Abstract

This article is dedicated to an in-depth analysis of the protection of civilians during the war in the Great Lakes region, with a particular focus on the Republic of Burundi. The central objective is to explore in depth the various aspects of civilian protection, encompassing violence, human rights violations, forced displacement, and other devastating consequences of war that impact civilian populations in this complex region. Focusing on the specific context of Burundi, this study aims to understand the complex realities facing civilians, highlighting the specific challenges they face during armed conflict. The ultimate aim is to formulate recommendations and solutions to improve the protection of human rights and promote human dignity in this particular context. Through an integrated approach, combining qualitative and quantitative methods, the study aims to provide an in-depth analysis that contributes to the understanding of the complex dynamics related to the protection of civilians in the Great Lakes region, with a focus on Burundi. Ultimately, the aim is to lay the foundations for effective action to alleviate the suffering of civilians during periods of conflict and to encourage constructive initiatives in favor of peace and justice. The use of qualitative and quantitative methods, with Alain Bouchard's qualitative data coding system and sampling technique, enabled us to collect reliable data from 95 Congolese refugees, 39 UNHCR staff, 96 displaced persons, and 33 Burundian authorities. These data were analyzed using statistical software dedicated to the social sciences. The results reveal the complexity and gravity of the challenges faced by civilian populations in times of conflict, underlining the crucial importance of a strategic approach to more effective protection of human rights and human dignity, particularly in the Burundian context. It is in this perspective that our study on the protection of civilians during war in the Great Lakes countries, focusing on the Republic of Burundi, was carried out, with the aim of promoting lasting peace and fundamental respect for human dignity.

Keywords

Protection, Civil, War, Country, Great Lakes, Burundi

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1. Introduction

The study on the protection of civilians during war in the Great Lakes region, focusing on the specific case of the Republic of Burundi, is of crucial importance given the complex and often tumultuous history of this African region. Great Lakes countries such as Burundi have been marked by armed conflict, inter-ethnic violence and political upheaval, leaving a legacy of suffering and vulnerability for the civilian population (Sindayigaya, 2023b). This study seeks to analyze the many facets of the problem of civilian protection in this context, examining the underlying causes, the dynamics of conflict and the consequences for individuals caught up in hostilities. The Great Lakes region has been the scene of protracted conflicts, with direct repercussions on the daily lives of civilians (Great Britain. HM Prison Service, 1999). The study will address the implications of these conflicts on the security of populations, highlighting the unique challenges faced by Burundian civilians, confronted with constant threats to their lives and well-being. The analysis will also include a historical perspective to better understand how past events have helped shape the current context of civilian protection during war (Charlesworth, 1992; Sindayigaya, 2025). The specific case of Burundi will be examined in detail, given its complex political history and deep scars resulting from internal conflicts. The study will explore the local and national factors that have fuelled the violence, including ethnic tensions, political rivalries and territorial issues, in order to better understand the origins of the problem. The aim is to shed light on the mechanisms that have contributed to the vulnerability of Burundian civilians, and to identify existing gaps in protection policies (Sunzu, 2022a).

The underlying problem lies in the disproportionate scale of human rights violations and war crimes perpetrated against civilians, both in Burundi and in the Great Lakes region. Testimonies and reports attest to harrowing cases of murder, rape, forced displacement and other atrocities, inflicting unimaginable suffering on civilians, often trapped at the heart of conflicts. These barbaric acts underline the urgent need for intervention to protect the lives and dignity of vulnerable civilian populations. A crucial dimension of this problem lies in the issue of impunity, where the absence of effective mechanisms to bring the perpetrators of these crimes to justice reinforces a climate of impunity, thus encouraging the perpetuation of violence. Judicial systems, weakened by conflict, struggle to guarantee fair justice, accentuating the challenges of holding perpetrators to account. This impunity perpetuates a destructive cycle that compromises the stability and security of civilian populations (Sabates-Wheeler & Verwimp, 2014; Sindayigaya, 2022).

The humanitarian dimension adds further complexity, with humanitarian access challenges for organizations engaged in delivering crucial aid to conflict-affected civilians. Obstacles such as ongoing fighting, logistical impediments and restrictions imposed by the authorities hamper efforts to alleviate suffering and meet the basic needs of vulnerable populations. The protection of particularly fragile groups, such as women and children, intensifies the concern, exposing these segments of the population to systematic violence and lasting trauma. The protection of civilians during war, particularly in the Great Lakes region and specifically in Burundi, requires an integrated and coordinated approach. The complexity of ethnic and political dynamics, the involvement of non-state armed groups and the need for post-conflict reconciliation underline the importance of concerted action at national and international level to ensure effective protection of human rights and human dignity. Finally, this study will seek to propose practical recommendations for improving the protection of civilians during war in the Great Lakes region, highlighting the need for an integrated approach involving legal, humanitarian and post-conflict reconciliation measures.

