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Social health protection in low and middle income countries: reinventing models for people facing social exclusion

By Maymouna Ba
on June 27, 2014

Maymouna Ba is a Research fellow at ‘Le Centre de Recherches sur les Politiques sociales’ (CREPOS), Dakar


The introduction of social health protection programmes in most of the low and middle Income Countries (LMICs) at the turn of the millennium was targeted at people identified as the outcasts of the implemented health financing strategies: the poorest. Increasingly, the emergence of UHC as a driver for health financing reforms is also being seen as an opportunity to expand healthcare coverage to other vulnerable groups and to improve their access to healthcare services. Unfortunately, despite the growing UHC momentum, it seems that many of these new programmes struggle to reach the most-in-need.

This was the core issue explored by the Health Inc research project in the past three years. Health Inc looked at the impact of social exclusion on – presumably inclusive – health financing arrangements implemented in LMICs. The research was conducted in India, Ghana and Senegal.

Social Health Protection (SHP) programmes, both targeted and universal ones, have shown limited success when it comes to the inclusion of socially excluded people in these programmes. The results show that beyond the issues related to design and implementation, these programmes face strong difficulties to turn round processes of social exclusion based on gender, residency, age, etc. These processes are often even exacerbated by several other social, political and cultural factors at play in the setting in which the programme is implemented.

These factors explain to a great extent the low utilization of these programmes among the targeted groups. Let’s present some Health Inc findings.

In Ghana, National Health Insurance Scheme (NHIS) enrolment is skewed towards the richer quintiles, and those who are not covered by the NHIS are also not integrated in the political and civic life as well, it turns out. In India, the Rashtriya Swasthya Bima Yojana (RSBY) programme, offering subsidized health insurance coverage to people living below the poverty line (BPL), even enhances processes of social exclusion that affect the underprivileged groups, e.g. the scheduled tribes.

In Senegal, the Plan Sésame, an exemption policy which removes user fees for older people in public facilities, shows similar results. Implemented since 2006, so far it has been more beneficial to urban dwellers belonging to the higher socio-economic quintiles, especially those who live near a public hospital. Though necessary, the removal of user fees was not sufficient to lift the multidimensional access barriers to health care. More precisely, it did little – if anything – to address the core problem of physical access, nor did it offer a satisfactory response to the ever increasing risk of precariousness related to ageing in Senegal, a risk that traditional solidarity models are no longer able to deal with.

The limited success of Plan Sésame calls for innovative policy responses in order to address the issue of social exclusion, especially for groups who face multiple, intertwined vulnerabilities (poverty, lack of education, physical frailty, social discrimination and/or isolation). Though well-intentioned, this exemption policy struggled to trigger the social transformation necessary to address the exclusionary processes affecting the older population in Senegal nowadays.

Unfortunately, Plan Sésame is anything but an exception. Most of the social health protection strategies currently implemented in LMICs reveal rather than mitigate inequities. The UHC momentum provides an opportunity to rethink practices in the field of social health protection, in order to tackle social exclusion in a more effective way. For example, the focus on NCDs in the post-2015 “MDG+” debate offers a great opportunity to discuss better adaptation of health services to the needs of ageing populations. To date, our health systems are far from being ready for this epidemiological transition.

Triggering meaningful social transformation is thus a condition for the full realization of UHC, requiring a multi-sectorial approach and a strong political will in order to improve the overall effectiveness of these strategies in terms of equity. Put differently, social determinants and UHC need to go hand in hand.

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