Solidarity or Financial Sustainability

Abstract

Objectives: Although community-based health insurance (CBHI) seemed promising to improve access to health care, its implementation has been slow and laborious. We hypothesize that the existing tension between the competing objectives of solidarity and financial sustainability that are pursued by CBHI may partly account for this. This paper aims to evaluate if there is a gap between CBHI subscribers' values and their promoters', and to determine which characteristics of subscribers and CBHIs are associated with their values. Methods: A study of all Senegal CBHI organizations was undertaken in 2002. The analysis includes: 1) content of interviews with subscribers and promoters; and 2) multilevel logistical analysis of the links between characteristics of subscribers (n=394) and organizations (n=46) and composite indicators representing values (redistribution, solidarity when difficulties, solidarity between healthy and unhealthy). Results: Promoters emphasize financial sustainability; subscribers are split between financial sustainability and solidarity. Men, polygamous families and individuals with a lower socio-professional status are twice as likely to be in favour of redistribution; subscribers who participate in decision-making and those who think their CBHI is facing difficulties are less in favour of solidarity. At CBHI level, although the variance was significant, none of the variables were retained. Conclusion: More attention should be given to reducing the gap between promoters' and subscribers' values, and to increasing member participation in the processes involved in implementing CBHI. This could help all actors involved to understand and improve determinants of enrolment in, and performance of CBHI, thus increasing access to health care for vulnerable populations in developing countries.

Community-based health insurance programmes and the national health insurance scheme of Nigeria: challenges to uptake and integration

“…The large majority of papers were based on cross-sectional and/or household surveys, case studies and interviews. Two studies [ 12 , 13 ] were carried out from a provider perspective and highlighted problems with poor understanding of schemes by ministry staff and conflicts between subscriber and promoter values. Several studies focused on willingness to pay [ 14 - 17 ].…”

Community health insurance amidst abolition of user fees in Uganda: the view from policy makers and health service managers

“…In another study, conducted in Senegal, it was found that implementation of CHI schemes has been slow and laborious. This was explained in part by tension between the competing objectives pursued by both promoters and subscribers [ 7 ]. In addition to minimal knowledge and understanding of CHI by providers and policy implementers, studies have indicated that poor knowledge and understanding on the part of the schemes beneficiaries is also a contributing factor to low enrollment in Uganda [ 10 , 13 ].…”

“…Only two key studies in Africa have focused on knowledge and understanding of CHI by managers of health services. A study on the Maliando scheme in Guinea Conakry offered insight into perceptions of health providers at both operational and managerial levels [ 6 ], while another study looked at solidarity and financial sustainability based on an analysis of the values of CHI subscribers and promoters in Senegal [ 7 ].…”

Abolishing User Fees in Africa

“…A fundamental rule in programme evaluation is that “impact questions should ask whether a program achieved its ultimate objectives” [ 5 ]. A pre-payment scheme does aim to increase utilisation and, ultimately, help restore the health of its users.…”

“…In Rwanda, funding agencies sponsor free CBHI coverage for the worst-off, but research results are not yet available. In fact, it is well known that CBHI [ 4 , 5 ] and cost-recovery schemes based on user fees [ 6 ] are not concerned with the worst-off nor with equity.…”