Informal Sector Workers’ Perceptions of Health Insurance Coverage in South Kivu Province, Democratic Republic of Congo ()
1. Introduction
Perception of workers in the informal sector; This is a barometer of understanding of workers in the informal economy, which includes all those who work without earning enough money, but out of necessity to survive for a tomorrow in terms of health insurance. The others call informal sector, a sector gathering all productive activities of goods and services escaping the control of the State as provided by the bill on social security of July 15, 2016. Health insurance coverage; this is coverage that social security provides as cover for basic social risks such as sickness, maternity, disability, death, industrial accidents and occupational diseases and old age.
The aim of this study is to assess the perceptions of workers in the informal sector with regard to health insurance coverage, to identify the problems inherent in health insurance for workers in the informal sector and, finally, to assess the role of political players with regard to health insurance.
In the 2030 Agenda for Sustainable Development, adopted by the United Nations General Assembly in September 2015, Member States recommitted themselves to promoting the health and well-being of their populations. Several of the 17 Sustainable Development Goals included in this agenda have health-related targets, such as Goal 3 (Enable all people to live in good health and promote well-being for all at all ages). Target 3.8 (Achieve universal health coverage, including financial protection and access to essential quality health services and essential medicines and vaccines that are safe, effective, of high quality and affordable), as well as other health-related targets related to other sustainable development goals, are essential to achieving Goal 3 as a whole (Sindayigaya & Toyi, 2023a, 2023b).
Low- and middle-income countries such as the DRC, Ghana, Peru and Vietnam are striving to extend health insurance coverage to their populations. Upper-middle-income countries such as Colombia, Costa Rica and Thailand have already achieved success (Buhendwa et al., 2023; David et al., 2023; Jonya et al., 2023). Universal health coverage means ensuring that the entire population has access to the preventive, curative, palliative, rehabilitative and health-promoting services it needs, and that these services are of sufficient quality to be of reasonable cost (Sindayigaya, 2023b).
The DRC has recently embarked on an unprecedented social protection drive, to establish a degree of equity in access to basic social services through the implementation of Universal Health Coverage, which is still at an embryonic stage. This program makes social protection a priority, since the authorities’ main concern is to remove financial barriers to access to quality healthcare. The idea is to enable all Congolese citizens, whatever their income and wherever they may be, to benefit from basic social health services, without having to remove any obstacles (Banque Mondiale, 2009). In the DRC, 93.5% of current household health expenses are met by direct payment without cost-sharing (ULB, UCL, & Université de Liège, 2014).
In the field of health, it was noted that over 90% of Congolese had no form of health coverage, whereas world health statistics put the coverage index at 39% for the DRC for the period 2022 (World Health Statistics, 2022). This percentage includes the informal sector and the rural world, for the most part (Nyabenda & Sindayigaya, 2023; Sindayigaya, 2022; Sindayigaya & Nyabenda, 2022). In parallel with the policy of free health care for women in childbirth (Ndayisenga & Sindayigaya, 2024b, 2024a; Sindayigaya, 2023a), recently introduced in all health facilities throughout the country, it is estimated that the problem of access to health care will be only half solved, as the development and promotion of mutual health insurance schemes was seen as the best way to ensure coverage for those who have no health insurance at all, has not been at all successful in the DRC.
This work provides concrete information that can benefit not only workers in the informal sector, but also managers of mutual health insurance schemes in the DRC (Buhendwa et al., 2023; Nduwimana & Sindayigaya, 2023a, 2023b). The study can be characterized as a successful example of effective collaboration between associations, mutual and national and international organizations that share their experience in supporting activities of common interest such as health insurance. Health insurance has been, is and will always be a paramount of people’s life whether in developed countries (Ahlin et al., 2016; Kuttner, 1999; Sindayigaya, 2022, 2024; Woolhandler & Himmelstein, 2017) but also in poor and developing country (Gambhir et al., 2019; Hooda, 2020; Prinja et al., 2012).
This study was carried out in the province of Sud-Kivu in the Democratic Republic of Congo. This province shares its borders from north to south with Rwanda, Burundi and Tanzania. The province is bordered to the north by North Kivu and to the west and southwest by the province of Maniema. The province covers an area of 69,128 sq∙km and has an estimated population of 5,772,000 (Liste des divisions administratives en République Démocratique du Congo, 2022).
