Time to abandon amateurism and volunteerism: addressing tensions between the Alma-Ata principle of community participation and the effectiveness of community-based health insurance in Africa

### Summary box The 1978 Alma-Ata declaration asserted that primary healthcare ‘requires and promotes maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary healthcare.’1 It enshrined community participation in health management. Thirty years on, however, WHO’s 2008 report on primary healthcare2 noted the weak progress in this area and reaffirmed the need to mobilise people’s participation. The declaration formulated in anticipation of the second international conference on primary healthcare, slated for October 2018 (Kazakhstan), reiterates these principles by promoting community participation in healthcare governance, management and funding and by considering populations to be coproducers of health. In Africa, the development of community-based health insurance (CBHI: autonomous, not-for-profit, voluntary member-based organisations …