Understanding demand for
community-based health insurance
in Senegal: The role of social capital
and related determinants
Philipa Mladovsky
16th March 2011
AfHEA, Saly
Outline
• Background to CBHI in LMIC
• Aims of study and methods
• Results
• Conclusions
Why is community based health insurance (PHI)
needed in low and middle income countries (LMIC)?
• OOP on health: between 30 – 40% for all LMIC
regions except South Asia where around 50%
• High levels of OOP reduce access to health
care, especially among the poorest, and
increase catastrophic expenditure
• Need to reduce OOP by developing
prepayment mechanisms: what form should
these take?
CBHI
• CBHI provides financial protection from the
cost of seeking health care at the point of use.
• Three main features:
– prepayment of a premium for health services by
individuals or families;
– community control (NGOs, religious, womens’
organisations etc)
– and voluntary membership
Rapid growth of CBHI schemes
Countries
1997
2000
2003
Estimation 2006
11
23
42
120
6
26
35
60
18
20
22
30
Côte d'Ivoire
0
29
36
47
Guinée
6
27
55
90
Mali
7
22
51
102
Mauritanie
0
0
3
5
Niger
6
12
9
19
19
29
79
130
Tchad
3
4
7
11
Togo
0
7
9
12
Total
76
199
348
626
Bénin
Burkina Faso
Cameroun
Senegal
Source : Inventaires de la Concertation (www.concertation.org)
But limited population coverage…
• 95% of the schemes have fewer than 1000 members –
so under 1 million people enrolled in 11 African
countries in 2006
• …is CBHI a viable policy option?
Aims of study
•
Understand demand (or lack thereof) for CBHI
•
Existing conceptual frameworks:
a) Neo-liberal economic framework
•
Focuses on e.g. willingness-to-pay, information, quantity & price (Dror,
2001; Pauly, 2004; Preker, 2004; Zweifel, 2004)
b) Institutional economics or ‘health system’ framework
•
Focuses on broader institutional context, analyzing e.g. interactions
between insureds, insurance schemes, health service providers and
the state (Bennett, 2004a, 2004b; Criel et al., 2004; ILO, 2002)
Limitations of the conceptual frameworks
• Both models are based on concept of rational
utility maximizing homo economicus
• Rational individualist model does not
systematically explain the effect of social
context on CBHI
What is social capital?
• Definition debated but useful starting point:
“the information, trust and norms of reciprocity
inhering in one’s social network” (Woolcock,
1998):153
• Empirical studies suggest that higher levels of
social capital are positively correlated with
improved development outcomes – the
‘missing link’?
MUCAPS case studies
CBHI
scheme
and region
1. Soppante
(Thies)
2. Ndondol
Geographic
context
Membership
profile
Rural, covers
several
districts
•Formal and
informal sector
workers
• Mixed
ethnicities
•Mixed religions
• Primary
care
•
Secondary
care
•Agricultural
sector
•One ethnic
group (Serer)
• Mixed religions
• Linked to a
micro-credit
scheme
• Primary
care