2. Methods and Methodology
2.1. Location Map of the Study Area
Figure 1 is a map of the research zone with all indications denoting localization.
2.2. Type of Study
The present study is and qualitative descriptive study carried out in the East of the DRC in the Province of South Kivu, where the vast majority of informal sector workers are concentrated in the town of Bukavu and its surroundings, scouring the atrocities of armed groups in the province’s interior. Despite the Congolese government’s efforts to pacify the entire country, pockets of insecurity persist, preventing the population from organizing their activities properly. This survey was carried out among workers in the informal sector.
Figure 1. Localisation map.
2.3. Methods Used
2.3.1. Observation
For this technique, we made a direct observation which helped us to know how the workers of the informal sector go about their business; we observed them for a few days (one to two days) having already made contact with their managers;
We took note as we went along; of this observation, there was also participant observation, which is obviously a way of collecting data that could take us longer, because we have to take full part in the activities of workers in the informal sector in order to know whether our various observations are valid (http://www.socialresearchmethods.net/kb/qualapp.php)
2.3.2. Guided Discussion Groups
For this qualitative data collection technique, we selected 9 health zones out of the 34 in South Kivu Province; we opted for the Focus Group method, which is a qualitative method of collecting data from people from the same background or sharing the same experience (men among themselves, women among themselves and young people among themselves) who were brought together to talk about adherence to the social security service in general, and health insurance in particular, which interests us as researchers. Our group contained 6 to 8 people from each category of informal sector workers, and we formed a focus group of six to eight people maximum to talk about informal sector workers’ perceptions of social security and/or social protection/health insurance (MSF, 2023, two-thousand and nineteen/Guide de collecte de données qualitatives), for each health zone we chose, with the aim of convincing them to join and/or enroll in health insurance; This enabled us to obtain different points of view from the free expressions (Kristiansen & Grønkjær, 2019) of each of the participants on the theme chosen for discussion, as well as a series of terms and expressions used in our local language, Swahili for those living in the city, and Mashi and Kihavu for those living in the villages, so that we could easily understand each other.
We tried to bring together homogeneous groups to avoid an inhibiting effect on certain people, particularly women (Dawson, 1993, Mandersson and TALO); this group consisted of two to three people per chosen category and per chosen study environment, i.e. 27 discussion groups which were brought together to discuss the problem of social security and/or social protection/health insurance for each chosen health zone; Overall, there were more or less 27 guided discussion groups; but women and young people attended irregularly, i.e. they weren’t that interested.
This number of six to twelve people per focus group allowed everyone to express themselves freely (Kristiansen & Grønkjær, 2018).
2.3.3. In-Depth Individual Interview
This interview enabled us to deepen the results of our study (Janet, 2007). We prepared an interview guide in advance, with at least five or six key questions. The interview was organized with some leaders of associations of different categories of workers in the informal sector and some leaders who manage social security and/or social protection/health insurance on how they coordinate or manage activities related to social security and/or social protection/health insurance in their respective entities for which we felt they might have more personal experience so that they could contribute a little to improving knowledge on aspects of our research theme, Adhesion and factors influencing health insurance coverage for informal sector workers in the province of Sud-Kivu, D.R-Congo.
We also had a meeting with some of the coordinators of the various associations for the different categories. We have, notably: the Association des cambistes, l’Association des Vendeurs d’ Unité, l’Association des vendeurs des pagnes, l’Association des vendeurs d’autres articles, les Artisans, l’Association des Pêcheurs, les Vendeurs de sables et autres, l’association des camionneurs, ACCO (taximen), motards, Travailleurs des Maisons, Autres (Agriculteurs), but all these categories were grouped into three: agriculteurs, commerçants et artisans. We also needed tools for workers in the informal sector where each worker in each category would have to present a list of their workers;
Throughout the discussion, we made sure that the main points were recorded, our assistant or the participants could jot down their thoughts on papers, and when we noticed that the participants were tired, we asked them to rest a little for a few minutes to resume afterwards (Mperejimana & Sindayigaya, 2023; Niyongabo & Sindayigaya, 2023; Sabiraguha et al., 2023; Toyi & Sindayigaya, 2023).
