The development of the community

The development of the community-based health insurance schemes in sub-Saharan
Africa: what are the real membership determinants?
Jacques Defourny and Julie Failon
(Centre d’Economie Sociale, Université de Liège, Belgium)
Currently, many countries in sub-Saharan Africa still experience a context of extreme
poverty and are facing serious health problems. Whereas healthcare services were previously
subsidized to a significant extent by the public sector, they have been based, since the
Bamako Initiative (1987), on the financial participation of users, according to a logic of cost
recovery. The progressive withdrawal of the states from the financing of healthcare systems
has had important consequences for the populations, in particular in the informal sector.
Moreover, the private insurance markets being insufficiently developed or inaccessible to
many individuals, large segments of the populations have no access to any health insurance
system. These groups, being deprived of any form of social protection, are financially unable
to benefit from good-quality healthcare services.
In an attempt to provide an answer to these difficulties, health micro-insurance
systems have been created for some fifteen years in sub-Saharan Africa. As a means of
improving the access of the poor to healthcare services, these systems constitute a relevant
alternative for the populations with no social protection. This is why they raise today a lively
interest on the part of many actors, both public and private. Although recent, this
phenomenon is gaining ground in the sub-region; the "Concertation", a platform bringing
together the actors supporting the development of community-based health insurances
(CBHI) schemes in Africa, has already listed 622 organizations in eleven French-speaking
countries of Western and Central Africa (Concertation, 2004). Since then many other
initiatives have been developed.
Nevertheless, many initiatives do not go beyond the experimental stage and are faced
with numerous obstacles in their development. It is estimated that the various health microinsurance systems currently reach together only about 1% of the population (Criel and
Waelkens, 2004). The present article will focus mainly on CBHI schemes, as they currently
constitute one of the most developed and successful forms of health micro-insurance
(Fonteneau, 2003; BIT/STEP, 2000) among the various projects, whose diversity is linked to
the variety of actors, organizational choices and operational mechanisms (Simpleton and
Gotsadze, 2003). Moreover, CBHI schemes can be analyzed from the perspective of the
social economy and solidarity-based economy, even though the concept of "third sector"
itself is being questioned, to a large extent, in sub-Saharan Africa (Defourny and Sarambe,
2007).
Despite the multiplication of these models, we have to acknowledge that the
enrolment rates remain particularly weak; coverage of the target population only rarely
reaches 10% (De Allegri et al., 2006). Many authors have already observed this fact and
undertaken research on the determinants of participation, by analyzing the factors which are
specific to membership (Atim, Criel, Waelkens, De Allegri, Dong, Fonteneau, Jütting, Tine,
Musango, Schneider… 1 ). Nevertheless, the methodologies used, size of the samples,
characteristics of the surveyed individuals, inclusion or not of non-members in the surveys,
1
Several of these authors have carried out various studies, sometimes working together (see references).
geographical areas etc. vary to a very significant extent from one author to the other. This is
why the first part of our article will consist in synthesizing the empirical studies carried out to
date and in drawing the main lessons from these various surveys and statistical processing,
beyond the methodological differences. We will thus take into account various variables,
such as the socio-economic characteristics of the households, financial capacity of the
populations, quality of the healthcare services, forms of enrolment, degree of trust toward the
CBHI scheme, geographical accessibility, information and awareness-rising campaigns and
presence of traditional self-help and solidarity systems.
In the second part of the article, we will fine-tune the interpretation of these results
through a more socio-anthropological analysis regarding the logics of the various actors
involved, their perceptions of the quality of the healthcare supply, as well as their
representations of illness. On the basis of a survey recently carried out by Failon (2007) in
Benin, we will thus try to understand the significances and the stakes underlying the
behaviours of the various partners within CBHI schemes.
As a conclusion, we will try to draw some major lessons regarding the roles of the
promoters and supporting NGOs in the establishment of CBHI schemes and in the
sustainability of the latter, in order to improve the access of sub-Saharan populations to
good-quality healthcare and to ensure them financial protection.
References
ATIM, C.,
2000, Contribution financière des mutuelles de santé au financement, à la
fourniture et à l’accès aux soins de santé : Synthèse de travaux de recherche menés dans
neuf pays d’Afrique de l’Ouest et du Centre, STEP, Bureau International du Travail, Genève.
BENNET, S., GOTSADZE, G.,
2003, « Le renforcement des capacités et la consolidation des
conditions de mise en œuvre au niveau communautaire », in DROR, D., PREKER, A. (sous la
direction de), 2003, Réassurance sociale. Stabiliser les micro-assurances santé dans les pays
pauvres, Editions ESKA, Washington DC, pp.225-244.