• Mainly women
• Petty traders
• Associational
membership
• Mixed
ethnicities
• Mixed religions
• Primary
care
Rural, covers
one district
(Diourbel)
3. Wer Ak
Werle
(Dakar)
Urban /
peri-urban,
covers 2
districts
*Includes current members and ex members
Benefits
Membershi
p fee and
premium
1,000 CFA
family
membership
card
%
current
members
Number of
members*
(households) & %
population
coverage
Estimated
target
populatio
n (households)
985 (30%)
3,333
20%
1997
464 (21%)
2,166
29%
2001
678 (5%)
13,604
41%
2000
Year of
initiatio
n
200 CFA /
month /
beneficiary
1,000 CFA
family
membership
card
150 CFA /
month /
beneficiary
1,000 CFA
family
membership
card
200 CFA /
month /
beneficiary
Methodology
• Household survey
• Stratified sampling:
Soppante
Sample
Ndondol
Wer Ak Werle
NM
M
NM
M
NM
M
103
138
125
116
112
126
Significant results:
Household level:
• HH age
• Expenditure
• Wealth
• Membership of
associations
• Expenditure on
associations
Individual level:
• Is a godparent
• Has homonyms
• Believes
cooperation likely
Soppante
HH age <40
HH age 40-49
HH age 50-59
HH age 60-69
HH age >70
Female HH
HH size <5
HH size 5-8
HH size 9-12
HH size 13-16
HH size >16
Polygamous HH
Ex low
Ex q2
Ex q3
Ex q4
Ex high
Wealth low
Wealth q2
Wealth q3
Wealth high
HH no ed
HH literate
HH primary ed
HH second ed
Disability
Chronic illness
Recent illness
Christian
Muslim
Mixed relig
Wolof
Poular
Serer
Mixed eth
Other eth
Assoc 0
Assoc 1-5
Assoc 6-10
Assoc increase
Assoc stable
Assoc decrease
Contrib <€1.5
Contrib €1.5 - 7.4
Contrib >€7.5
Godparent
Homonym
Lend money
Borrow money
Others distant
Others close
Others v close
Control decision low
Control decision 2
Control decision 3
Control decision 4
Control decision high
Cooperation low
Cooperation med
Cooperation high
Trust low
Trust 2
Trust 3
Trust 4
Trust 5
SC1
1.00
0.29*
0.16**
0.21**
0.16**
1.09
1.00
1.17
0.79
1.81
2.49
1.87
1.00
1.34
1.21
4.09**
5.75**
1.00
1.38
2.68*
2.76**
1.00
1.12
0.8
0.45
0.76
0.98
0.99
1.00
0.14
SC2
1.00
0.37
0.2**
0.27*
0.23**
1.06
1.00
1.08
0.64
1.37
1.89
1.84
1.00
1.43
1.54
3.35**
5.76
1.00
1.93
2.45*
2.65*
1.00
1.05
0.71
0.46
0.78
1.04
1.13
SC3
1.00
0.41
0.2**
0.33
0.24*
1.6
1.00
1.18
0.6
1.45
1.79
1.42
1.00
1.56
1.42
2.6*
5.26**
1.00
1.76
3.02*
2.58**
1.00
1.1
0.87
0.63
0.79
0.91
1.19
SC4
1.00
0.56
0.28*
0.5
0.32
1.45
1.00
1.22
0.68
1.93
2.2
1.33
1.00
1.48
1.55
3.05*
6.16**
1.00
1.61
2.08
2.41*
1.00
1.31
1.17
0.69
0.79
1.05
1.08
SC5
1.00
0.57
0.35
0.53
0.32
1.18
1.00
0.99
0.69
1.4
2.56
1.03
1.00
1.67
1.52
3.77**
6.16**
1.00
1.86
2.67*
2.37*
1.00
1.15
0.96
0.49
0.71
0.96
1.03
SC6
1.00
0.11**
0.05***
0.07**
0.04***
1.73
1.00
1.46
0.91
2.97
3.54
1.64
1.00
2.11
1.44
4.33**
6.73**
1.00
1.15
2.44
2.19
1.00
1.32
0.73
0.35
0.82
1.5
0.78
SC7
1.00
0.1**
0.05***
0.05***
0.05***
1.53
1.00
1.09
0.79
1.86
3.02
1.29
1.00
2.46
1.69
3.67**
7.94***
1.00
1.68
2.25
3.62
1.00
1.07
0.83
0.31
0.8
1.09
1.04
SC8
1.00
0.34
0.19**