2. Methods and Methodology

2.1. Choice of Study Area

The delimitation of the geographical field implies the precise identification of the geographical units of observation and the rigorous circumscription of the object of study in space. Our geographical field of investigation was restricted to the 95 Congolese refugees residing in the Kinama/Gasorwe camp, the 39 UNHCR staff members, the 96 displaced persons in the Buterere Quartier Kiyange area, and the 33 Burundian authorities interacting with these refugees and displaced persons. The target population of this study on the protection of civilians during war in the Great Lakes region, focusing specifically on the Republic of Burundi, includes individuals directly affected by armed conflict in this area. These are mainly Burundian civilians who have lived or are currently living in difficult conditions as a result of violence, human rights violations, forced displacement and other devastating consequences of war.

This population includes men, women and children who have been exposed to the various risks and traumas engendered by armed conflict. Women, in particular, are often victims of systematic sexual violence, while children may be forcibly recruited as soldiers, exposing them to long-term physical and psychological trauma. Civilians trapped at the heart of conflicts, confronted with difficult humanitarian conditions, also make up a significant part of the population studied. In addition, vulnerable groups, such as displaced persons, refugees and those residing in areas directly affected by hostilities, are included in the scope of analysis of this study. The ethnic and cultural diversity of the Burundian population is also taken into account, as inter-ethnic dynamics can influence the risks and experiences of different segments of society. In short, the population of this study is Burundian civilians directly affected by the complex realities of war, seeking to understand the various aspects of the protection of human rights and human dignity in this difficult context.

2.2. Concepts

The definition of conceptual and theoretical fields of reference in social science research obeys epistemological requirements. It constitutes a decisive step in the construction of the research object. These fields, though separate (from conceptualization to theorization), are articulated to enable an original clarification of the scientific orientation of the research.

The notion of “protection” refers to actions, measures or mechanisms aimed at ensuring the safety, preservation and well-being of individuals, groups or property. It encompasses a variety of contexts and can be applied to different fields, ranging from physical security to the preservation of rights, the environment and individual freedoms. Protection often involves setting up preventive measures to avoid damage, risks or threats. It can be legal, social, environmental, humanitarian, or linked to other spheres of activity, depending on the specific context in which it is used. In short, protection seeks to guarantee the safety and integrity of individuals and their property, as well as the preservation of fundamental values (Albert, 2004).

The term “civilian” has several meanings depending on the context, but generally speaking, it refers to a person who is not in the military or on active service in the armed forces. Here are some of the common meanings of the term “civilian” (Sowers et al., 2017). Non-military: In a military context, the term “civilian” refers to anyone who is not a member of the armed forces. Civilians are ordinary individuals living in society outside the military framework (Daley & Popplewell, 2016; Sindayigaya, 2023b).

Non-Criminal: In law, “civil” can mean non-criminal. Civil cases involve disputes between individuals, organizations, or entities that are not criminal in nature. This includes areas such as family law, contract law, and financial disputes. Relating to Civil Society: The term “civil” can also be used to describe activities, institutions, or movements that are not affiliated with government or the armed forces. For example, civil society encompasses organizations and individuals acting outside the government framework (Daley & Popplewell, 2016; Sindayigaya, 2023a). Ordinary or Non-Specialized: Something can be described as “civil” to indicate that it is common, ordinary, or non-specialized. For example, a civil aircraft is a non-military aircraft used for commercial trave. Polite or Courteous: The adjective “civil” can also be used to describe behavior that is polite, respectful of social norms and good manners.

War” is a state of armed conflict between political groups, national entities or nations. It is a complex, multifaceted concept that encompasses military confrontations, hostilities and violent clashes between opposing parties (Quénivet, 2008). The term “country” generally refers to a distinct geographical and political entity with defined borders, sovereignty, government and permanent population.

The “Great Lakes” generally refer to a group of large freshwater lakes located in a specific geographical region. There are several regions in the world with this name, but most often the term is associated with the East African region, where the African Great Lakes are located. Here’s a more detailed definition in this context (Claessens et al., 2021). The Great Lakes are a collection of freshwater lakes, often of significant size, that are geographically grouped together in a given region. In the African context, the main lakes included are Lake Victoria, Lake Tanganyika, Lake Malawi, Lake Albert, Lake Edward and Lake Kivu (Bizibu Kushombere, 2018). The term “Great Lakes” is frequently used to refer to the East African region in which these lakes are located. This region includes countries such as Burundi, the Democratic Republic of Congo, Kenya, Rwanda, Tanzania and Uganda (Sindayigaya, 2025).

Africa’s Great Lakes play a crucial ecological and economic role in the region. They harbor significant biodiversity, are sources of many natural resources, and are used for fishing, shipping and other economic activities. Each of the African Great Lakes has its own watershed, contributing to the region’s hydrological dynamics. The rivers and streams that feed these lakes, and those that flow from them, are an integral part of the region’s ecosystem (Sindayigaya, 2025).

