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

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 programmes 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 organizations' (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 enrolees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrolees 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 enrolees 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 professionalizing 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.

Reforms for financial protection schemes towards universal health coverage, Senegal.

Advancing the public health insurance system is one of the key strategies of the Senegalese government for achieving universal health coverage. In 2013, the government launched a universal health financial protection programme, la Couverture Maladie Universelle. One of the programme's aims was to establish a community-based health insurance scheme for the people in the informal sector, who were largely uninsured before 2013. The scheme provides coverage through non-profit community-based organizations and by the end of 2016, 676 organizations had been established across the country. However, the organizations are facing challenges, such as low enrolment rates and low portability of the benefit package. To address the challenges and to improve the governance and operations of the community-based health insurance scheme, the government has since 2018 planned and partly implemented two major reforms. The first reform involves a series of institutional reorganizations to raise the risk pool. These reorganizations consist of transferring the risk pooling and part of the insurance management from the individual organizations to the departmental unions, and transferring the operation and financial responsibility of the free health-care initiatives for vulnerable population to the community-based scheme. The second reform is the introduction of an integrated management information system for efficient and effective data management and operations of the scheme. Here we discuss the current progress and plans for future development of the community-based health insurance scheme, as well as discussing the challenges the government should address in striving towards universal health coverage in the country.

Faire progresser le système public d'assurance maladie est l'une des principales stratégies du gouvernement sénégalais, qui ambitionne de rendre les soins de santé accessibles à tous. En 2013, le gouvernement a lancé un programme de protection financière global en la matière, la Couverture Maladie Universelle. L'un des objectifs de ce programme consistait à établir un régime communautaire d'assurance maladie pour les personnes appartenant au secteur informel, encore largement non assurées auparavant. Ce régime fournit une couverture par le biais d'organismes communautaires sans but lucratif. Fin 2016, 676 organismes de ce type avaient été créés aux quatre coins du pays. Néanmoins, ces organismes sont confrontés à des défis tels que le faible taux d'inscription et la transférabilité réduite de la gamme d'avantages sociaux. Pour y remédier, mais aussi pour améliorer la gouvernance et les opérations du régime communautaire d'assurance maladie, le gouvernement a planifié et partiellement appliqué deux réformes d'envergure depuis 2018. La première implique une série de réorganisations institutionnelles afin d'accroître la mutualisation des risques. Ces réorganisations consistent à transférer la mutualisation des risques et une partie de la gestion de l'assurance de chacun des organismes vers les unions départementales, et à confier au régime communautaire la responsabilité financière et la mise en œuvre des initiatives destinées à prodiguer des soins de santé aux populations les plus vulnérables. La seconde prévoit l'introduction d'un système de gestion intégrée de l'information afin d'administrer les données et les opérations plus rapidement et avec davantage d'efficacité. Dans ce document, nous évoquons les progrès actuels et les projets de développement futur du régime communautaire d'assurance maladie. Nous traitons également des défis que le gouvernement doit relever, ainsi que des efforts déployés pour offrir une couverture maladie universelle à l'ensemble du territoire.

La promoción del sistema público de seguro médico es una de las estrategias clave del Gobierno senegalés para lograr la cobertura sanitaria universal. En 2013, el gobierno lanzó un programa de protección financiera universal de la salud, la Couverture Maladie Universelle. Uno de los objetivos del programa era establecer un sistema comunitario de seguro médico para las personas del sector informal, que en su mayoría no tenían seguro antes de 2013. El sistema proporciona cobertura a través de organizaciones comunitarias sin fines de lucro y, a finales de 2016, se habían establecido 676 organizaciones en todo el país. Sin embargo, las organizaciones se enfrentan a desafíos, como las bajas tasas de inscripción y la baja portabilidad del paquete de prestaciones. Para hacer frente a los desafíos y mejorar la gobernanza y el funcionamiento del sistema comunitario de seguro médico, desde 2018 el Gobierno ha planificado y aplicado parcialmente dos reformas importantes. La primera reforma implica una serie de reorganizaciones institucionales para elevar las fuentes de riesgo. Estas reorganizaciones consisten en la transferencia de la mancomunación de riesgos y parte de la gestión de los seguros de las distintas organizaciones a los sindicatos departamentales, y en la transferencia de la operación y la responsabilidad financiera de las iniciativas de atención gratuita de la salud para la población vulnerable al sistema comunitario. La segunda reforma consiste en la introducción de un sistema integrado de información de gestión para una gestión de datos y un funcionamiento eficientes y efectivos del sistema. Aquí se discuten los avances actuales y los planes para el desarrollo futuro del sistema comunitario de seguro médico, así como los desafíos que el gobierno debe abordar en su lucha por lograr la cobertura sanitaria universal en el país.