The choice of people we met depended on the quality of the information we gathered. In order to identify the persons, we had to specify:
2.4. Recruitment or Selection Criteria for Focus Groups
To select the focus groups, we concentrated on individuals (formal sector workers) corresponding to the given target criteria. We therefore selected workers from the informal sector who were in a position to argue their answers on the basis of the skills they had already acquired in their activities (15) Uzzle, 2020 Focus groupe (réussir le recrutement de son focus groupe).
To do this, we drew up a pre-selection manager for potential participants and asked for their contact details, so that we could reach them at an opportune moment.
To set up the focus group, we brought together between 7 and 10 people (workers in the informal sector) who formed groups, each of whom spoke freely about what they understood by health insurance.
Below these 7 respondents, people were very sensitive to the leader’s charisma.
Once we had more than 10 respondents, we did not take any more, to avoid difficulties in the interview process and in everyone’s ability to speak.
The sample was composed of individuals who were homogeneous on certain criteria. We also avoided taking informal workers from the same background to avoid being together, i.e. next to each other. We avoided taking people who were used to taking part in group interviews, and we avoided saying too much (we had just given the main theme (Criterion, 2016).
2.5. Drawing up the Qualitative Interview Guide
In order to structure the focal groups, a qualitative interview guide was drawn up in line with the research objectives; it included seven questions:
Tell us about your last visit to a health facility, or one of your dependents; how much did you pay for medical care?
Have you heard of the Mutuelle de Santé, and if so, have you been impressed by this organization?
Are you familiar with CNSS (Caisse Nationale de Sécurité Sociale), or have you heard of it? What do you think of it?
What factors discourage or encourage you to sign up for mutual health insurance (social protection) or social security?
What fears or hesitations do you have about joining a mutual health insurance scheme (social protection) or joining the CNSS (social security)?
What could help you cover some of your social risks, such as illness, maternity and disability?
Can this meeting help you or encourage you to do it more often?
Data analysis
The recordings of the discussions were transcribed word by word, as faithfully as possible, immediately after the sessions, using word-processing software and Nvivo (verbatim extracts).
The anonymization of participants was carried out at the transcription stage, using the abbreviation of the chosen moderator’s name and that of our name as observer to indicate the difference between moderator and observer.
We analyzed the verbims ourselves, using N’vivo software for coding.
Each part of the transcripts was classified into a category or node representing the idea it conveyed;
These categories were then grouped into more general themes, or broken down into sub-categories in a circle, so that everyone could see themselves.
3. Presentation of Results
3.1. Level of Perception of Informal Sector Workers Regarding Health Insurance in South Kivu in Congolese in South Kivu
Most of the respondents said they had already heard of health insurance coverage, although their perceptions varied. However, financial capacity, i.e. the very high cost of contributions, remains the main reason why they do not join the health insurance scheme, as does the distance they have to travel to declare and pay their contributions.
The very long period between joining and receiving the 1st treatment (more than 3 months); is also one of the factors discouraging workers in the informal sector from joining or subscribing to health insurance. Other factors include poor governance, lack of satisfaction with health insurance services, and the selection of care to be provided to by community health insurance schemes.
Some of the others declared that this health insurance coverage only benefits those who created it, and another group declared that even if this health insurance is established, it will not be applied normally like all the other systems or laws in the country, which obliges them to say that public power does not exist in R. D.R.C this was declared by most in their local language.
When asked about this by health facility providers, they put it this way: health insurance coverage won’t have any impact on the socio-economic situation of informal workers. It will be like all the other insurance systems in the country, which are easy to read, but have no follow-up as to their practicability (Jonya & al., 2023, 2024; Ndikumana, 2023b, 2023a; Nyabenda & Sindayigaya, 2024; Toyi & Sindayigaya, 2023).
The others added that this health insurance coverage will bring no change; contrary to the interview with the CNSS Sud-Kivu Provincial Directorate, which said that currently the new social security law N˚16/009 of July 15, 2016, setting the general rules of social security advocates a reform enshrining the improvement of social coverage through the extension of the general social security scheme. This covers the pension branch, the ISSA occupational risks branch, Convention N˚102 on the minimum standard, Recommendation N˚202 on social security bases, and the recommendations of the Inter-African Conference on Social Security (CIPRESS). This strategy has also focused on the ongoing search for consensus with the social partners (ISSA, 2022, reform of the general social security system in the DRC).
