Operational and Structural Factors Influencing Enrolment in Community-Based Health Insurance Schemes: An Observational Study Using 12 Waves of Nationwide Panel Data from Senegal

Scaling Up Departmental Health Insurance Units in Senegal: A Mixed-Method Study

In response to the failure of community-based health insurance (CBHI) at the municipal level, some African countries are implementing district or departmental CBHIs to improve universal health coverage. After creating two CBHIs at the departmental level in 2014, Senegal launched a campaign to disseminate the model in 2022. This article presents the stakeholders' perspectives on the factors and challenges of scaling up CBHI departmentalization in Senegal. The study uses a mixed-methods approach, utilizing concept mapping and a focus group to examine scaling up departmentalization. The sample size consists of 22 individuals involved in the process. The quantitative analysis includes hierarchical cluster analysis, multidimensional scaling analysis, and the Pearson coefficient test. The qualitative analysis involves content analysis to triangulate the findings. Participants identified 125 factors to consider for the departmentalization of CBHI. They were categorized into nine clusters according to their degree of importance (I) and ease to organize (F): service package (I: 4.07; F: 2,26), communication (I: 4.05; F: 2.96), governance (I: 3.96; F: 2,94), human and logistical resources (I: 3.94; F: 2,82), financing (I: 3.90; F: 2,31), involvement of the authorities (I: 3.82; F: 2.75), community involvement (I: 3.81; F: 2.76), membership (I: 3.70; F: 2.24, strategic planning and implementation (I: 3.57; F: 2,62). The main challenges faced were a process perceived as precipitous and vertical and needing more negotiation and consultation. The conditions for accompaniment and public funding availability need to be sufficiently considered. The study proposes avenues for action to promote the scaling up of CBHI departmentalization in Senegal.

Combining social protection interventions for better food security: Evidence from female-headed households in Amhara region, Ethiopia

Ethiopia introduced its flagship poverty-targeted social protection program, the Productive safety net program (PSNP), in 2005 and Community-Based Health Insurance (CBHI) in 2011. Although both programs operate in several districts with some overlaps, evidence is scarce on how these large-scale programs jointly affect the food security of vulnerable groups. This study examines the impacts of a combination of these programs on food security outcomes among female-headed households in a chronically food-insecure and drought-prone district. Cross-sectional data were collected from 365 female-headed households selected through multi-stage sampling technique and analyzed using Inverse-probability-weighted regression adjustment (IPWRA) strategy to assess the effect of the programs on food security. The results show that while 63.6% of sample households are enrolled in CBHI and 48.8% are beneficiaries of PSNP's conditional cash transfer (CCT) component, membership in both social protection programs was 38.9%. The IPWRA analysis finds that inclusion in the CCT combined with CBHI, on average, increased dietary diversity score by 0.918 (95% CI 0.779-1.057) and food consumption score by 0.576 (95% CI 0.464-0.688). It also reduced household food insecurity access scale by 8.658 (95% CI -9.775 - -7.541). In all assessments, a combination of CBHI and CCT always produced results of a larger magnitude than each of CBHI and CCT alone. The findings provide evidence of the potentials of integrating social protection programs to increase food security outcomes among the most vulnerable and marginalized groups in a developing country. In addition, the results have also useful implications to achieve sustainable development goals related to ending hunger and achieving food security among vulnerable groups.

External influences over Senegalese health financing policy: delaying universal health coverage?

Senegal has long sought solutions to achieve universal health coverage (UHC). However, in a context dependent on international aid, the country faces multiple external pressures to choose policy instruments. In this commentary, we propose an analysis of this influence. The empirical material comes from our involvement in analysing health reforms for 20 years and from many interviews and observations. While studies have shown that community-based health insurance (CBHI) was not an appropriate solution for UHC, some international actors have influenced their continued application. Another global partner proposed an alternative (professional and departmental CBHI), which was counteracted and delayed. These issues of powers and influences of international and national consultants, established in a neo-liberal approach to health, have lost at least a decade from UHC in Senegal. The alternative now appears to be acquired and is scaling up at the country level, witnessing a change in the current policy paradigm.

Innovations in mutuality: challenges and learnings for the Universal Health Insurance Plan in Mali

BACKGROUND

Many Sahel countries in Africa are looking for solutions for universal health coverage (UHC). Mali is in the process of adopting the Universal Health Insurance Plan, which allows for the mutualisation of existing schemes. Its operationalisation requires numerous adjustments to the current mutualist proposal and innovations in the system. The study focuses on innovations experienced in mutuality and their conditions of scale for UHC in Mali.

METHODS

This is qualitative research by multiple case studies. It is based on the collection of data by interviews (n=136), at a national and local level, on the analysis of documents (n=42) and a long field observation (7 months). The analytical framework concerns the dissemination and maintenance of health innovations (Greenhalgh et al, 2004).

RESULT

The analysis of this innovation shows an interest in the technical and institutional viability that determines its performance and scale-up. The procrastination and scepticism displayed at the highest level of the state and the international level, the reluctance, both financial and ideological, to renew the old mutualist proposal, penalise this Malian experiment.