Burundi is a landlocked country in East Africa, located in the Great Lakes region. Here is a detailed definition of Burundi. Geographic location: Burundi is located in the central part of East Africa, bordering Tanzania to the south and east, Rwanda to the north, and the Democratic Republic of Congo to the west (Daley & Popplewell, 2016). The capital of Burundi is Bujumbura, located on the shores of Lake Tanganyika, on the border with the Democratic Republic of Congo (Ndericimpaye & Sindayigaya, 2023). Burundi has a diverse population, mainly made up of ethnic groups such as Hutus, Tutsis and Twas. Burundi’s total population is around 11 million. Kirundi is the official language and is widely spoken throughout the country. French and English are also used, notably in administrative and educational fields. Burundi has a complex history, marked by periods of ethnic conflict, notably between Hutus and Tutsis. It gained independence from Belgium in 1962. Since then, the country has experienced periods of political stability and instability. Burundi’s economy is mainly agricultural, with a large rural population dependent on subsistence farming. Exports include coffee, tea and sugar. The country has also faced economic and social challenges, including episodes of conflict (Sunzu, 2022a). The majority of Burundi’s population is Christian, with a significant proportion of Catholics and Protestants. There are also Muslim communities and traditional religious practices. Burundi is a presidential republic with a multi-party system. The president is both head of state and head of government. The country has gone through periods of political conflict, notably during the civil war between 1993 and 2006. Burundi is a member of several international organizations, including the United Nations, the African Union and the East African Community (Sunzu, 2022b).

2.3. Data Collection Techniques and Tools

Documentary research has become one of the most important methods of data collection. Thus, every social fact is an event which, scarcely realized, already belongs to the past; it is therefore by the trace it has left that the observer can reach it, and this trace comes under documentary observation. This approach facilitated the review of previous studies dealing with the in-depth analysis of civilian protection during war in the Great Lakes region, with particular emphasis on the Republic of Burundi. Consequently, the empirical nature of this study led to the choice of the interview technique for gathering qualitative information. The use of these methods was made possible by data collection instruments such as the questionnaire and the interview guide. The questionnaire, administered using an indirect approach, enabled the acquisition of quantitative data which were then analyzed using statistical software dedicated to the social sciences. Thus, qualitative and quantitative approaches were jointly employed to achieve an in-depth analysis of the protection of civilians during war in the Great Lakes region, with a particular focus on the Republic of Burundi. In short, this study is a continuation of previous experiments aimed at exploring in depth the protection of civilians during war in the Great Lakes region, with a specific focus on the Republic of Burundi. The target population for this study includes 7422 Congolese refugees in the Kinama/Gasorwe camp, 66 UNHCR staff, 87200 displaced people from the Buterere Quartier Kiyange zone, and 50 Burundian authorities interacting with these refugees and displaced people.

When the population under study is less than or equal to 1,000,000 individuals, we match it to a sample of 96 individuals with a margin of error of 10%. The following formula helped us determine the sample size.

$nc=\frac{n}{1+\frac{n}{N}}$ By developing $nc=\frac{n}{1+\frac{n}{N}}=\frac{n}{1+\frac{N+n}{N}}=\frac{n}{1}x\frac{N}{N+n}$

$nc=\frac{nx N}{N+n}$

N = Total parent population (target population).

nc = Corrected sample.

The total universal sample of a finite universe is n = 96.

For Congolese refugees in the Kinama/Gasorwe camp, the population was 7422. Using Alain Bouchard’s formula, the sample is: nc = (96 × 7422)/(7422+ 96) =94.77; ~95 Individuals. For HCR staff, the population was 66. Using Alain Bouchard’s formula, the sample is: nc = (96 × 66)/(66+ 96) =39.11; ~39 individuals;

For displaced persons in the Buterere Quartier Kiyange area, the population was 87200. Using Alain Bouchard’s formula, the sample is: nc = (96 × 87200)/(96+ 87200) = 95.89; ~96 individuals;

For the Burundian authorities interacting with these refugees and displaced persons, the population was 50. Using Alain Bouchard’s formula, the sample is: nc = (96 × 50)/(96 + 50) = 32.87; ~33 individuals. Our sample consisted of 95 Congolese refugees residing in the Kinama/Gasorwe camp, 39 UNHCR staff, 96 displaced people from the Buterere Quartier Kiyange zone, and 33 Burundian authorities interacting with these refugees and displaced people. Data analysis is the methodical process of bringing order, structure and meaning to the mass of information collected. The data collected were subjected to qualitative and quantitative analysis. Qualitative data were examined thematically, while quantitative data were processed using SPSS software.

3. Analysis Results

This part of the article presents the data collection for this study. It also deals with the data analysis and interprets and discusses the results/conclusions and interpretation of the results. Data are collected using a questionnaire. However, a quantitative and qualitative research methodology was used to interpret the results found in the field.

The results of the question aimed at determining the institutional or organizational affiliation of respondents, reflect a significant diversity within the sample (see Figure 1). Notably, 10% of respondents identified themselves as belonging to a Burundian government authority, illustrating the presence of government representatives within the respondent cohort. At the same time, 20% said they were affiliated with international humanitarian organizations, highlighting the involvement of international players in the humanitarian sphere in Burundi. A further 10% said they belonged to local non-governmental organizations, underlining the involvement of civil society players at local level. The most predominant category was refugees and displaced persons, representing 60% of respondents, underlining the importance of giving a direct voice to the populations most affected by conflict. The distribution of institutional affiliations suggests significant implications for the diversity of perspectives brought to the study. Government representatives could offer crucial insights into local policies and initiatives, while international humanitarian actors can share their expertise on global civilian protection practices. Local non-governmental organizations could contribute with contextual perspectives and an in-depth understanding of community dynamics. The strong representation of refugees and displaced persons lends a particularly relevant dimension to the study, giving a direct voice to those most affected by conflict and offering invaluable insight into their experiences.

