The impact of stakeholder values and power relations on community-based health insurance coverage: qualitative evidence from three Senegalese case studies

Abstract

Continued low rates of enrolment in community-based health insurance (CBHI) suggest that strategies proposed for scaling up are unsuccessfully implemented or inadequately address underlying limitations of CBHI. One reason may be a lack of incorporation of social and political context into CBHI policy. In this study, the hypothesis is proposed that values and power relations inherent in social networks of CBHI stakeholders can explain levels of CBHI coverage. To test this, three case studies constituting Senegalese CBHI schemes were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. The five most important themes pertaining to social values and power relations were: voluntarism, trust, solidarity, political engagement and social movements. Analysis of these themes raises a number of policy and implementation challenges for expanding CBHI coverage. First is the need to subsidize salaries for CBHI scheme staff. Second is the need to develop more sustainable internal and external governance structures through CBHI federations. Third is ensuring that CBHI resonates with local values concerning four dimensions of solidarity (health risk, vertical equity, scale and source). Government subsidies is one of the several potential strategies to achieve this. Fourth is the need for increased transparency in national policy. Fifth is the need for CBHI scheme leaders to increase their negotiating power vis-à-vis health service providers who control the resources needed for expanding CBHI coverage, through federations and a social movement dynamic. Systematically addressing all these challenges would represent a fundamental reform of the current CBHI model promoted in Senegal and in Africa more widely; this raises issues of feasibility in practice. From a theoretical perspective, the results suggest that studying values and power relations among stakeholders in multiple case studies is a useful complement to traditional health systems analysis.

Linking communities to formal health care providers through village health teams in rural Uganda: lessons from linking social capital

“…This largely left the VHTs dependent on the formal health care providers for executing the referrals. In Senegal, Mladovsky et al found that the dependency of community-based health insurance (CBHI) schemes on hospitals left the CBHI schemes with little negotiating power for their goals and interest [57]. In countries like Pakistan, the Lady Health Worker programme was hailed as effective partly because the programme invested in, among other things, maintaining strong ties with existing community resources such as traditional birth attendants [5].…”

“…However, this study also shows that attention needs to paid to how the incentives given to the CHWs can affect the trust of community members over time. Mladovsky et al, for example, show that ‘volunteering by CBHI staff built trust in CBHI among the target population.’ ([57] p. 776). While the VHTs were recruited as volunteers, some community members perceived them as drawing salaries from the government, and in practice, their work is facilitated leading to a perception that they occupy a privileged position.…”

Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo

“…These findings are consistent with previous study results highlighting the weak bargaining power of MHOs in their relationship with providers. Reasons evoked in this earlier work are their relative insignificance for hospital finances [23], a position of monopoly of providers in rural areas [24], and power imbalances [25,26].…”

Understanding the limitations of “quasi‐mandatory” approaches to enrolment in community‐based health insurance: Empirical evidence from Tanzania

“…By design, the voluntary aspect was very clear; but when it came to implementation, the responsibilities were left to local government leaders, who created a sense of compulsory enrolment in some areas. Although the involvement of community leaders may have had a positive impact on the uptake of CBHI schemes, sometimes, they exerted coercive mechanisms that may have contradicted the voluntary nature of CBHI schemes . In our case, we have seen imposed participation (both by design and by practice) that created a sense of obligation for some participants in both CHF cases.…”

“…The common demand side features that influence enrolment decisions include social‐economic and demographic factors, especially those related to access to and quality of healthcare; knowledge on health insurance; and willingness and ability to pay . On the supply side, attention has been paid to schemes' design and management issues, where premium prices, benefit packages, methods of premium collection, and administration capabilities have been reported to affect CBHI uptake . The voluntary nature of CBHI schemes has also been described as challenging their sustainability, since people who experience illness appear to be more interested, resulting in a low rate of participation of healthy population groups .…”