Making health insurance responsive to citizens: the management of members' complaints by mutual health organisations in Kinshasa, Democratic Republic of Congo.

INTRODUCTION: In moving towards universal health coverage, a number of low-income and middle-income countries have adopted community-based health insurance (CBHI) as a means to reduce both the inequity in healthcare access and the burden of catastrophic health expenditures linked to user fees. However, organisations managing CBHIs face many challenges, including a poor relationship with their members. In the Democratic Republic of the Congo, CBHI schemes are managed by mutual health organisations (MHOs) and are in the process of enhancing their accountability and responsiveness to members' needs and expectations. This study assessed how MHOs have managed member complaints and their performance in grievance redressal. METHODS: Using a sequential mixed-methods approach, we drew insights from four types of sources: review of approximately 50 relevant documents, 25 in-depth interviews (IDIs) with CBHI managers, 9 IDIs with health facility managers, 1063 surveys of MHO members and 15 focus group discussions (FGDs) comprising an additional 153 MHO members. MHO members in this study belonged to three different MHOs (Lisanga, La Borne and Mutuelle de santé des Enseignants de l'Enseignement Primaire, Secondaire et Professionnel) in the capital, Kinshasa. RESULTS: The document review showed that there were no clear administrative processes for the implementation of the grievance redressal arrangement measures resulting in low member awareness of these measures. These results were confirmed by the IDIs. Of 1044 members surveyed, only 240 (23%) were aware of the complaint measures, and 201 (84%) of these declared they had used the measures at some point in time, 181/201 (90%) users who had used the measures declared being satisfied with the response provided. The FGDs confirmed that most members lack knowledge on the grievance redressal procedures, but those who were aware had made use of them and were often satisfied with the response provided. CONCLUSION: MHOs should urgently improve communication with their members on the range of redressal measures put in place to address grievances. Attention should be given to properly monitor existing arrangements, and possibly adapt them with well-documented and communicated standard operating procedures.

A multifaceted intervention to improve syphilis screening and treatment in pregnant women in Kinshasa, Democratic Republic of the Congo and in Lusaka, Zambia: a cluster randomised controlled trial.

BACKGROUND: Despite international recommendations, coverage of syphilis testing in pregnant women and treatment of those found seropositive remains limited in sub-Saharan Africa. We assessed whether combining the provision of supplies with a behavioural intervention was more effective than providing supplies only, to improve syphilis screening and treatment during antenatal care. METHODS: In this 18-month, cluster randomised controlled trial, we randomly assigned (1:1) 26 urban antenatal care clinics in Kinshasa, Democratic Republic of the Congo, and Lusaka, Zambia, to receive a behavioural intervention (opinion leader selection, academic detailing visits, reminders, audits and feedback, and supportive supervision) plus supplies for syphilis testing and treatment (intervention group) or to receive supplies only (control group). The primary outcomes were proportion of pregnant women who had syphilis screening out of the total who attended the clinic; and the proportion of women who had treatment with benzathine benzylpenicillin out of those who tested positive for syphilis at their first antenatal care visit. This trial is registered at ClinicalTrials.gov, number NCT02353117. FINDINGS: The 18-month study period was Feb 1, 2016, to July 14, 2017. 18 357 women were enrolled at the 13 intervention clinics and 17 679 women were enrolled at the 13 control clinics at their first antenatal care visit. Syphilis screening was done in a median of 99·9% (IQR 99·0-100·0) of women in the intervention clinics and 93·8% (85·0-98·9) in the control clinics (absolute difference 6·1% [95% CI 1·1-14·1]; p=0·00092). Syphilis treatment at the first visit was done in a median of 100% (IQR 99·7-100·0) of seropositive women in intervention clinics and 43·2% (2·6-83·2) of seropositive women in control clinics (absolute difference 56·8% [12·8-99·0]; p=0·0028). INTERPRETATION: A behavioural intervention, together with the provision of supplies, can lead to more than 95% of women being screened and treated for syphilis. The sole provision of supplies is sufficient to reach such levels of screening coverage but is not sufficient to ensure high levels of treatment. FUNDING: Bill & Melinda Gates Foundation.