Reforms for financial protection schemes towards universal health coverage, Senegal

Advancing the public health insurance system is one of the key strategies of the Senegalese government for achieving universal health coverage. In 2013, the government launched a universal health financial protection programme, la Couverture Maladie Universelle. One of the programme's aims was to establish a community-based health insurance scheme for the people in the informal sector, who were largely uninsured before 2013. The scheme provides coverage through non-profit community-based organizations and by the end of 2016, 676 organizations had been established across the country. However, the organizations are facing challenges, such as low enrolment rates and low portability of the benefit package. To address the challenges and to improve the governance and operations of the community-based health insurance scheme, the government has since 2018 planned and partly implemented two major reforms. The first reform involves a series of institutional reorganizations to raise the risk pool. These reorganizations consist of transferring the risk pooling and part of the insurance management from the individual organizations to the departmental unions, and transferring the operation and financial responsibility of the free health-care initiatives for vulnerable population to the community-based scheme. The second reform is the introduction of an integrated management information system for efficient and effective data management and operations of the scheme. Here we discuss the current progress and plans for future development of the community-based health insurance scheme, as well as discussing the challenges the government should address in striving towards universal health coverage in the country

Informed push distribution of contraceptives in Senegal reduces stockouts and improves quality of family planning services.

Contraceptive use in Senegal is among the lowest in the world and has barely increased over the past 5 years, from 10% of married women in 2005 to 12% in 2011. Contraceptive stockouts in public facilities, where 85% of women access family planning services, are common. In 2011, we conducted a supply chain study of 33 public-sector facilities in Pikine and Guediawaye districts of the Dakar region to understand the magnitude and root causes of stockouts. The study included stock audits, surveys with 156 consumers, and interviews with facility staff, managers, and other stakeholders. At the facility level, stockouts of injectables and implants occurred, on average, 43% and 83% of the year, respectively. At least 60% of stockouts occurred despite stock availability at the national level. Data from interviews revealed that the current "pull-based" distribution system was complex and inefficient. In order to reduce stockout rates to the commercial-sector standard of 2% or less, the Government of Senegal and the Senegal Urban Reproductive Health Initiative developed the informed push distribution model (IPM) and pilot-tested it in Pikine district between February 2012 and July 2012. IPM brings the source of supply (a delivery truck loaded with supplies) closer to the source of demand (clients in health facilities) and streamlines the steps in between. With a professional logistician managing stock and deliveries, the health facilities no longer need to place and pick up orders. Stockouts of contraceptive pills, injectables, implants, and intrauterine devices (IUDs) were completely eliminated at the 14 public health facilities in Pikine over the 6-month pilot phase. The government expanded IPM to all 140 public facilities in the Dakar region, and 6 months later stockout rates throughout the region dropped to less than 2%. National coverage of the IPM is expected by July 2015.

Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal.

BACKGROUND: Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SP's acceptability is unknown. We measured acceptability of SP among DMPA IM users. STUDY DESIGN: This open-label observational study was conducted in clinics in three districts in Senegal and community-based distribution services in two districts in Uganda. Experienced DMPA IM users were offered SP by community health workers (CHWs) or clinic-based providers. SP decliners were asked to discuss their reasons. Those who received SP were interviewed pre- and postinjection and 3 months later, when they were asked if they would select SP over DMPA IM if it were available. RESULTS: One hundred twenty women in Uganda and 242 in Senegal received SP (117 and 240 were followed up, respectively). Nine Ugandan and seven Senegalese SP decliners were interviewed. Three months after receiving SP, 84% [95% confidence interval (CI)=75%-93%] of Ugandan participants and 80% (95% CI=74%-87%) of Senegalese participants said they would select SP over DMPA IM. Main reasons for selecting SP were fewer side effects, liking the method, fast administration, less pain and method effectiveness. Thirty-four adverse events were reported but were not serious. No pregnancies were reported. CONCLUSION: Current DMPA IM users in Senegal and Uganda accepted SP, and most preferred SP over DMPA IM. SP can be safely introduced into FP programs and administered by trained CHWs, with expectation of client uptake. IMPLICATIONS: We found SP acceptable and safe in diverse settings among current intramuscular DMPA users, including those who received SP from CHWs. This provides evidence that SP would be used and could therefore reduce unmet family planning needs if introduced into family planning programs.

Provider acceptability of Sayana® Press: results from community health workers and clinic-based providers in Uganda and Senegal.

BACKGROUND: Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SP's acceptability is unknown. We measured acceptability of SP among clinic-based providers (Senegal only) and community health workers. STUDY DESIGN: This open-label observational study was conducted in clinics in three districts in Senegal and community-based services in two districts in Uganda. Providers administered SP to clients seeking reinjection of DMPA IM. We conducted in-depth interviews with 86 providers (52 in Senegal, 34 in Uganda) to assess their experiences providing SP to clients. RESULTS: Almost all providers (84/86; 98%) preferred SP over DMPA IM. The main reason Uganda providers preferred SP was the prefilled/all-in-one design made preparation and administration easier and faster. Some providers thought the SP all-in-one feature may decrease stock outs (DMPA IM requires syringe and vial). Providers also felt clients preferred the shorter SP needle because it is less intimidating and less painful. Similarly, the main reasons Senegal providers preferred SP were its characteristics (prefilled/all-in-one) and client preference (especially less pain). They also saw a potential to increase access to FP, especially through community-based distribution. Providers from both countries reported SP introduction would be enhanced through client counseling and community engagement. Providers also said SP must be accessible, affordable and in stock. CONCLUSION: Almost all providers preferred SP over DMPA IM. Provider recommendations should be considered during SP introduction planning. IMPLICATIONS: We found that SP was acceptable to both clinic-based FP providers and community health workers. Providers' positive attitudes towards SP may facilitate introduction and uptake of this method.