Time to abandon amateurism and volunteerism: addressing tensions between the Alma-Ata principle of community participation and the effectiveness of community-based health insurance in Africa10.1136/bmjgh-2018-001056 - Ridde, Valéry; Asomaning Antwi, Abena; Boidin, Bruno; Chemouni, Benjamin; Hane, Fatoumata; Touré, Laurence (BMJ Global Health, 2018)
Forty years after the 1978 Alma-Ata declaration, the second international conference on primary health care in October 2018 is expected to reaffirm the place of communities in health systems management and governance. In parts of Africa, community-based health insurance (CBHI)—with communities at the centre—is still seen as a strategy for achieving universal health coverage (UHC)—but there are tensions between the Alma-Ata principle of community participation, as currently interpreted, and CBHI. The tension relates particularly to the community’s role in terms of the voluntary nature of CBHI membership and volunteer involvement of the community in governance andmanagement—this tension requires a rethink of the role of communities in CBHI. We use examples of Rwanda, Ghana, Mali and Senegal to demonstrate the challenges associated with the place of communities in CBHI, and the need to reduce the role of community volunteers in CBHI and instead focus on professionalising management. Countries that still wish to rely on CBHIs for UHC must find ways to make populations enrolment compulsory, and strengthen the professionalisation of CBHI management, while also ensuring that communities continue to have a place in CBHI governance.
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