0.25**
0.19**
1.31
1.00
1
0.69
1.44
2.05
1.66
1.00
1.46
1.61
3.39**
5.76
1.00
1.72
2.58**
2.55*
1.00
1.08
0.82
0.57
0.8
1.17
1.01
SC9
1.00
0.41
0.23**
0.3*
0.25*
1.13
1.00
0.96
0.53
1.27
1.39
1.75
1.00
1.52
1.54
3.45**
4.86**
1.00
2.05
2.6**
3.05**
1.00
1
0.73
0.58
0.82
0.97
1.05
SC10
1.00
0.42
0.22**
0.29*
0.24**
1.34
1.00
1.04
0.65
1.35
1.95
1.7
1.00
1.43
1.43
3.26**
5.69**
1.00
1.76
2.99**
2.54*
1.00
1.02
0.88
0.65
0.86
1.16
1.01
SC11
1.00
0.44
0.25**
0.34
0.28*
1.41
1.00
0.8
0.53
1.17
1.59
1.96
1.00
1.46
1.41
3.17**
6.14***
1.00
2.03
2.85**
2.91**
1.00
1.18
0.98
0.75
0.83
1.1
1.14
SC12
1.00
0.44
0.27**
0.31*
0.27*
1.51
1.00
0.89
0.54
1.25
1.59
1.6
1.00
1.4
1.32
2.95**
5.24**
1.00
2.07
2.95**
2.69**
1.00
1.04
0.84
0.7
0.91
1.25
0.94
SC13
1.00
0.53
0.25**
0.3*
0.26*
1.2
1.00
0.91
0.72
1.8
2.29
1.61
1.00
1.32
1.44
3.41**
8.67***
1.00
2.32
2.43*
3.03**
1.00
1.22
0.83
0.69
1.07
1.19
1.14
1.00
1.11
1.71
1.76
0.15
1.00
4.67**
47.9***
1.00
1.18
1.59
1.00
1.22
3.09*
3.85***
5.69***
1.16
1.55
1.00
2.47
2.89
1.00
0.99
2.35
1.43
1.76
1.00
2.11
3.16*
1.00
0.74
0.42
0.52
0.87
Significant results:
Household level:
• HH age
• Wealth
• HH education
• Religion
Individual level:
• Borrowing money
• Feeling close to
others in village
• Control over
decisions made in
the village
Ndondol
HH age <40
HH age 40-49
HH age 50-59
HH age 60-69
HH age >70
Female HH
HH size <5
HH size 5-8
HH size 9-12
HH size 13-16
HH size >16
Polygamous HH
Ex low
Ex q2
Ex q3
Ex q4
Ex high
Wealth low
Wealth q2
Wealth q3
Wealth high
HH no ed
HH literate
HH primary ed
HH second ed
Disability
Chronic illness
Recent illness
Christian
Muslim
Mixed relig
Wolof
Poular
Serer
Mixed eth
Other eth
Assoc 0
Assoc 1-5
Assoc 6-10
Assoc increase
Assoc stable
Assoc decrease
Contrib <€1.5
Contrib €1.5 - 7.4
Contrib >€7.5
Godparent
Homonym
Lend money
Borrow money
Others distant
Others close
Others v close
Control decision low
Control decision 2
Control decision 3
Control decision 4
Control decision high
Cooperation low
Cooperation med
Cooperation high
Trust low
Trust 2
Trust 3
Trust 4
Trust 5
SC1
1.00
1.2
2.28
1.31
5.31**
1.01
1.00
0.64
2.16
2.34
3.33
0.59
1.00
1.55
0.74
1.27
1.35
1.00
0.86
2.3**
1.78
1.00
1.63
1.27
6.29
1.91
1.05*
0.71
1.00
0.2**
0.15**
SC2
1.00
1.09
1.81
1.07
4.76**
1.24
1.00
0.59
1.72
1.89
2.95
0.77
1.00
1.42
0.69
1.4
1.27
1.00
0.89
2.25**
1.94
1.00
1.47
1.15
5.21*
2.26*
1.13
0.76
SC3
1.00
1.33
2.36
1.39
5.67***
0.98
1.00
0.59
1.76
2
2.81
0.63
1.00
1.59
0.7
1.29
1.26
1.00
0.86
2.13*
1.8
1.00
1.58
1.43
5.78*
1.96
0.97
0.71
SC4
1.00
1.63
2.93*
2.05
7.57
1
1.00
0.39
1.26
1.51
2.21
0.75
1.00
1.6
0.75
1.39
1.47
1.00
0.89
1.89
1.82
1.00
1.7
1.37
6.94**
2.18
0.9
0.65
SC5
1.00
1.43
3.28**
1.48
8.15
0.77
1.00
0.08
0.2
0.22
0.26
0.66
1.00
1.48
0.79
1.26
1.17
1.00
0.82
1.94
2.02
1.00
1.96
1.33
4.27
2.33
0.9
0.74
SC6
1.00
1.22
2.12
1.26
4.39**
0.88
1.00
0.77
2.32
2.77
3.88
0.56
1.00
1.56
0.65
1.29
1.22
1.00
0.92
