Impact of community-based health insurance on healthcare utilisation and out-of-pocket expenditures for the poor in Senegal

OBJECTIVES: This study aims to assess the impact of the subsidised community health insurance scheme in Senegal particularly on the poor. DESIGN AND SETTING: The study used data from a household survey conducted in 2019 in three regions, representing 29.3% of the total population. Inverse probability of treatment weighting approach was applied for the analysis. PARTICIPANTS: 1766 households with 15 584 individuals selected through a stratified random sampling with two draws. MAIN OUTCOME MEASURES: The impact of community-based health insurance (CBHI) was evaluated on poor people’s access to care and on their financial protection. For the measurement of access to care, we were interested in the use of health services and non-withdrawal from care in case of illness. To assess financial protection, we looked at out-of-pocket expenditure by type of provider and by type of service, the weight of out-of-pocket expenditure on household income, non-exposure to impoverishing health expenditure and non-exposure to catastrophic health expenditure. RESULTS: The results indicate that the CBHI increases primary healthcare utilisation for non-poor (OR 1.36 (CI90 1.02–1.8) for the general scheme and 1.37 (CI90 1.06–1.77) for the special scheme for indigent recipients of social cash transfers), protect them against catastrophic (OR 1.63 (CI90 1.12–2.39)) or impoverishing (OR 2.4 (CI90 1.27–4.5)) health expenditures. However, CBHI has no impact on the poor’s healthcare utilisation (OR 0.61 (CI90 0.4–0.94)) and do not protect them from the burden related to healthcare expenditures (OR: 0.27 (CI90 0.13–0.54)). CONCLUSION: Our study found that CBHI has an impact on the non-poor but does not sufficiently protect the poor. This leads us to conclude that a health insurance programme designed for the general population may not be appropriate for the poor. A qualitative study should be conducted to better understand the non-financial barriers to accessing care that may disproportionately affect the poorest.