BIT/STEP,
2000, Micro-assurance santé. Guide d’introduction aux mutuelles de santé en
Afrique, Organisation internationale du Travail, Genève.
CONCERTATION,
2004, Inventaire des mutuelles de santé en Afrique. Synthèse des travaux de
recherche dans 11 pays, La Concertation entre les acteurs de développement des mutuelles
de santé en Afrique, Dakar (En ligne).
http://www.concertation.org
CRIEL, B., BLAISE, P., FERRETTE, D., 2006, « Mutuelles de santé en Afrique et qualité des soins
dans les services : une interaction dynamique », in DUSSAULT, G., FOURNIER, P., LETOURMY, A.
(éd.), 2006, L’assurance maladie en Afrique francophone : améliorer l’accès aux soins et
lutter contre la pauvreté, Banque mondiale, Washington DC, pp. 353-372.
CRIEL, B., WAELKENS, M.-P.,
2003, « Declining subscriptions to the Maliando Mutual Health
Organisation in Guinea-Conakry (West Africa): what is wrong? », Social Science Medicine,
vol. 57, n° 7, pp. 1205-1219.
CRIEL, B.,
1998, District-based health insurance in sub-Saharan Africa, Part II: Case-studies,
Studies in Health Services Organisation & Policy, Antwerp.
DE ALLEGRI, M., SANON, M., SAUERBORN, R.,
2006, « “To enrol or not enrol?”: A qualitative
investigation of demand for health insurance in rural West Africa », Social Science Medicine,
62 (6), pp. 1520-1527.
DE ALLEGRI, M., KOUYANTÉ, B., BECKER, H., GBANGOU, A., POKHREL, S., SANON, M.,
SAUERBORN, R., 2006, « Understanding enrolment in community health insurance in sub-
Saharan Africa: a population-based case-control study in rural Burkina Faso », Bulletin
World Health Organisation, 84 (11), pp. 852-858.
DE ALLEGRI, M., SANON, M., BRIDGES, J., SAUERBORN, R.,
2006, « Understanding consumers’
preferences and decision to enrol in community-based health insurance in rural West
Africa », Health Policy, 76(1), pp. 58-71.
DEFOURNY, J.
& SARAMBE, I., 2007, « Les approches de l’économie sociale et solidaire face
aux mutuelles de santé en Afrique », Centre d’Economie Sociale, Université de Liège.
DONG, H. et
al., 2003, « Willigness-to-pay for community-based insurance in Burkina Faso »,
Health economics, 12, pp. 849-862.
DUBOIS, F.,
2002, Les déterminants de la participation aux mutuelles de santé : Etude
appliqué à la mutuelle Leeré Laafi Bolem de Zabré, DES en Gestion du Développement,
Université de Liège.
FAILON, J.,
2007, Approche socio-anthropologique de la micro-assurance santé. Etude de
deux systèmes au Bénin, Institut des Sciences Humaines et Sociales, Université de Liège.
FONTENEAU, B.,
2003, Les défis des politiques de micro-assurance santé en Afrique de
l’Ouest. Cadre politique, environnement institutionnel, fonctionnement et viabilité, Hoger
Instituut voor de arbeid, Leuven.
JÜTTING, J.,
2005, Health insurance for the poor in developing countries, Ashgate publishing,
England.
MUSANGO, L., MARTINY, P., PORIGNON, D., DUJARDIN, B.,
2004, « Le profil des membres et des
non membres des mutuelles de santé du Rwanda : le cas du district sanitaire de Kabutare »,
Cahier de santé, vol. 14, n° 2, pp. 93-99.
NYSSENS, M., VERMER, M.-C., WÉLÉ, P.,
2007, « La régulation des mutuelles de santé au
Bénin », GRAP/OSC, Louvain-la-Neuve.
SCHNEIDER, P.,
2005, « Trust in micro-health insurance: an exploratory study in Rwanda »,
Social Science & Medicine, 61, pp. 1430-1438.
WAELKENS, M.-P., CRIEL, B.,
2002, « Etude de la perception sociale de MUCAS Maliando »,
in : Le projet PRIMA en Guinée Conakry. Une expérience d’organisation de mutuelles de
santé en Afrique rurale, CRIEL, B., BARRY, A., VON, ROENNE, F., 2002, Bruxelles, Medicus
Mundi Belgique.
WAELKENS, M.-P., CRIEL, B.,
2004, Les mutuelles de santé en Afrique subsaharienne. Etat des
lieux et réflexions sur un agenda de recherche, HNP Discussion Paper, Banque Mondiale,
Washington DC.