2.14
1.68
1.00
1.56
1.33
6.29*
2.16
0.97
0.72
SC7
1.00
1.41
2.45
1.46
5.35**
0.98
1.00
0.6
1.99
2.3
2.98
0.59
1.00
1.61
0.74
1.25
1.44
1.00
0.85
2.11*
1.84
1.00
1.52
1.25
5.99*
2.01
1
0.74
SC8
1.00
1.27
2.22
1.31
5.48***
1.06
1.00
0.6
1.98
2.21
3.05
0.63
1.00
1.57
0.71
1.31
1.37
1.00
0.89
2.13*
1.75
1.00
1.59
1.32
5.72*
1.94
1
0.69
SC9
1.00
1.09
2.2
1.24
5.57***
1.11
1.00
0.59
1.86
2.13
2.59
0.63
1.00
1.53
0.71
1.29
1.2
1.00
0.77
2.19*
2.07
1.00
1.59
1.14
6.15*
1.76
1
0.68
SC10
1.00
1.35
2.25
1.48
6***
1.11
1.00
0.63
2.16
3.07
4.58
0.63
1.00
1.93
0.79
1.8
1.96
1.00
0.89
2.3**
1.76
1.00
1.51
1.35
6.51**
2.1
0.87
0.67
SC11
1.00
1.35
2.36
1.48
6.21***
0.88
1.00
0.62
1.8
2.23
3.32
0.67
1.00
1.42
0.75
1.41
1.4
1.00
0.89
2.39**
2.06
1.00
1.44
1.44
5.43*
2.15
0.99
0.72
SC12
1.00
1.32
2.41
1.36
5.36**
0.98
1.00
0.57
1.96
2.43
3.06
0.64
1.00
1.63
0.78
1.42
1.4
1.00
0.79
2.2*
1.73
1.00
1.56
1.41
6.65**
1.99
1.01
0.69
SC13
1.00
1.41
2.3
1.3
4.88**
0.78
1.00
0.59
2.12
2.43
2.82
0.58
1.00
1.77
1.04
1.55
1.62
1.00
0.72
2.59**
2.11
1.00
1.58
1.39
4.28
1.88
1.16
0.78
1.00
1.32
0.93
1.00
1.26
1.43
1.00
0.52
0.48
1.00
1.5
0.49
1.63
1.13
1.4
1.81*
1.00
0.64
0.37*
1.00
1.34
3.36**
1.19
1.08
1.00
1.78
1.26
1.00
1.67
0.62
1.44
2.25
Significant results:
Household level:
• Size
• Expenditure
• Wealth
• Education
• Recent illness
• Ethnicity
• Membership of
associations
• Number of
associations
Individual level:
• Borrowing money
• Control over
decisions
Wer Ak Werle
HH age <40
HH age 40-49
HH age 50-59
HH age 60-69
HH age >70
Female HH
HH size <5
HH size 5-8
HH size 9-12
HH size 13-16
HH size >16
Polygamous HH
Ex low
Ex q2
Ex q3
Ex q4
Ex high
Wealth low
Wealth q2
Wealth q3
Wealth high
HH no ed
HH literate
HH primary ed
HH second ed
Disability
Chronic illness
Recent illness
Wolof
Poular
Serer
Mixed eth
Other eth
Christian
Muslim
Mixed relig
Assoc 0
Assoc 1-5
Assoc 6-10
Assoc increase
Assoc stable
Assoc decrease
Contrib <€1.5
Contrib €1.5 - 7.4
Contrib >€7.5
Godparent
Homonym
Lend money
Borrow money
Others distant
Others close
Others v close
Control decision low
Control decision 2
Control decision 3
Control decision 4
Control decision high
Cooperation low
Cooperation med
Cooperation high
Trust low
Trust 2
Trust 3
Trust 4
Trust 5
SC1
1.00
1.01
1.2
1.37
0.8
0.66
1.00
1.38
1.06
3.93*
SC2
1.00
0.98
1.15
1.27
0.76
0.68
1.00
1.24
0.91
3.07*
SC3
1.00
1.12
1.25
1
0.6
0.63
1.00
1.21
0.89
4.24*
SC4
1.00
0.96
1.33
1.55
0.76
0.77
1.00
1.15
0.88
2.68
SC5
1.00
1.13
1.36
1.59
0.63
0.44**
1.00
1.8
0.98
2.61
SC6
1.00
0.95
0.94
0.97
0.68
0.6
1.00
1.02
0.87
2.42
SC7
1.00
1
1.11
1.24
0.74
0.63
1.00
1.03
0.8
2.32
SC8
1.00
1.05
1.18
1.33
0.8
0.66
1.00
1.35
1.03
3.54
SC9
1.00
1
1.11
1.32
0.77
0.62
1.00
1.13
0.75
2.5
SC10
1.00
1.01
1.16
1.28
0.74
0.65
1.00
1.06
0.76
2.66
SC11
1.00
0.96
0.84
1.5
0.6
0.63
1.00
1.37
1.01
3.18
SC12
1.00
1.08
1.25
1.63
0.79
0.7
1.00
1.06
0.72
2.97
SC13
1.00
1.08
1.22
1.38
0.77
0.77