CONCLUSION

This innovation is a decisive step in ensuring the health coverage of Mali's agricultural and informal sectors. The reform will need to be amplified and supported in the future to expect the scale-up of a cheaper, technically and institutionally more efficient system. Without a political intention to mobilise national resources and accept a fundamental paradigm shift in health financing, the search for the financial viability of mutuality may, again, be at the expense of the performance.

Effects of a free health insurance programme for the poor on health service utilisation and financial protection in Senegal

INTRODUCTION

Implemented in 2013 in Senegal, the Programme National de Bourses de Sécurité Familiale (PNBSF) is a national cash transfer programme for poor households. Besides reducing household poverty and encouraging children's school attendance, an objective of the PNBSF is to expand health coverage by guaranteeing free enrolment in community-based health insurance (CBHI) schemes. In this paper, we provide the first assessment of the PNBSF free health insurance programme on health service utilisation and health-related financial protection.

METHODS

We collected household-level and individual-level cross-sectional data on health insurance in 2019-2020 within the Niakhar Population Observatory in rural Senegal. We conducted a series of descriptive analyses to fully describe the application of the PNBSF programme in terms of health coverage. We then used multivariate logistic and Poisson regression models within an inverse probability weighting framework to estimate the effect of being registered in a CBHI through the PNBSF-as compared with having no health insurance or having voluntarily enrolled in a CBHI scheme-on a series of outcomes.

RESULTS

With the exception of health facility deliveries, which were favoured by free health insurance, the PNBSF did not reduce the unmet need for healthcare or the health-related financial risk. It did not increase individuals' health service utilisation in case of health problems, did not increase the number of antenatal care visits and did not protect households against the risk of forgoing medical care and of catastrophic health expenditure.

CONCLUSION

We found limited effects of the PNBSF free health insurance on health service utilisation and health-related financial protection, although these failures were not necessarily due to the provision of free health insurance per se. Our results point to both implementation failures and limited programme outcomes. Greater commitment from the state is needed, particularly through strategies to reduce barriers to accessing covered healthcare.

The resilience of two departmental health insurance units during the COVID-19 pandemic in Senegal

BACKGROUND

In its pursuit of solutions for universal health coverage (UHC), Senegal has set up two departmental health insurance units (UDAMs) since 2014. Few studies on the resilience of health systems in Africa have examined health insurance organisations. This article aims to understand how these two UDAMs have been resilient during the COVID-19 pandemic and the restrictive measures imposed by the State to maintain services to their members and reimbursements to healthcare providers.

METHODS

This study was a multicase study with multiple levels of analysis using a conceptual framework of resilience and analysis of organisational configurations. Empirical data are derived from document analysis, observations for 6 months and 17 qualitative in-depth interviews.

RESULTS

The results identified three main configurations concerning (1) safety and hygiene, (2) organisation and planning and (3) communication for sustainable payment. The UDAM faced the pandemic with resilience processes to absorb the shock and maintain service to their members. The UDAM learnt positive lessons from crisis management, such as remote work or the ability to support members in their care in hospitals away from their headquarters. They have innovated (transformative resilience) with the organisation of electronic payment and the use of social networks to raise funds and communicate with members. Strengthening their effectiveness after the shock of the departure of the donors in 2017 contributed to the adaptation and even transformation from the pandemic shock of 2020 and 2021. The study shows that leadership, team dynamics and adaptation to contexts are drivers of resilience processes.

CONCLUSION

Both UDAMs adapted to the shocks of the pandemic and government measures to maintain the services of their members and their organisational routine. This resilience confirms that UDAMs are one of the possible solutions for UHC in the Sahel.

Factors determining membership in community-based health insurance in West Africa: a scoping review

BACKGROUND

In many low-income countries, households bear most of the health care costs. Community-based health insurance (CBHI) schemes have multiplied since the 1990s in West Africa. They have significantly improved their members' access to health care. However, a large proportion of users are reluctant to subscribe to a local CBHI. Identifying the major factors affecting membership will be useful for improving CBHI coverage. The objective of this research is to obtain a general overview of existing evidence on the determinants of CBHI membership in West Africa.

METHODS

A review of studies reporting on the factors determining membership in CBHI schemes in West Africa was conducted using guidelines developed by the Joanna Briggs Institute. Several databases were searched (PubMed, ScienceDirect, Global Health database, Embase, EconLit, Cairn.info, BDPS, Cochrane database and Google Scholar) for relevant articles available by August 15, 2022, with no methodological or linguistic restrictions in electronic databases and grey literature.

RESULTS

The initial literature search resulted in 1611 studies, and 10 studies were identified by other sources. After eliminating duplicates, we reviewed the titles of the remaining 1275 studies and excluded 1080 irrelevant studies based on title and 124 studies based on abstracts. Of the 71 full texts assessed for eligibility, 32 additional papers were excluded (not relevant, outside West Africa, poorly described results) and finally 39 studies were included in the synthesis. Factors that negatively affect CBHI membership include advanced age, low education, low household income, poor quality of care, lack of trust in providers and remoteness, rules considered too strict or inappropriate, low trust in administrators and inadequate information campaign.

CONCLUSIONS

This study shows many lessons to be learned from a variety of countries and initiatives that could make CBHI an effective tool for increasing access to quality health care in order to achieve universal health coverage. Coverage through CBHI schemes could be improved through communication, improved education and targeted financial support.

Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders

Background

Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.

Methods

This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.

Results

The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.

Conclusions

Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.