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

Abstract

IntroductionImplemented in 2013 in Senegal, theProgramme 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.MethodsWe 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.ResultsWith 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.ConclusionWe 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 impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence

“…Insurance increased the total number of ANC visits during pregnancy. The magnitude of positive significant impact of health insurance on the number of ANC during pregnancy ranged from 43% [47] to 56% [48]. On the other hand, insurance did not have a significant positive impact on having an ANC visit in the first trimester except for Indonesia [46].…”

“…Additionally, there was a multi-country study that encompassed three countries: Ghana, Rwanda, and Indonesia [46]. Most studies (n = 14) were nationally representative of the population, while the remaining three were carried out in specific region(s) within the specified country [42,48,49]. Three studies were specifically conducted in rural settings [42,48,49], and no studies focused on urban settings exclusively.…”

“…Most studies (n = 14) were nationally representative of the population, while the remaining three were carried out in specific region(s) within the specified country [42,48,49]. Three studies were specifically conducted in rural settings [42,48,49], and no studies focused on urban settings exclusively. The rest of the studies (n = 14) covered both rural and urban areas.…”

“…Specifically, 85.7% of the studies found a significant positive impact between health insurance and delivery with assistance from a skilled attendant, 83.3% reported a significant positive impact on delivery at a health facility, and 75.0% indicated a significant positive impact on having at least four ANC visits during pregnancy. In contrast, the evidence on the impact of health insurance on contraceptive use [40], postnatal care [36,38,40,41,45] and financial protection [43,48,50] indicators was scanty, variable and inconclusive. Certain indicators (ANC at health facility, postnatal care visit at health facility in less than 2 months after delivery, OOPE due to ANC, and OOPE due to PNC) were not included in the analysis, because these indicators were only reported in articles that were excluded due to their serious risk of bias.…”

Improving healthcare accessibility for pregnant women and children in the context of health system strengthening initiatives and terrorist attacks in Central Mali: a controlled interrupted time series analysis

“… 14 For the latter, it intends to develop its system of community-based health insurance (CBHI). Given the state of international knowledge on the inefficiency of these CBHI, and the challenges of the ability to pay membership by populations, 15 16 the State decided, as in Senegal, 17 to subsidise membership at 50%.…”