Figure 1. Insights into participants’ institutional links.

Figure 1 shows that of the 25 Musaco members, more than seven-tenths operate in rural areas and have a positive gap of 309.8% in 2022 compared with 2002, i.e. an increase of 209.8% in membership over twenty years. The average annual increase is therefore almost 21 members. In urban areas, on the other hand, there will be a decline in membership of 53%, or 47%.

However, it is essential to note that the majority representation of refugees and displaced persons raises methodological considerations. While this perspective is crucial, it is important to consider the possible biases associated with this concentration. The results raise the question of how individual perspectives and experiences may influence the overall results of the study. Researchers should be attentive to this aspect when interpreting the data, recognizing the diversity of experiences within the refugee and displaced population itself. In conclusion, the varied distribution of institutional affiliations reflects the complexity of the actors involved in civilian protection in Burundi.

Indeed, a significant proportion of 70% felt that the impact of the war was “very serious”. This prevalence of pessimistic opinion underlines the severity of the consequences that the civilian population is currently enduring within Burundi’s conflict context. These results suggest a reality marked by considerable humanitarian challenges and suffering, reinforcing the need for urgent action to mitigate the devastating effects of the conflict. An examination of the responses also shows that 15% of respondents consider the impact to be “significant”. This nuance indicates recognition by a minority but not insignificant portion of the population surveyed of the war’s significant impact on Burundian civilians. These results suggest the diversity of perceptions within the population studied, illustrating the complexity of conflict dynamics and their varied impacts on individuals. On the other hand, a mere 2% considered the impact to be “weak”, and only 3% described it as “moderate”. These contrasting perspectives underline the divergence of opinions within the sample, suggesting differences in experience and outlook among respondents. The diversity of perceptions may stem from a variety of factors, such as geographical proximity to conflict zones, personal experiences, or even institutional affiliations.

Figure 2. Perceptions of the current impact of the war on the civilian population in Burundi.

The inclusion of diverse voices enriches the quality of the research by offering multiple perspectives, although researchers should be aware of possible biases associated with the concentration of responses among refugees and displaced persons. This institutional diversity underlines the importance of a holistic and inclusive approach in analyzing results, aiming to integrate the multiple dimensions of the realities experienced by civilian populations during conflict.

Analysis of the responses to the question on the current impact of the war on the civilian population in Burundi reveals a predominantly gloomy perception among respondents (see Figure 2).

Finally, it is interesting to note that 10% of respondents chose not to answer this question. This may reflect the sensitivity and complexity of war-related experiences, underlining the need to respect participants’ feelings and misgivings. It also highlights the delicate nature of research in conflict contexts, where responses may be influenced by emotional and security factors. In conclusion, analysis of these results highlights the urgent need to address the serious consequences of the conflict in Burundi, as perceived by the overwhelming majority of respondents. However, the diversity of perspectives within the sample underlines the importance of adopting a nuanced and comprehensive approach in understanding the complex realities associated with the war and its impact on the civilian population.

An assessment of the effectiveness of existing civilian protection measures in Burundi, as perceived by respondents, reveals deep concern about the current effectiveness of these arrangements (see Figure 3). The overwhelming predominance of the response “Not at all effective” by 65% of participants highlights a high level of dissatisfaction and skepticism towards current civilian protection initiatives. These results suggest a largely negative perception of the ability of existing mechanisms to prevent and mitigate violence and human rights violations in the context of protracted conflict. At the same time, the low percentage of positive responses, with only 5% considering the measures to be “Effective” and a further 5% assessing them as “Moderately Effective”, highlights a minority who perceive some usefulness in the current initiatives. These divergent responses underline the polarization of opinions within the survey population, perhaps reflecting varied experiences and different expectations of existing protection mechanisms. The results also show that none of the respondents rated the measures as “Very effective”, highlighting an apparent widespread lack of confidence in the effectiveness of current efforts to protect civilians. This finding calls into question the relevance and impact of existing strategies, underlining the need to reassess current approaches to better address the needs and concerns of the civilian population.

In conclusion, analysis of these results highlights the urgent need for a critical reassessment of civilian protection mechanisms in Burundi. The preponderance of negative responses indicates widespread dissatisfaction and raises essential questions about the effectiveness of current strategies. These results call for in-depth reflection on the design and implementation of more effective protection measures, while taking into account the diversity of experiences and expectations within the civilian population (see Figure 3).

Figure 3. Assessment of the effectiveness of civilian protection measures in Burundi.

