Senegal's health insurance overhaul stalls amid fears of lost control

<p><strong>Introduction:</strong> In Senegal, community-based health insurance (CBHI) schemes have long been favoured as the main instrument for achieving universal health coverage (UHC). Historically managed by community volunteers, these schemes have struggled with financial sustainability and coverage effectiveness. In response, Senegal launched a reform in 2022, transitioning from communal to departmental CBHI schemes to enhance management and service delivery. This study aims to explore the challenges associated with implementing this reform in the country.</p><p><strong>Methods:</strong> The qualitative study was conducted from 2020 to 2023, utilizing 27 in-depth interviews with stakeholders from four regions to explore the roles of social actors, ideas, power dynamics, and context in the reform. The interviews specifically aimed to capture the dynamics of support and resistance to the transition from communal to departmental CBHI. Data were analyzed using a thematic analysis approach.</p><p><strong>Results:</strong> Findings reveal significant resistance among existing communal CBHI managers who fear loss of autonomy and financial control. Stakeholders expressed concerns over the rapid and top-down approach of the reform process, which many felt was forced upon them without adequate consultation. Despite these challenges, some stakeholders recognized the potential benefits of professional management and streamlined operations to enhance healthcare accessibility and efficiency.</p><p><strong>Conclusion:</strong> The study shows that despite encountering resistance stemming from entrenched ideas, values, and power dynamics, the reform has been accepted and is currently being implemented. The role that departmental CBHI will play in the ongoing reform process remains to be seen.</p>