They added that health insurance improves satisfaction, reduces absenteeism, and helps retain employees. From a personal point of view, every employee would like to be able to count on the health coverage offered by their company, and we agree with this opinion. On the other hand, offering medical insurance also contributes to the health of the company.
According to recent surveys conducted in the USA by Tempus Global Group 2023, 75% of employees with good health insurance also report high job satisfaction, and consider themselves loyal to their employers. When companies invest in quality health insurance for their staff, they can reap great benefits in the long term. In today’s fiercely competitive market, companies that offer a comprehensive package of healthcare benefits increase their chances of hiring the most promising young talent, as private healthcare costs soar around the world.
Quality medical insurance is also a way of reducing operating costs, as employees are generally more inclined to accept a position with a lower salary when health insurance benefits are provided. Of course, hiring a great employee is only half the battle (Buhendwa et al., 2023; Ciza & Sindayigaya, 2023; Mpabansi, 2023). A quality healthcare package will also help the company retain its team-otherwise, the in-demand professional will seek these benefits elsewhere. With good health insurance, employees also feel more motivated at work and, as a result, have fewer absences - and take fewer days off to recover from health problems. It’s clear: a healthy workforce is a more productive workforce with a better working environment (Tempus Global Group, 2023)
In the current study, we noted that our informants (workers in the informal sector) perceived health insurance coverage as, for some, helping workers to gain the right of access to health care, especially the most disadvantaged, as this right has long been flouted in the country; those surveyed believed that health insurance coverage in South Kivu would set up national health insurance schemes; for others, health insurance coverage is nothing more than a system for holding to ransom workers and others who would like to join this system, because, they say, there is nothing to hope for in this country.
In the present study, the vast majority of the population surveyed (informal sector workers) felt much more strongly about the universality of the social protection system, where everyone should be able to benefit from health insurance coverage. Most respondents said they had never heard of health insurance coverage, although their perceptions varied. Some said it only benefits those who designed and managed it, and another group said that even if it is established, it will not be enforced like any other law in the country, prompting them to say in their dialect that “the state is dead and childless. Others declared that this health insurance coverage will have no impact on the situation of informal workers; it is like all the other laws in the country, which are easy to read, but have no follow-up as to their practicability.
Data from interviews with workers in the informal sector give us a good idea of this very special relationship between the Congolese and their healthcare system. In line with the 1 - 2 - 3 survey on employment, the informal sector and household consumption/2012, the image of the State in the minds of many Congolese is negative. More often than not, the State is absent from their consciousness. The State, its resources and prerogatives are regularly equated with rents that should be monopolized for oneself and one’s family. Public services then become an opportunity for undue enrichment, resulting in mediocre performance. In the direct wake of this degradation, we observe the erosion of national sentiment and respect for public authority. Ultimately, the country’s unity, peace and stability are at stake.
Vulnerability, and with it poverty, is on the increase (Sindayigaya, 2023b; Sindayigaya & Nyabenda, 2022). The majority of Congolese live on less than one US dollar a day, considered the poverty line. In cities and rural areas alike, situations of indigence, whether temporary or chronic, are multiplying and intensifying. Despite recent progress, the majority of children do not have access to quality education. School infrastructure and supervision are largely inadequate. As a result, the school wastage rate is high, so that the majority of school-age children do not attend any school at all. In addition, quality nutrition for young children (aged 0 - 5) remains a problem throughout South Kivu province, and indeed throughout the country, including in the major towns. Access to healthcare for most Congolese is very poor, not only because the cost of services regularly exceeds their financial capacity, but also because the quality of the services offered is mediocre.
Indeed, the second demographic and health survey (Miniplan & Minisanté, 2013-2014) shows 3.1% employer-provided health insurance coverage, with variations of 6.2 in urban areas and 0.4 in rural areas. As for community mutual, the survey showed a coverage rate of 1.4%, with variations of 1.9% in urban areas and 0.9% in rural areas. With regard to access to maternity care, the same survey found that 24% of women in rural areas and 6% in urban areas had given birth at home (Survey 1 - 2 - 3, 2012).
