the manuscript. All authors red, commented and approved the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe authors confirm that all pertinent data are contained within this document. However, additional data can be made available upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Neglected health systems research: governance and accountability. Research issues 3. Alliance for health policy and systems research. World Health Organ. 2008. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/alliance-hpsr/AllianceHPSR\u003c/span\u003e\u003cspan address=\"https://www.who.int/alliance-hpsr/AllianceHPSR\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCriel B, Waelkens M-P, Kwilu NF, Coppieters Y, Laokri S. 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BMC Health Serv Res. 2023;23(1):762. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-023-09765-1\u003c/span\u003e\u003cspan address=\"10.1186/s12913-023-09765-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e POMUCO : Platform of mutual health organizations in Congo (\u003cem\u003ePlateforme des organisations des mutuelles de sant\u0026eacute; du Congo)\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e PNPS : National Social Protection Support Program (\u003cem\u003eProgramme National d\u0026rsquo;appui \u0026agrave; la Protection Sociale)\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e PNPMS : National Program for promoting mutual health organizations (\u003cem\u003eProgramme National de Promotion des Mutuels de Sant\u0026eacute;)\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community-based health insurance, mutual health organization, health financing system, accountability and responsiveness, Democratic Republic of Congo","lastPublishedDoi":"10.21203/rs.3.rs-8005371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8005371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFor community health insurance (CHI), building a trustful relationship with affiliates is a major challenge. In the absence of national health insurance, mutual health organizations (MHOs) are functioning as community-based health insurance (CBHIs). MHOs have been considered as one of the building blocks of the financial mechanisms to access quality health care. This study intended to explore procedures used by MHOs to enhance their social accountability and responsiveness.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative case study to investigate institutional arrangements and its implementing measures. Data were collected through a documentary review of more than 50 local related documents, 34 in-depth interviews with MHO and health facility managers, and 15 focus group discussions with MHO members. We focused on identifying and analyzing the existing institutional arrangements, their implementation, and their perceived effectiveness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe distinguished five institutional arrangements with 35 related measures for implementing these arrangements. MHO managers perceived them to be successful, while their members disagreed, and most of them did not have good knowledge of these implementing measures. For MHO managers, potential contributing factors to this perceived success were the coaching from MHO platforms, the 2017 law regulating MHOs, the inclusion of MHOs in the national UHC strategy, the nature of membership affiliation, and MHO managerial capacities.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTo build trustful relationships and to engage into an effective dialogue between MHO managers and members, MHOs should build their internal capacities in implementing key institutional arrangements and related measures to improve their social accountability and responsiveness.\u003c/p\u003e","manuscriptTitle":"Exploring social accountability and responsiveness procedures of Community-based Health Insurance in Kinshasa, Democratic Republic of Congo, using qualitative approach research","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:15:15","doi":"10.21203/rs.3.rs-8005371/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-12T12:56:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T12:59:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-17T08:37:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-15T11:55:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-11-15T11:52:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73dbc872-2fa5-4548-bcd7-a02361122319","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T09:15:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 09:15:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8005371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8005371","identity":"rs-8005371","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}