Mandatory Membership of Community-Based Mutual Health Insurance in Senegal: A National Survey

ABSTRACT With the low adhesion to voluntary mutual health insurance, Senegal’s policymakers have sought to understand the feasibility of compulsory health insurance membership. This study aims to measure the acceptability of mandatory membership in community-based mutual health insurance (CBHI) and to understand its possible administrative modalities. The study consists of a national survey among a representative population sample selected by marginal quotas. The survey was conducted in 2022 over the phone, with the random composition method among 914 people. The questionnaire measured the socio-economic characteristics of households, their level of acceptability concerning voluntary and compulsory membership, and their level of confidence in CBHIs and the health system. Respondents preferred voluntary (86 %) over mandatory (70 %) membership of a CBHI. The gap between voluntary and compulsory membership scores was smaller among women (p=0.040), people under 35 (p=0.033) and people with no health coverage (p=0.011). Voluntary or compulsory membership was correlated (p=0.000) to trust in current CBHIs and health systems. No particular preference emerged as for the preferred administrative channel (e.g. death certificate, identity card, etc.) which could enable to enforce the mandatory character. The results confirmed the well-known challenges of building universal health coverage on the basis of CBHIs, a model which is poorly appreciated and whose low performance reduces the acceptability of populations to adhere to it, be it on a voluntary or mandatory basis. Suppose Senegal persists in its health insurance approach. In that case, it will be essential to strengthen the performance and funding of CBHIs, and to gain population trust to enable a mandatory or more systemic membership.