3.2. Determinants of Access to Healthcare for Workers in the Informal Sector
According to interviews with informal sector workers, everyone should be able to benefit from health insurance coverage. The Congolese population has not been stable on the health care system since the departure of the colonists in 1961, the majority never cease to shout loud and clear about health expenses, to access care, most believe that in a potentially rich country, it is not normal that people die of hunger for lack of means to pay for health care and that they are covered even from land very rich in minerals (Buhendwa et al., 2023). These same workers in the informal sector use self-medication for lack of means, others resort to traditional medicine, others use prayer chambers, and others sell valuables or mortgages to benefit from care and others resort to family members, it’s only a few people who use their wages to seek treatment (Benninger & Savahl, 2017; Everett et al., 2021; Sindayigaya, 2020; Sindayigaya & Nyabenda, 2022). These same people declare that those who almost died for lack of means to be treated must have sold part of their fields for those who live in rural areas and those in urban areas must have sold a precious object to pay for treatment, all this is due to the slackening of the population by public power.
3.3. Problems Inherent in Providing Health Insurance Coverage for Workers in the Informal Sector
The problems encountered by workers in the informal sector are, firstly, the lack of sufficient means to join the Social Security Service (Ciza & Sindayigaya, 2023; Mpabansi, 2023; Ndikumana, 2023a; Niyongabo & Sindayigaya, 2023); secondly, the inability to realize the amount to contribute, the distance to travel to declare and pay social security contributions (Ndayisenga & Sindayigaya, 2024b, 2024a; Ndikumana, 2023b; Sindayigaya, 2023a); thirdly, the lack of awareness of the social security and social protection service at the CNSS and/or the lack of hope of being able to reach the age of 65 to benefit from a retirement pension (Aubert & Bachelet, 2012; Commission de réforme des pensions 2020-2040, 2014). The amount they have to contribute to both the social security system and the social protection system (health insurance) is very high in relation to what they earn. Most groups said that political actors are not in government on behalf of the people, because health and other basic needs are not on their agenda. Others said that the government intervenes, but in an insignificant way.
3.4. The Role of Political Actors in Health Insurance Coverage in South Kivu, DR. Congolese
The image of the State in the minds of many Congolese is negative. More often than not, the State is absent from their consciousness. The State, its resources and its prerogatives are regularly likened to rents to be hoarded for oneself and one’s family. With regard to the assessment of the role of political actors (public authorities) in Congolese social security and social protection, most people in both urban and rural areas stated in interviews that in DR. Congo in general, and in South Kivu in particular, the country’s authorities are very lax when it comes to health care; this is why there is a high number of private polyclinics and medical centers, which are in fact in the majority, and why the State has given the majority of health facilities to the management of religious denominations, which also work to further their own interests, and why the State no longer has a say, because it does not follow up. This laxity on the part of the Congolese State in monitoring the health of its people means that the people are abandoned to their sad fate, and this prevents them from being optimistic about the sustainability of this health and/or social protection system. Yet the national social protection policy in the DRC was voted in September 2015 and have voted strategic guidelines based on 3 strategic axes for which the Congolese social protection policy must be based in particular.
The promotion of mechanisms guaranteeing access to basic social services and basic income security for vulnerable people. Over the past 5 decades, the Congolese government has been thinking in terms of rapidly establishing a nationwide social protection base comprising basic social security guarantees, under which all members of Congolese society would have effective lifelong access to essential health care. The program also aimed to guarantee income security during childhood, working life and old age, with a view to facilitating access for the poor and vulnerable to essential goods and services such as education, food and nutrition.
This strategic axis is structured around three programs based on pilot projects:
Program 1: promote universal health coverage
Program 2: Ensure that children, boys and girls alike, have access to healthy, balanced food, education and quality, local health care.
Program 3: Guarantee access to basic social services and a minimum income for people in difficult situations, including the elderly National Social Protection Policy.
To compensate for the lack of public involvement in the population’s health care, the first reaction of those surveyed was to introduce fee-paying systems. However, numerous studies have warned policy-makers against such systems, which can seriously undermine the quality of care, especially for the poorest people3. Unfortunately, this is not the case in the DRC. Even if the public sector could intervene, there is little chance that this support would reach the intended beneficiaries. Health systems financed by public contributions and/or by contributions to risk-pooling health insurance schemes are a major step forward. These financing mechanisms dissociate direct payment from the use of healthcare services, and can thus guarantee access to healthcare for even the most vulnerable.
