[Mutual insurances in Africa: Issues and perspectives]. / Les mutuelles en Afrique : Enjeux et perspectives.

From the end of the 1970s, the promotion of the community and the participation of populations in the health system reinforced the idea that mutual health insurance was a potentially major player in the extension of coverage against health risks. But the history of mutuality in Africa was quickly strewn with pitfalls. The structural adjustment plans and the increase in the financial contribution of users under the impetus of the Bamako initiative put a stop to the spirit of community mutual insurances. Today, mutual insurances are once again at the heart of international and national initiatives with the promotion of the (UHC) Universal Health Coverage. But they must overcome their historical shortcomings through professionalization and compulsory membership. This movement seems to be underway, while at the same time facing the challenge of preserving the place of communities in health systems, a founding principle of the mutualist movement.

[Extension of health coverage and community based health insurance schemes in Africa: Myths and realities]. / L'extension de la couverture maladie par les mutuelles communautaires en Afrique : mythes et réalités.

This article tackles the perspectives and limits of the extension of health coverage based on community based health insurance schemes in Africa. Despite their strong potential contribution to the extension of health coverage, their weaknesses challenge their ability to play an important role in this extension. Three limits are distinguished: financial fragility; insufficient adaptation to characteristics and needs of poor people; organizational and institutional failures. Therefore lessons can be learnt from the limits of the institutionalization of community based health insurance schemes. At first, community based health insurance schemes are to be considered as a transitional but insufficient solution. There is also a stronger role to be played by public actors in improving financial support, strengthening health services and coordinating coverage programs.

[Meeting the Abuja and Millennium Development Goals: the state more than ever]. / Atteindre les objectifs d'Abuja et les Objectifs du millénaire pour le développement : l'État plus que jamais ?

In the 1980s and 1990s, healthcare policies in poor countries were largely based on the privatization of the healthcare supply. Over the past decade, this trend has led to the expansion of private initiatives in both the nonprofit and profit-seeking sectors. Assessments of these initiatives show mixed results and sometimes pernicious effects. It is accordingly necessary to review and redesign policies to enable public entities and States to once again become leaders in the development of integrated and socially inclusive health policies.

[The extension of national health insurance in Senegal: progress and obstacles]. / L'extension de l'assurance-maladie au Sénégal: avancées et obstacles.

This article analyzes the progress and the difficulties in the expansion of the Senegalese national health insurance scheme. The methodology is based, on one hand, on institutional data and documents, and on the other hand, on interviews with various actors in the health system. We present the health insurance extension scheme and place it in the context of the experience of other poor countries in sub-Saharan Africa. Mutual health insurance has a particularly important place in this extension. We then assess the state of progress of the extension of this mutual health insurance to show the uncertainties in the achievement of the reforms. Finally, we discuss the structural limitations and the conditions of the program's success. We underline in particular the necessity of a more systemic approach.

[Flourishing of micro-units of health care in Benin]. / La prolifération des micro-unités de santé au Bénin.

The end of the marxist-leninist regime in Benin in 1990 has allowed a steady growth of what can be named "the micro-units of health care" at the periphery of cities. Demand for care from the urban poor and urban lower-middle classes is mainly directed towards these micro-units instead of the public (or private) official health centers. "Micro-units of health care" are small for-profit houses where primary care is delivered to buying patients by young health graduates who could not find a post in the official health system. Micro-units are blossoming in Benin, they are not registered and of course not controlled. The basic reasons for their success can be identified as followed: (i) modest investment, low cost and consequently low price; (ii) near the users; (iii) unsophisticated health care; (iv) no competition from the official health system; (v) the users give to these units a higher confidence than to the official health structures, the latter having of course a much higher medical standard; (vi) warm welcome and personalized services. It is probable that, twenty years ago, those who, in Alma Ata made the famous declaration on primary health care did not thought about these micro-units in Benin. It is certain that these micro-units are implementing a great deal of the principles highlighted by the Declaration of Alma Ata.