Operational and structural factors influencing enrolment in community-based health insurance schemes: an observational study using 12 waves of nationwide panel data from Senegal

Abstract

Community-based health insurance (CBHI) has been implemented in many low and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programs is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes—also termed ‘mutual health organisations’ (MHO) in francophone countries—and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017–2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrollees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrollees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrollees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (−16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalising and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time.

Factors that foster and challenge the sustainability of departmental health insurance units in Senegal

“…Yet, the State has understood the importance of professionalization in the management of CBHIs and, in 2017, decided to finance (only) 6 months’ salary for a (single) manager in each CBHI in the country. While this contribution remains minimal and far from the situation of the UDAMs, recent research among 618 CBHIs in 43 departments of the country (excluding the two UDAMs) confirms the relevance of an approach based on professionalization to make them more effective and efficient (Rouyard et al, 2022).…”

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

“…Studies highlighted two dimensions of the target population’s confidence in CBHI: on the one hand, confidence in the management of the system which depends on the skills and integrity of the CBHI managers, and on the other hand, confidence in the ability of the CBHI scheme to achieve its stated objectives. The target populations frequently adopt a cautious attitude at the launch of a CBHI scheme, preferring to observe before participating [ 15 – 17 , 23 , 28 , 34 , 35 , 43 , 45 – 48 ]. Other studies indicate that doubts about the honesty of the CBHI leaders or previous experiences with embezzlement may have a negative impact on membership [ 19 , 35 , 42 , 43 , 45 – 48 ].…”

“…The target populations frequently adopt a cautious attitude at the launch of a CBHI scheme, preferring to observe before participating [ 15 – 17 , 23 , 28 , 34 , 35 , 43 , 45 – 48 ]. Other studies indicate that doubts about the honesty of the CBHI leaders or previous experiences with embezzlement may have a negative impact on membership [ 19 , 35 , 42 , 43 , 45 – 48 ].…”

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

“…Important factors may be the presence of financing shortfalls of the PNBSF programme, the lack of professionalisation of the Senegalese CBHI management, 49 or the operational capacity of the CBHI organisations. 50 …”