The most striking prevalence is that of “Forced displacement”, cited by an overwhelming 95% of respondents. This response highlights the scale of the problem of forced displacement in Burundi, underlining the heartbreak and suffering endured by civilians forced to leave their homes as a result of hostilities. Human rights violations” are also widely identified as a crucial challenge, cited by 67% of participants. This concern reflects the seriousness of violations of civilians’ fundamental rights during the war, probably including acts of violence, abuse and even war crimes. These results highlight the need for particular attention to the protection of human rights in Burundi’s conflict context. Another significant challenge is “limited access to basic services”, highlighted by 70% of respondents. This response indicates that, in addition to forced displacement and human rights violations, access to essential services such as health, education and other basic needs is also greatly compromised. These results underline the critical humanitarian dimension of the situation, requiring increased efforts to ensure decent living conditions for war-affected civilians. As for the “Other” responses, noted by 35% of participants, this could indicate a diversity of specific challenges not covered by the predefined categories. This variability underlines the complexity of the realities experienced by the civilian population, underscoring the importance of understanding local and individual specificities for an effective response. Finally, respondents who chose not to answer this question (15%) underline the sensitivity of the challenges addressed and the need to respect participants’ wishes not to share certain experiences. These results underline the need for an ethical and respectful approach to data collection and interpretation in contexts of conflict.

Analysis of the responses to the question on the main challenges facing Burundian civilians during the war reveals a series of major concerns among the population surveyed (see Figure 4).

Analysis of the responses concerning the effectiveness of justice mechanisms for dealing with human rights violations during the war in Burundi reveals deep dissatisfaction among the majority of respondents (see Figure 5 below).

Figure 4. Major challenges facing Burundi’s civilian population in wartime.

Figure 5. Assessment of the effectiveness of justice mechanisms for human rights violations during the war in Burundi.

A worrying finding emerges, with an overwhelming 72% of participants believing that these mechanisms are “Not at all effective”. This response underlines the widespread lack of confidence in the ability of the Burundian justice system to adequately deal with human rights violations in times of conflict. The low percentages of positive evaluations, such as “Very effective” (1%) and “Effective” (2%), reflect a minority who perceive some usefulness in existing justice mechanisms. However, these minimal figures underline the need for a comprehensive reassessment and improvement of current approaches to enhance the effectiveness of justice mechanisms in the specific context of wartime Burundi. The “Moderately effective” segment was chosen by 6% of respondents, showing a slight recognition of the effort, but at the same time suggesting that substantial improvements are needed to strengthen the credibility and effectiveness of the judicial system in protecting human rights. Finally, the notable proportion of participants who chose not to answer the question (9%) may indicate a certain reluctance to openly discuss the performance of the justice system. This reluctance may be attributed to concerns about security, confidentiality or a more general distrust of the authorities.

In conclusion, these results underline the urgent need for substantial reforms to strengthen the confidence and effectiveness of justice mechanisms in Burundi during periods of war. The predominantly negative opinions call for in-depth reflection on systemic obstacles and the design of solutions that meet the expectations and needs of civilian populations affected by the conflict.

Analysis of the responses concerning the expected role of international actors in the protection of civilians in Burundi during the war reveals diverse perspectives among the respondents (see Figure 6). The predominant response was “Diplomatic mediation”, chosen by a significant majority of 50% of participants. This preference underlines the desire for peaceful conflict resolution through international negotiation and mediation, emphasizing the search for political rather than military solutions. Military intervention” was cited by 10% of respondents, suggesting that a minority are inclined to accept or consider foreign military intervention as a means of protecting civilians. These results highlight a division of opinion on the effectiveness and legitimacy of foreign military intervention in the Burundian context. The “Humanitarian Assistance” option was selected by 30% of participants, indicating a significant recognition of the need for practical help to alleviate the suffering of war-affected civilians. This underlines the importance attached to immediate humanitarian needs in conflict situations, such as access to food, drinking water, healthcare, and other forms of assistance.

Figure 6. Role of international actors in the protection of civilians in Burundi during wartime.

The “Other” option was chosen by 2% of respondents, leaving room for varied and potentially specific interpretations that don’t fit into the predefined categories. This diversity underlines the complexity of expectations of international players, underscoring the need for a nuanced approach tailored to local realities (see Figure 6 above).

Finally, the choice of “I do not wish to answer” by 8% of participants underlines the sensitivity of the question, and may reflect mistrust of international players or concerns about the confidentiality of the opinions expressed (see Figure 7). This reservation underlines the importance of transparency and confidentiality in gathering information in complex contexts such as conflict zones.

Figure 7. Coordination challenges for international actors in the protection of civilians in Burundi.

3.1. Socio-Demographic, Structural and Institutional Characteristics of Musaco

Representation of the Musaco Boards of Directors at Remusaco General Meetings.

Figure 8. Structure of a musaco. legend: Controls and monitoring-evaluations.

Figure 8 shows that the network of Musaco has an Executive Secretariat and a Board of Directors to achieve its objective of improving access to healthcare and supporting the development and consolidation of its member health mutualism. The supreme decision-making body is the General Assembly, which comprises all the Boards of Directors of the 25 Musaco members. It is chaired by the Arch-bishop.

The city lost an average of 5 members a year in 2022, compared with 2002. The question remains as to why these disparities exist. Some of them are certainly due to data imbalances. Quality control of the figures revealed incomplete and missing statistics for many Musaco companies. Eight of the 25, or .32, have complete, regular and extrapolable data for the period 2002 to 2022. They are presented in Table 1 below.