1.00
1.14
0.81
3.62*
0.34
1.00
0.97
1.3
1.29
2.93*
1.00
0.56
0.76
1.19
1.00
0.56
0.79
1.22
1.44
0.68
1.88*
1.00
1.24
0.86
0.62
0.31**
0.44
1.00
1.11
1.38
1.42
2.95**
1.00
0.55
0.81
1.00
1.00
0.46
0.74
0.98
1.59
0.7
2.01*
0.3
1.00
0.98
1.35
1.24
2.28
1.00
0.4**
0.67
0.66
1.00
0.41*
0.7
1.11
1.05
0.62
2.42**
0.45
1.00
1.02
1.41
1.32
2.68*
1.00
0.5*
0.76
0.91
1.00
0.4*
0.68
0.96
1.37
0.75
1.91*
0.43
1.00
0.72
1.36
0.7
1.87
1.00
0.49
1.27
0.93
1.00
0.48
0.55
1
1.46
0.6
2.88**
0.41
1.00
1.34
1.06
1.34
2.29
1.00
0.59
0.88
1.22
1.00
0.53
0.72
0.84
1.36
0.68
2.43**
0.42
1.00
1.18
1.18
1.31
2.4
1.00
0.57
0.84
1.23
1.00
0.49
0.7
0.89
1.72
0.7
2.3**
0.45
1.00
1.09
1.44
1.45
3.07**
1.00
0.57
0.8
1.03
1.00
0.47
0.68
1.01
1.65
0.7
2.14**
0.43
1.00
1.19
1.33
1.28
2.36
1.00
0.57
0.91
0.96
1.00
0.45
0.72
1.12
1.33
0.63*
2.03*
0.42
1.00
1
1.43
1.27
2.75*
1.00
0.5*
0.79
0.94
1.00
0.44
0.73
0.95
1.79
0.68
2.15**
0.43
1.00
0.87
1.38
1.03
2.61*
1.00
0.5*
0.79
1
1.00
0.41*
0.57
0.72
2.23
0.7
1.85
0.44
1.00
1.22
1.54
1.43
3.11**
1.00
0.51
0.86
1.03
1.00
0.4*
0.63
1.07
1.44
0.68
2.03*
0.48
1.00
1.02
1.63
1.43
3.71**
1.00
0.55
0.93
0.99
1.00
0.49
0.67
0.9
2.17
0.7
1.99*
1.00
2.18
1.00
6.58***
18***
1.00
0.74
0.21**
1.00
1.21
1.46
1.22
1.06
0.66
2.52***
1.00
0.84
1.48
1.00
1.99
2.87**
4.32***
5.57***
1.00
1.79
1.91
1.00
1.24
0.3
0.73
0.71
The role of social capital?
• Social capital seems to play a different role in different types of
CBHI scheme
• Explained by social structure of schemes?
• Soppante: heterogeneity of members and large size of scheme
attracts people with wider social networks, more trust & norms of
generalised reciprocity
social capital important determinant of
enrolment
• Ndondol: homogeneity of members, rural context and small size of
scheme
existing solidarity, information and norms of reciprocity
between target population
social capital less important
determinant of enrolment
• Wer Ak Werle: heterogeneity of members, urban context and large
size of scheme is counteracted by existing solidarity of women’s
group enrolment mechanism. Control over decisions and
membership of associations probably explained by enrolment
strategy. Qualitative results indicate this has potential to influence
quality of care.
Tentative policy implications
• Members of CBHI have greater social capital (more
extensive social networks and greater reciprocity and
solidarity) than non-members in some contexts
• Direction of relationship not clear but probably SC is a
cause, not effect of enrolment (qualitative data will help
clarify)
Tentative policy implications
• CBHI schemes should utilise existing social
capital to increase and retain membership
numbers (eg enrolment through existing
associations)
• CBHI schemes should develop strategies to
target groups with low social capital who are
possibly not only economically but also
socially excluded from initiatives to improve
access to health care