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3. Health Security on the Move: Biobureaucracy, Solidarity, and the Transfer of Health Insurance to Senegal
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three Health Security on the Move: Biobureaucracy, Solidarity, and the Transfer of Health Insurance to Senegal Angelika Wolf “Ce n’est pas facile!” Mr. Dembele shook his head. He was trying to understand the difference between budget and capital, as well as between budget and money. Understanding this was necessary to evaluate the financial viability of his mutual health organization in one of the quarters of Diourbel town in Senegal. As one of the many volunteers in the administration of such an organization , he had been invited to participate in a workshop on “planning, monitoring and evaluation for administrators of mutual health organizations.”1 For two days he and the other 30 participants attempted to learn how the administration of a mutuelle de santé—a mutual health organization—should work, in particular how its staff should organize, oversee, and assess their organization . The workshop was conducted by one of the district hospital’s vice directors under the auspices of the regional office of the Health Ministry. It was, however, organized by the umbrella organization of the regional health insurance initiative Coordination Régionale des Mutuelles de Santé de Diourbel (CoRMUSAD) and financed by the German Society for Technical Cooperation (Gesellschaft für technische Zusammenarbeit, GTZ), a development organization working on behalf of the German government. Such events occasionally occur in Diourbel and comprise part of development organizations’ activities to set up mutual health organizations (MHos) in Senegal. The workshop opened with speeches by the president of CoRMUSAD and the health ministry representative. Then, one of the vice presidents of the regional hospital, who is also responsible for supporting MHos, began with the workshop program. His PowerPoint presentation mainly focused on issues such as corporate planning and objectives of MHos, the most important goal being to raise the number of members in the MHo and to secure membership fees. The two factors of income from membership fees and an increasing number of participants in the MHo would determine its survival. Each MHo must be economically independent, economic self-sufficiency HEALTH SECURITY oN THE MoVE 93 being a major goal since financial support from German development aid was to be limited to only a few years. After this warning about the limited period of support, the vice director turned to the topics of the day. As the title of the workshop suggests, the meeting was completely dedicated to administration issues. In the technical language typical for development organizations, he tried to teach the participants how to distinguish functional viability from financial viability and how to make use of the corresponding formulas. From time to time, especially when confusion among the workshop participants arose, he was supported by a young man who sought to clarify the problems by referring to the participants ’ daily situations. The young man was a Senegalese sociologist employed by GTZ to coordinate the newly funded MHos and to support them in keeping records and writing reports. He and some teachers among the participants would reassure their fellows if matters appeared too complicated. When I spoke with the vice director during the coffee break, he stressed: “The problem is the level of administrative professionalism; only two or three organizations work on a high level, otherwise it’s simply too low. In this way they have no chance to survive.” However, the participants’ remarks indicated a contrary attitude: they were dubious that any MHo administrator really needed to know all these intricacies of management and accounting to run their organization. Nevertheless, the workshop went on with some more bureaucratic refinement, and after two days of hard work each participant received a certificate presented by the regional representative of the Health Ministry.2 The account of this workshop shows some of the complications that occur in conjunction with the establishment of health insurance schemes in the informal sector of many African countries. Supported by transnational agencies, laymen are expected to develop mutual health organizations so as to assure access to health services for poor people in their communities. In order to do so, they must acquaint themselves with administrative constraints. Thus, the transfer of health insurance takes part within a certain framework of biobureaucracy.3 Kohrmann (2005) introduced this term to describe the relationship between actors and a health-related bureaucracy. This understanding of health, however, is bound to biomedicine and the concept of biology . Increasing concerns about how to finance biomedical services accompany the global flow of biomedicine and lead to the emergence of this new form of bureaucracy in the...