[Extension of health coverage and community based health insurance schemes in Africa: Myths and realities]

Impact of community-based health insurance on healthcare utilisation and out-of-pocket expenditures for the poor in Senegal

OBJECTIVES

This study aims to assess the impact of the subsidised community health insurance scheme in Senegal particularly on the poor.

DESIGN AND SETTING

The study used data from a household survey conducted in 2019 in three regions, representing 29.3% of the total population. Inverse probability of treatment weighting approach was applied for the analysis.

PARTICIPANTS

1766 households with 15 584 individuals selected through a stratified random sampling with two draws.

MAIN OUTCOME MEASURES

The impact of community-based health insurance (CBHI) was evaluated on poor people's access to care and on their financial protection. For the measurement of access to care, we were interested in the use of health services and non-withdrawal from care in case of illness. To assess financial protection, we looked at out-of-pocket expenditure by type of provider and by type of service, the weight of out-of-pocket expenditure on household income, non-exposure to impoverishing health expenditure and non-exposure to catastrophic health expenditure.

RESULTS

The results indicate that the CBHI increases primary healthcare utilisation for non-poor (OR 1.36 (CI90 1.02-1.8) for the general scheme and 1.37 (CI90 1.06-1.77) for the special scheme for indigent recipients of social cash transfers), protect them against catastrophic (OR 1.63 (CI90 1.12-2.39)) or impoverishing (OR 2.4 (CI90 1.27-4.5)) health expenditures. However, CBHI has no impact on the poor's healthcare utilisation (OR 0.61 (CI90 0.4-0.94)) and do not protect them from the burden related to healthcare expenditures (OR: 0.27 (CI90 0.13-0.54)).

CONCLUSION

Our study found that CBHI has an impact on the non-poor but does not sufficiently protect the poor. This leads us to conclude that a health insurance programme designed for the general population may not be appropriate for the poor. A qualitative study should be conducted to better understand the non-financial barriers to accessing care that may disproportionately affect the poorest.

Exploring the Role of Social Representation in Micro-Health Insurance Scheme Enrolment and Retainment in Sub-Saharan Africa: A Scoping Review

Low enrolment in micro-health insurance (MHI) schemes is a recurring issue affecting the viability of such schemes. Beyond the efforts addressing low subscription and retention in these schemes, little is known on how social representations are related to micro-health insurance schemes enrolment and retention. This scoping review aimed at exploring the role of social representations in shaping enrollment and retention in MHI in sub-Saharan Africa. We reviewed qualitative, quantitative and mixed methods studies conducted between 2004 and 2019 in sub-Saharan Africa. We limited our search to peer-reviewed and grey literature in English and French reporting on social representations of MHI. We defined social representations as conventions, cultural and religious beliefs, local rules and norms, local solidarity practices, political landscape and social cohesion. We applied the framework developed by Arksey and O’Malley and modified by Levac et al. to identify and extract data from relevant studies. We extracted information from a total of 78 studies written in English (60%) and in French (40%) of which 56% were conducted in West Africa. More than half of all studies explored either cultural and religious beliefs (56%) or social conventions (55%) whereas only 37% focused on social cohesion (37%). Only six papers (8%) touched upon all six categories of social representation considered in this study whereas 25% of the papers studied more than three categories. We found that all the studied social representations influence enrollment and retention in MHI schemes. Our findings highlight the paucity of evidence on social representations in relation to MHI schemes. This initial attempt to compile evidence on social representations invites more research on the role those social representations play on the viability of MHI schemes. Our findings call for program design and implementation strategies to consider and adjust to local social representations in order to enhance scheme attractiveness.

Universal health insurance in Africa: a narrative review of the literature on institutional models

Introduction

Several African countries have introduced universal health insurance (UHI) programmes. These programmes aim to extend health insurance to groups that are usually excluded, namely informal workers and the indigent. Countries use different approaches. The purpose of this article is to study their institutional characteristics and their contribution to the achievement of universal health coverage (UHC) goals.

Method

This study is a narrative review. It focused on African countries with a UHI programme for at least 4 years. We identified 16 countries. We then compared how these UHI schemes mobilise, pool and use funds to purchase healthcare. Finally, we synthesised how all these aspects contribute to achieving the main objectives of UHC (access to care and financial protection).

Results

Ninety-two studies were selected. They found that government-run health insurance was the dominant model in Africa and that it produced better results than community-based health insurance (CBHI). They also showed that private health insurance was marginal. In a context with a large informal sector and a substantial number of people with low contributory capacity, the review also confirmed the limitations of contribution-based financing and the need to strengthen tax-based financing. It also showed that high fragmentation and voluntary enrolment, which are considered irreconcilable with universal insurance, characterise most UHI systems in Africa.

Conclusion

Public health insurance is more likely to contribute to the achievement of UHC goals than CBHI, as it ensures better management and promotes the pooling of resources on a larger scale.