Understanding demand for community-based health insurance in Senegal: The role of social capital and related determinants Philipa Mladovsky 16 th 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 Source : Inventaires de la Concertation (

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?

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) Aims of study

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 Limitations of the conceptual frameworks

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 *Includes current members and ex members

Methodology Household survey Stratified sampling: SoppanteNdondolWer Ak Werle NMM M M Sample

Significant results: Household level: HH age Expenditure Wealth Membership of associations Expenditure on associations Individual level: Is a godparent Has homonyms Believes cooperation likely

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

Significant results: Household level: Size Expenditure Wealth Education Recent illness Ethnicity Membership of associations Number of associations Individual level: Borrowing money Control over decisions

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