Publicly-funded health care is almost non-existent in the DRC, and if it were, it would not be easy to implement, as it is in other low-income developing countries, due to the small number of taxpayers and the limited resources of the tax collection and fraud repression services. Health insurance, whether nationally organized, voluntary and administered by local authorities, professionals (teachers’ health insurance), or even students, is not without its problems either. And yet, health insurance systems are currently attracting a great deal of interest. They are characterized by the fact that the burden of financing does not fall entirely on the government, and that the total cost of insured healthcare is shared between various partners. We suggest cost-sharing, i.e. the state pays ¾ of the cost of care, and the individual pays ¼ of the cost, which can lighten the burden on the state budget, and partly explain why governments are obliged to take a greater interest in the health insurance of their population.
Despite the mastery of the macroeconomic framework and growth recorded over the past decade, and the envisaged political stability, poverty has remained high (64.5%) in the Democratic Republic of Congo (DRC). Also, the spatial distribution of the fruits of this economic growth over the past ten years has been inequitable between cities and territories, as much as between territories. What’s more, nearly 20 of the country’s 26 mainly rural provinces have poverty levels above the national average. (23) RNDH, 2017, UNDP). It was to correct these inequalities and break the intergenerational cycle of poverty that the President of the Republic decided to implement, with public funding and the support of technical and financial partners, the Local Development Program for the 145 territories PDL-145T. Backed by the National Strategic Development Plan (24) PNSD) 2019-2023, the Government Action Program (PAG) 2021-2023 and the Accelerated Presidential Program to Fight Poverty and Inequality (25) PPALCPI), the PDL-145T is organized around four (4) components, namely:
Component 1: Improving rural populations’ access to basic socio-economic infrastructure and services. This component aims to set up basic socio-economic infrastructure (agricultural feeder roads, photovoltaic micro-power stations, solar streetlights, boreholes and mini-networks, schools, health centers, markets, administrative buildings for sectors and territories, and housing for the territory’s leading staff) with the aim of opening up territories and helping to improve living and educational conditions for populations;
Component 2: Promoting the development of rural economies and local value chains. This component will focus on supporting the development of local production and service activities, with a view to creating the conditions needed to revitalize rural and local economies and put them on the path to emergence. The ultimate aim is to improve productivity, increase rural household income and ensure food security;
Component 3: Strengthen local development management capacities, with the aim of developing technical, organizational, institutional and community capacities for good local development management. Ultimately, this component aims to empower local communities to produce quality services in rural areas, based on the decentralization approach.
Component 4: Develop a geo-referenced monitoring information system capable of providing information on program progress. The main aim of this component is to set up an effective system for monitoring and evaluating the program’s progress. Ultimately, this system will serve as an instrument for monitoring the implementation of public policies and programs, in order to assess the impact of development results at all levels in the materialization of the overall development vision, and to be used as a decision-making tool for adjusting public policies. vii It should be noted that a cross-cutting dimension will be integrated into the implementation of all program activities to take into account the gender and environmental dimensions, as well as the principles of social equity (young people, people living with disabilities) and fundamental human rights. The expected effects of implementing this Program are as follows:
1) Access by the populations of the 145 territories to basic socio-economic infrastructures and services is significantly improved, and their economic activities and well-being are enhanced;
2) The economies of the territories are revitalized and energized;
3) The local development management capabilities of state, territorial and community players are strengthened (26) The Local Development Program is dedicated to the 145 territories (PDL-145T).
Strengthening and extending reliable and economically viable social insurance systems. A reform of the general social security system was instituted by its decree-law No 16/009 of July 15, 2016 laying down the rules relating to the general social security system to solve all these problems;
The third axis is the strengthening of the institutional framework, capacities and financing of social protection. This cross-cutting strategy is based on the five pillars defined by the national social protection policy: governance, financing, capacity building, research and communication. In spite of all this, some respondents revealed that 2 out of 10 Congolese are able to afford health care in South Kivu, mainly those with paid employment or a commercial activity.