Table 1. Musaco with complete and regular data (2020 to 2022).

As it can be seen from Table 1, membership has fallen over the past three years in all the areas studied. The exceptions are the Musaco of Kalehe and Ibanda, where membership rose from 3351 to 4867 and from 1970 to 2570 respectively between 2020 and 2022. Using the MIO integrated organizational model, we can identify the deficits observed on the basis of actors and external factors, inputs, outputs and the socio-technical transformation process. This process includes structure and leadership, the analysis of which also enables us to shed light on pathologies of structural and management origin. Two (unofficial) organisation charts below, drawn up on the basis of the report, provide photographs of the links observed. We will come back to them in the discussion of the results.

At the institutional level, the Réseau des Mutuelles de Santé Communautaires “Remusaco”, operates in accordance with organic law N˚17/002 of 08.02.2017 determining the fundamental principles relating to mutual health insurance. Since 2016, Remusaco has replaced the former structure known as the Cellule d’Appui aux Mutuelles de Santé (CAMPS). The organizational charts in Figure 1 and Figure 2 have thus been strengthened. However, the organizational/institutional well-being is still not very perceptible. The challenge of Musaco’s individual self-management remains unresolved. The environmental situation is changing without any adjustment or adaptation mechanisms being put in place. Routine takes hold. It seems to inhibit innovation and dynamism.

Furthermore, the structural analysis and the relational flows that take place show that we are in the presence of a structural configuration dominated by the technostructure. This is because, in addition to training activities, three types of technical support from the administrative head office to Musaco are perceptible: support in monitoring and evaluating the execution of activities and the level of achievement of performance indicators; general control of administration and finances; and verification of relations with partner health institutions responsible for providing health care to members. A reading of the organisation charts using structural configuration theory reveals a Remusaco structure dominated by the techno-structure (Mintzberg, 2019; Pichault et al., 2020). Figure 8 above shows that Musaco is subject to checks by the technostructure and the executive.

3.2. Indicators of Overall Operating Condition

Figure 9. Growth in the number of Musaco (community health mutualism).

Figure 9 indicates that from 10 functional health mutualism in 2007, the number has increased year by year, rising from 10 to 25 Musaco in 2016. However, the number of members has fluctuated up and down over the same period, as shown below (see Figure 10 below).

Figure 10. Musaco membership growth 2007 to 2022.

As can be seen from Figure 10, Musaco’s membership trends have fluctuated considerably. Over the period from 2006 to 2013, membership showed an upward trend: from 29,648 members in 2006 to 118,105 members in 2013, an increase of more than 450% in 2013 compared to 2007. This upward trend has been reversed, from 118,105 members in 2013 to 46,880 in 2022, a drop of almost 60% in 2022 compared with 2013 (in 10 years). On the other hand, the number of Musaco members rose from 23 in 2013 to 25 in 2022, a two-year increase of almost 9%. We therefore need to shed some light on the factors that explain the contrast between the fall in membership numbers and the rise in the number of Musaco members. The trend lines below show the differences between rural and urban areas.

Figure 11. Members in rural areas compared with urban areas.

The illustration from Figure 11 demonstrates that over the entire period from 2007 to 2022, the average annual membership was 43,973 in rural areas compared with 27,587 in urban areas. The student’s t-test (p-value = .012) shows that there is a significant statistical difference between rural and urban areas in terms of average membership. There is an imbalance in the data observed in these graphs.

Over the past fourteen years, membership has fluctuated considerably. In most years there have been withdrawals. As Figure 12 shows, from 2008 to 2013, membership rose in both towns and villages, peaking in 2012. Since then, there have been withdrawals, with membership plummeting to 26,727 in 2014 and 21,690 in 2017. The slight increase in membership observed in 2019 has not reached previous levels. In general, membership trends are the same in rural and urban areas. However, rural areas record much higher membership than urban areas. At a closer look, the drop-out rate is more pronounced in the city than in the village. The following Figure 12 below shows this.

Figure 12. Membership trend curves (2008-2022).

Figure 13. Withdrawal rate for members.

Figure 13 shows that the average withdrawal rate has generally varied from 51.40% in 2016 to a peak of 74.18% in 2021. The trend has remained relatively the same in rural and urban areas. The highest drop-out rates were observed in 2021, with 85.62% in urban areas and 72.54% in rural areas. This raises questions about the future of Musaco. All in all, the maximum withdrawal rate is 87.3%, compared with a minimum of 43.7% in 2021. The ANOVA test shows that the rate of variability of drop-outs between the Musaco programmes studied does not differ significantly (p-value = .8527), just as it is balanced between rural and urban areas (p-value = .6200). What then of the penetration rates among the target populations? Graph 11 below shows the trends.

Figure 14. Penetration rate among target populations.

According to Figure 14 above, the level of attrition worsens with low penetration or reach. Graph 6 above shows that the overall penetration rate has been falling steadily since 2018. The average penetration rate among target populations has fallen from 2.52% in 2018 to 1.57% in 2021. Urban areas show the lowest average penetration rate, relatively equal to .35%, from 2018 to 2021, compared with 1.73% in rural areas in 2021. The Kruskal Wallis test confirms this significant difference between penetration rates in the two areas (p-value = .0067). The penetration rates of the target population also vary significantly between different Musaco areas (p-value = .0008).

