Social capital and enrolment in community-based health insurance in Senegal

摘要

Universal coverage is a core health system goal which can be met through a variety of health financing mechanisms. The focus of this PhD is on one of these mechanisms, community-based health insurance (CBHI). CBHI aims to udprovide financial protection from the cost of seeking health care through voluntary prepayment by community members; typically it is not-for-profit and aims to be community owned and controlled. Despite its popularity with international policymakers and donors, CBHI has performed poorly in most low and middle income countries. The overarching objective of this PhD is therefore to understand the determinants of low enrolment and high drop-out in CBHI. The PhD builds on the existing literature, which employs mainly economic and health system frameworks, by critically applying social capital udtheory to the analysis of CBHI. A mixed-methods multiple case study research design is used to investigate the relationship between CBHI, bonding and bridging social capital at micro and macro levels and active community udparticipation. The study focuses on Senegal, where CBHI is a component of national health financing policy. The results suggest that CBHI enrolment is determined by having broader social networks which provide solidarity, risk pooling, financial protection and financial credit. Active participation in CBHI may prevent drop-out and increase levels of social capital. Overall, it seems udCBHI is likely to favour individuals who already possess social, economic, cultural and other forms of capital and social power. At the macro level, values (such as voluntarism, trust and solidarity) and power relations inhering in social networks of CBHI stakeholders are also found to help explain low levels of CBHI enrolment at the micro level. The results imply the need for a fundamental overhaul of the current CBHI model. It is possible that the needed reforms would require local institutions to develop new capacities and resources that are so demanding that alternative public sector policies such as national social health insurance might emerge as a preferable alternative.