The same surveys stipulate that there are irregularities in access to healthcare in the country in general, and in South Kivu province in particular, i.e. there are some more privileged categories, notably those in paid employment and shopkeepers. As we said earlier, many informal sector workers are unable to afford quality health care, depending on their living environment and income. The problems encountered by workers in the informal sector include:
Lack of means to pay social contributions, exorbitant amount to contribute, distance to travel to pay contributions, irregularity in social contribution payments,
It was thought that there would be a change in access to healthcare through the new Congolese social security approach by Decree-Law no. 16/009 of July 15, 2016, laying down the rules relating to the general social security scheme, but unfortunately, the majority of respondents said that nothing has changed so far. That this law drawn up on social security is good to read for its formal aspect, but follow-up is almost non-existent. The ability of informal sector workers to pay for health care remains a very serious problem. The same respondents also mentioned delays in the payment of family allowances, which are received irregularly, discouraging many informal sector workers from joining or registering with the social security service, even though the same approach stipulates that family allowances are allocated to the insured for each dependent child. These allowances are paid to the insured for the benefit of the children. Another aspect to worry about is that, for example, if Employer X has two workers for whom he pays 33111 FC each, each worker benefits from 7075 FC per working day as the SMIG (guaranteed inter-professional minimum wage), for the two of them that’s 66222 FC or 32.3 dollars at the rate of 2050 FC for one American dollar, and this figure is the rate of contributions in the DRC, which is 18%. These two workers have respectively 10 children, 9 children, and a total of 19 children for the two workers, each of whom should receive 8100 FC per month as family allowances. If we take 8100 FCX 19 children = 153.900 FC X 3 months (one Quarter) = 461700 FC, while the employer has only paid for these 2 workers 66222fc per month, and per Quarter, he has paid 66222 FC X3 = 198.666 FC; this little calculation leads us to say that at some point, things may come to a standstill at the social security fund in the DR-Congo because the CNSS pays more allowances to families than employers pay for these workers.
4. Discussion of the Results
Level of Knowledge of Social Security and/or Social Protection for Workers in the Informal Sector
Our results show that most respondents said they had never heard of health insurance coverage, although their perceptions varied. On the other hand, the majority of informal sector workers aged between 40 and 64 have sufficient knowledge of health insurance coverage. These results are comparable to those of BIZIBU KUSH. Pascal’s 2013 study on practical knowledge of social security in South Kivu province, in which 23.3% of workers and employers had sufficient knowledge of social security. The difference in knowledge between the 14 to 35 age group and the 40 to 64 age group can be explained by the fact that the 40 to 64 age group are former NGO workers who know the benefits of social security.
Indeed, workers in the informal sector aged between 40 and 64 are more exposed to risk as they approach retirement age than young people aged between 14 and 35. Most of the surveys said they had never heard of this health insurance coverage, although their perceptions varied. Some others said that this coverage system benefits only those who designed it, and another group said that even if this system is established, it will not be applied normally like all the other systems and laws in the country, which forces them to say that public power does not exist in the D.R.C.
The others added that this coverage would not bring about a change in the population’s social and health situation. In interviews with informal sector workers about their perceptions of health insurance coverage, many said they had never heard of this approach; others said it would have no impact on the situation of informal sector workers, like all the other laws in the country, which are easy to read, but have no follow-up as to their practicability. It only benefits those who have designed it, and not everyone knows about it.
In addition, the interview measure was addressed to the Social Security Department (CNSS), the latter stated that this new social security law N˚16/009 of July 15, 2016, laying down the general rules of social security advocates a reform enshrining the improvement of social coverage through the extension of the general social security scheme. This covers the pension branch, the ISSA occupational risks branch, Convention N˚102 on the minimum standard, Recommendation N˚202 on social security bases, and the recommendations of the Inter-African Conference on Social Security (CIPRESS).
This strategy has also focused on the ongoing search for consensus with the social partners (27) ISSA 2022, reform of the general social security system in the DRC).
Today, public services are becoming an opportunity for some to enrich themselves unduly, resulting in mediocre performance. In the neighborhoods and villages directly affected by this degradation, we can observe the erosion of national sentiment and respect for public authority.