Figure 15. Contribution recovery rate.

Figure 15 shows that despite the high drop-out rate and low penetration level, the level of collection has remained high overall (78.01% and above) from 2016 to 2021. The year 2019 recorded the highest average collection rate of 98.77% for both urban and rural areas. The lowest average rate was 88% in 2020 for both environments. It can also be seen that the rate of collection of contributions remained relatively stable in the urban environment from 2016 to 2019, falling from 2020 to 2021. For the rural environment, the lowest average collection rate was 87% in 2018. Using the Kruskal Wallis test, we conclude that there is no statistically significant difference between rural and urban recovery rates (p-value = .8368). The same is true for Musaco (p-value = .3383).

The care recovery rate has tended to fall; from an average annual rate of 94.18% in 2018, it has dropped to 39.37% in 2021 (see Figure 16). On the other hand, the retention rate has changed little: from 70.66% in 2019, it has fallen slightly to 68.91% in 2021. Despite the insufficient number of positive responses received, members generally remain loyal to their Musaco.

Figure 16. Proportion of care recoveries compared to loyalty recoveries.

3.3. Summary of the Main Analysis Results

In quantitative terms, the indicators in Table 2 below show a fairly worrying overall state of health, given the shortfalls in the recovery of healthcare costs and the number of members in towns and cities.

Table 2. Values of organizational health indicators.

According to Table 2, at the qualitative level, analysis based on the MIO and individual perceptions reveal instructive psychosocial and managerial realities. Obviously, personal perceptions are not binding in their entirety. However, even if, according to Gestalt theory, the whole is different from the sum of its parts, it remains clear that it is these parts that hold the whole together and act upon it, thus reifying the organisation. In summary, the proportions of the opinions expressed are shown in Table 3 below:

Table 3. Proportion of convergent and divergent perceptions by MIO-related category.

Table 3 shows the divergences and convergences by category. The divergences are based on analyses of the content of the reports and structured interviews with seven resource persons in the mutualism area studied. The results are given in proportions.

4. Discussion of the Results

The results were discussed from the angle of the integrated organizational model, considering the Remusaco network and each of the member Musaco as complex systems. The focus is on the key factors influencing the health and resilience of the targeted mutual. The first factor taken into account is the individual, his or her participation and work space. Cross-checking the data shows that perceptions are controversial when it comes to allocating staff according to the requirements of each post and the profile/skill of the occupant. In addition to the affinity criterion based on involvement in Catholic diocesan works, the criteria of diploma, morality and docility are cited for recruiting and assigning staff. From this point of view, the individual malaise that emerges when looking at the organizational structure is that of the isolation of the Musaco leader. Most of the time, they work alone in the office, whether in town or country, and do not belong to any union. There is no clear job description. In this case, according to many authors, confusion and ambiguity become common phenomena, especially when positions are not clearly defined, authority relationships obscure and information lines unorganized (Aubert et al., 2022; Chhabra et al., 2019). The distraught and isolated worker thus finds himself in a situation where his desires are inhibited. The psychoanalytical explanation based on the three Freudian principles of consciousness “Constancy-Pleasure-Displeasure-Reality” shows that the conscious subject makes a conscious choice between fulfilling his desire, postponing it, prohibiting it or trying to sublimate it (Chhabra et al., 2019). This shows the difference between the way psychoanalysis views the individual and the way it views Human Resources Management (HRM). The psychoanalytical approach is comprehensive and integrates the unconscious (Guénette & Chouinard, 2020; Nduwimana & Sindayigaya, 2023; Sindayigaya, 2020; Sindayigaya & Nyabenda, 2022). The HRM approach, on the other hand, sees the subject as a resource person who submits to the principles of instrumental rationality and strategic rationality. From these points of view, the reluctance to join (Index 100 in 2000 compared with 53 in 2022) and the continual withdrawals in certain Musaco (p-value .8527 and .6200) are directly linked to the low recovery rates, both for contributions and for health care for members. These members, like the employees, are rational. Faced with the perceived issue of whether or not to remain an employee/member, whether or not to join, whether or not to pay contributions, each member and each worker makes his or her own decision. With their personal interests and expectations in mind, members decide whether or not to contribute, depending on what they gain or lose by supporting their Musaco and ipso facto safeguarding their harmonious relationship with it. So there is no question here of a mechanical attachment. Rather, we are dealing with the calculation of the players involved.

