In an effort to establish universal health coverage (UHC), Senegal set up two departmental health insurance units (UDAM) to scale‐up health insurance to rural communities. Part of this innovation meant that health insurance was no longer managed by volunteers, but by professionals. Several years after the conclusion of the project in 2017 that supported their initial development, both UDAMs still operate successfully. This mixed methods research aims to understand the factors that have contributed to the sustainability of both UDAMs, as well as discuss the remaining challenges. The factors deemed favourable to sustainability are actions undertaken to ensure financial stability and organizational risk taking. However, the mobilization of the population, relationships with health professionals and the role of the State have been more difficult to organize. Challenges concern the payment of subsidies and the supply of medicines by the State and partnership with the health care system, the maintenance of contributions, the digitalization of administration, as well as fraud and abuse.

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