The sustainability of two departmental health insurance units in Senegal: A qualitative study

Despite decades of implementation, community-based health insurance (CBHI) in Africa has not effectively achieved Universal Health Coverage (UHC). As a response, from 2014 to 2017, a Belgian-Senegalese project organized an alternative solution: Departmental Health Insurance Units (UDAM). Professionals managed UDAMs at a departmental level, and healthcare providers charged a flat-rate fee. While research on sustainability is scarce in Africa, this study aims to understand the factors that explain why, four years after the end of the project, UDAMs are sustained. This qualitative research used Schell et al. (2013) conceptual framework on factors influencing sustainability. The data came from 13 months of field observations, a documentation review, 120 interviews at the local level and nine at the regional and national level, and a focus group. We carried out a thematic analysis according to the conceptual framework. The results show that central political support has strengthened over time. UDAMs have managed to stabilize their funding through State subsidies and social marketing strategies to improve membership. UDAMs kept their management fees at 13%, below the 25% standard proposed by the West African Economic and Monetary Union. Multiple partnerships have been established at international, national, and local levels. Building on the professionalization of its staff, UDAMs have strengthened their organizational capacity. Internal controls and a complaints system have been organized to improve UDAMs’ accountability. Many communication activities were carried out before the end of the project to prepare the exit strategy. With their extensive coverage (penetration rate over 60%), UDAMs impact the health system (between 2014 and 2021, they paid 2.5 million EUR to healthcare providers). Innovations have been implemented, such as organizing a group contribution based on collective work in fields of culture supported by the communities and local stakeholders. As part of its UHC strategy, Senegal decided at the end of 2022 to transition its 676 communal CBHI into 46 departmental units. The sustainability of two UDAMs has demonstrated the relevance of this model. However, sustainability can only be assured if the State prioritizes the health sector and donors place greater emphasis on alignment and sustainability. We need to study how it is organized to scale up nationally.