Analysis of the transformation process reveals a structure dominated by the techno-structure. Technocrats, controllers and assessors from Remusaco’s head office have greater authority over the Musaco office, whose Board of Directors has direct authority. The standards and procedures required to be applied by agents outside Musaco are thus brought to the fore, and managerial compassion is increasingly minimised. In the extreme, they become sources of stress. On the one hand, the results of our research concur with those of previous studies which have established that managerial compassion constitutes the lever of SO through the identification of mediating mechanisms and a mediating condition specific to the psychological state of the managers themselves (Grenier et al., 2022: p. 182). The analyses show that managers favour forecasts in terms of periodic performance standards; this is the opinion of 8 out of ten people (.8). This means that in these days, the focus is more on anticipatory regulation than on human relations. On the other hand, little attention is paid to regulation through alerts and errors (according to .7 and .6 respondents); management is generally less attentive to staff complaints and demands. On the other hand, the relatively moderate management does manage to give hope to the staff, who are paid a strict minimum and evaluated by Remusaco headquarters. This reveals that in its current configuration, Musaco’s organic structure is merely a representation of Remusaco. Its scope for initiative, innovation and entrepreneurship remains infinitesimal. This is borne out by the continuing fall in indicators of healthcare coverage by members (down from 94% to 39% over the last four years in rural and urban areas combined). Similarly, the penetration indicators are not significant, at .0067 and .0008 respectively in rural and urban areas. Our analyses show that 8 out of 25 Musaco, or 3 to 4 out of 10 mutualism, in both urban and rural areas, have operating indicators reflecting fairly good organizational health. The high level of significance observed in the collection of contributions (.8368) is due to external financial support for poor members and the state’s financial contribution for members who are primary and secondary school teachers. This does not reflect the monetary capacity of members in general. A new style of global management of the Remusaco network therefore seems to be needed to improve the state of organizational health. As many researchers have argued, this will involve reducing technocratic practices and getting the Musaco members of the Remusaco network more involved in the process of gradually weaning themselves off drugs. This will reduce extra-organizational stressors and improve workers’ psychological health indicators. They could develop positive emotions, reduce depressive symptoms and burnout, and be predisposed to job satisfaction, absenteeism and emotional exhaustion (Grenier et al., 2022: pp. 183-186).

The outputs and their reuse show a feverishness expressed by 8/10^th interviewees. The latter presumed that Musaco products were not used rationally. Nine out of 10 complained that Musaco provided little or no support for income-generating activities (IGAs) initiated by members. In their opinion, some of the Musaco’s products should be reused to strengthen their solidarity nuclei, “Nosomu”. These nuclei suffer from insufficient support in terms of structuring and organizational capacity building. Yet it is through the latter that the Musaco could support the social entrepreneurship of their members and strengthen their ability to pay contributions. In the absence of managers who use managerial compassion, members and staff lack a body that can listen attentively and sympathetically to their grievances, needs and complaints; they also lack an incentive framework to be present alongside each other to promote compassion at work and in the “Nosomu”, just as managers at different levels fail to act as models of compassion. Managers should be able to reconcile the best possible performance with the individual and collective fulfilment of their staff, and with the organizational and institutional development of Musaco/Remusaco. The overall periodic results appear mixed. Particularly in urban areas, there is still a weak chain reaction and little discernible dynamism in terms of inclusive access to care and support for development.

5. Conclusion

All in all, this work on the organizational health of community health mutualism aims to verify the hypothesis that the health of the organisation depends on factors such as the age and size of the structure, the commitment of the components, the levels of penetration and membership, the operating environment, the rates of recovery of care and contributions and the extent to which Musaco manages to support the social entrepreneurship of its members. In order to verify the interplay between the factors at play and Musaco’s health, we used the MIO as a systemic analysis tool, statistical methods and content analysis of the opinions of seven people of varying qualities in the Musaco area. The results show that, in general, Musaco and its Remusaco network are unwaveringly committed to the quest for organizational well-being, as evidenced by major achievements such as the continued growth in membership in rural areas: from index 100 to 310, a 210% increase over the past 21 years (2002 to 2022); the effort to apply and execute forecasts, standards and procedures; regular checks and evaluations; and the high level of commitment to establishing authority and respect for hierarchy. However, many challenges remain. Membership rates in urban areas are gradually falling, from an index of 100 in 2002 to 53.2% in 2022, an overall drop of 46.8% in twenty years, while there is no significant difference between the drop-out rate in urban and rural areas (p-value = .8527), or between Musaco in the city and Musaco in the countryside (p-value = .6200). There has also been a worrying decline in the healthcare recovery services provided by Musaco to urban members. Of the 94% who benefited from these services in 2018, only 39% did so in 2022. Musaco products are also perceived by eight out of 10 people as being poorly used, as is the lack of support for the empowerment of Musaco and local health leadership (.8 opinion).

At the end of the analyses, our study establishes that the current overall good health of Remusaco with its Musaco members is exposed to multiple challenges such as weaning and social entrepreneurship. It suggests that the network should support the structuring of its members into more entrepreneurial Musaco and Nosomu, more committed to reasonable weaning. That local health leadership should be able to encourage peers to transform their “Knowledge, Attitudes and-Practices” linked to Musaco; that member should direct their perceptions towards a more responsible pooling of social protection and towards the practice of “IGAs”, with a view to entrepreneurship. Further research could shed more light on the leadership of mutual organizations in the health insurance sector, on social entrepreneurship as a factor in the organizational health and resilience of Musaco in the face of ever-increasing disruption, and on members’ perceptions of the managerial compassion of the managers of their Musaco.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References