Ultimately, the country’s unity, peace, and stability are at stake. Vulnerability, and with it poverty, is on the increase. The majority of Congolese live on less than one US dollar a day, considered to be the poverty line. In both urban and rural areas, situations of temporary or chronic indigence are multiplying and intensifying. Despite recent progress, the majority of children do not have access to quality education. School infrastructure and supervision are largely inadequate. As a result, the school wastage rate is high, so the majority of school-age children do not attend any school at all. In addition, quality nutrition for young children (aged 0 - 5) remains a problem throughout the province in particular, and nationally in general, including in the major cities. Access to healthcare for most Congolese is poor. Not only does the cost of healthcare regularly exceed their financial capacity, but the quality of the services offered is mediocre. Indeed, the second demographic and health survey (28) EDS-RDC II. 2013-2014) shows 3.1% employer-provided health insurance coverage, with variations of 6.2 in urban areas and 0.4 in rural areas. As for community mutual, the survey showed a coverage rate of 1.4%, with variations of 1.9% in urban areas and 0.9% in rural areas. Regarding access to maternity care, the same survey noted a proportion of 24% in rural areas and 6% in urban areas of women who gave birth at home. 6-Enquête 1 - 2 - 3: Résultats de l’enquête sur l’emploi, le secteur informel et sur la consommation des ménages/2012 Politique Nationale de Protection Sociale of September 18, 2015. In addition, the distribution of infrastructure and medical skills across the national space is a source of major imbalances. Politically, peace has returned to the country, even if the situation remains tense in the east National Social Protection Program in the DRC, Volume 1, December 2016).
5. Conclusion and Recommendations
In most African countries, access to the health insurance system is reserved for workers in the formal sector, leaving out workers in the informal sector who make up over 80% of the continent’s active population and are therefore in a vulnerable situation (Mubalama Zibona, 2009). To achieve this, it relies on the complementarity of its 3 missions: to compensate and support all victims of illness and accidents; to set the rates of occupational injury/illness contributions for companies; and to prevent occupational accidents. Through its Occupational Risks branch, Assurance Maladie aims to promote a safer, healthier working environment by reducing occupational accidents and illnesses. To achieve this, it relies on the complementary nature of its 3 missions: to compensate and support all accident and illness victims; to set the rates of occupational injury/illness contributions paid by companies; and to prevent occupational accidents. To carry out these missions, the Occupational Risks branch relies in particular on the expertise of 2 players it funds, the French National Institute for Research and Safety (31) INRS) and Eurogip.
Health insurance carries out all its missions with the highest quality of service. To achieve this, it relies on a local network covering the entire country, and the commitment of 85,000 employees who work day after day at departmental, regional, and national levels. Together, daily, they bring our values of universality, solidarity, responsibility, and innovation to life.
To overcome the financial barriers to accessing healthcare, many population groups have decided to develop forms of social security and/or social protection, such as mutual health insurance.
In the DRC in general, and South Kivu in particular, the area of interest to our study, the idea of social security and/or social protection dates back to 1961, but curiously only 30% of the population have any knowledge of social security. Man has no rights other than those he acquires through his work; it is these rights that are recognized, this is the position of almost all developing countries (Prétot & Dupeyroux, 2011); this position was also adopted by most Western countries in the aftermath of the Second World War. Its implementation has led to the exclusion of a large part of the population from social protection. In other words, should the Congolese social security system be a “professionalism” system, determined and limited by a condition of membership linked to the professional activity of those subject to it, or on the contrary, a “universalist” system applicable to the entire national or resident population?
Structured interviews with workers in the informal sector lead us to advocate rejection of the occupational system since it is based on a restrictive conception of social security rights. Our approach consisted of finding out the perceptions of workers in the informal sector concerning health insurance coverage; and proposing strategic solutions aimed at improving the weak points and strengthening the strong points of social security, in particular by setting up “National” health insurance, which is public health insurance coverage, guaranteeing effective access to affordable, quality health (medical) coverage, and financial protection in the event of illness, is essential, both from the point of view of rights, but also of economic profitability. Access to medical care is recognized as one of the most fundamental rights and as a determining factor in boosting productivity and growth (ILO, 2017, Extending social protection).
6. Recommendations or Suggestions
We would ask the country’s authorities to grant compulsory social security (social insurance) to all the country’s inhabitants. That all the country’s citizens have access to essential health services and the means to guarantee a minimum level of income. Since the law is not clear on the number of children eligible for family allowances, we could pass a law limiting the number of children to be taken in charge to ≤6 for family allowances.