The role of the social and solidarity economy in the extension of health insurance in Senegal
- Cet article est une traduction de :
- Le rôle de l’Économie sociale et solidaire dans l’extension de l’assurance maladie au Sénégal [fr]
Résumés
L’économie sociale et solidaire sonne en Afrique comme une promesse de dépassement du lien historique entre sécurité sociale et salariat. Au Sénégal, l’ancrage juridique du processus d’extension de l’assurance maladie dans la logique de l’économie sociale et solidaire a été rattrapé par les conflits de perception de cette forme d’économie. L’engagement normatif et institutionnel dans l’extension de la couverture maladie n’a pas produit les résultats escomptés. Le financement public de l’assurance maladie est source d’une tension budgétaire qui montre déjà la fragilité d’un système vulnérable aux chocs endogènes et exogènes. L’ancrage social de l’assurance santé, dans son projet d’extension, est aussi porté par la décentralisation administrative qui peine à trouver un relais avec les ressorts historiques de la socialisation. Le volontariat serait producteur d’une dynamique sociale différentiée en creusant les inégalités. L’avenir de l’assurance maladie, en liaison avec la conservation du lien de solidarité, d’égalité et d’équité, dépend de la volonté à mobiliser les capacités contributives des professions libérales, travailleurs indépendants de l’économie formelle comme informelle.
Entrées d’index
Mots-clés :
économie sociale et solidaire, assurance maladie, mutuelles de santé, financement publicKeywords:
social and solidarity economy, health insurance, mutual health insurance, public financingPlan
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- 1 The first mutual health insurance scheme in Senegal was created in 1989 in a village called Fandene (...)
- 2 Explanatory statement on Law no. 2003-14 of 4 June 2003 on mutual health organisations: « mutual he (...)
- 3 In particular the assistance and insurance programmes of the Universal Health Coverage (Couverture (...)
- 4 « Plan stratégique de la Couverture Maladie Universelle 2013-2017 », Ministry of Health and Social (...)
- 5 African Union Social Policy Framework adopted in 2008; Harmonisation framework for the technical, f (...)
- 6 According to the World Bank, development depends directly on individuals’ ability to overcome the r (...)
- 7 See in particular: Law no. 2021/017 of 30 April 2017 on social mutuality in the Republic of Guinea; (...)
1The emergence of mutual health organisations in Senegal over 30 years ago1 corresponds perfectly to the realities of the social and solidarity economy. This is evidenced by the spontaneous manner in which these organisations appeared, by the way they are strongly based in and managed at local community level, as well as by the lack of an institutional and normative framework at the outset2. In Senegal as in most French-speaking black African States, these entities intended to cover primary health care later benefited from a form of institutional sponsoring3 by the public authorities following a realisation at national4, community5 and international6 level of how they have become closely linked to the objective of extending health cover to all of the population. All over French-speaking Black Africa, specific legislation7 has confirmed this link considered as indissoluble between social mutual funds and the implementation - on a large scale - of the fundamental right to social protection, and more specifically the right to health coverage.
- 8 X. Itcaina, « Economie sociale et solidaire », Dictionnaire des politiques territoriales, 2020, p. (...)
- 9 Art. 2 of the Orientation Law of 4 June 2021 on the social and solidarity economy, JORS (Official G (...)
2The social and solidarity economy refers first of all to an economy and not to an activity or a sector of the economy. The idea is that it could encompass all the aspects of the nation’s production of goods and services. Its distinctive features are seen as both its modes of operation, based on democracy, freedom of membership, solidarity, etc., and its particular purposes, which are human-centric8. In Senegal, the orientation law on the social and solidarity economy of 4 June 2021 provided a legal foundation for this form of economy, targeting « economic activities carried out with a human-centric approach, with a social or environmental purpose by cooperatives or mutual societies, enterprising associations, social enterprises or actors in the popular economy »9.
- 10 Art. 1 of Law no. 2003-14 of 4 June 2003 on mutual health insurance organisations: « A mutual healt (...)
- 11 J.-L. Laville, « Economie et solidarité. Esquisse d’une problématique », L’économie solidaire. Une (...)
- 12 P. D. Rousseau, « Malaise dans l’économie sociale et solidaire », SER Etudes, 9/2020, p. 57.
3Under the terms of Article 19 of the 2021 Law, « Social and Solidarity Economy » accreditation is granted only to companies that provide « by their activity, support for people in vulnerable situations due to their economic and social situation » as well as those that « contribute to the fight against health, social, economic, educational and civic exclusion and inequality or to the maintaining and strengthening of territorial cohesion ». The Law of 4 June 2003 on mutual health organisations, considers mutual health organisations, at least in spirit, as part of the social and solidarity economy10. These values are enshrined in Senegalese law and are perfectly in line with the criteria of the social and solidarity economy11, even though at the same time legal opinion repeatedly reminds us that the approach to the concept is constantly being renewed12.
- 13 C. Bec, « La sécurité sociale entre solidarité et marché », Revue Française de Socio-économie, 2020 (...)
- 14 J.-P. Chauchard, J.-Y. Kerbouc’h, C. Wilmann, « Droit de la sécurité sociale », LGDJ, 7th ed, p. 95 (...)
- 15 The State employees’ and customs and armed forces mutual organisations top up the civil servants’ h (...)
4Because it is social first and foremost, the social and solidarity economy resonates in Africa as a promise to create a link between social protection and society, which would therefore go beyond the traditional link between social security and wage employment. This runs contrary to what is understood by « mutual fund » (mutuelle) in France, where this category refers to an instrument for topping up a basic system of social protection13, and is therefore voluntary14; in Africa, on the other hand, this category is seen, first and foremost, as a way of providing initial access to the fundamental right to social security. A form of mutuality designed to top up basic protection nevertheless persists on a residual level15.
- 16 In 2015, a national survey carried out using the Annual Labour Declaration (DASMO) revealed that IP (...)
- 17 Civil servants’ health care expenses are partially covered by the national budget. Retirement pensi (...)
- 18 Salaried workers in the private and public sector and civil servants only benefit from social secur (...)
- 19 In 2018, there were 459,338 insured and beneficiaries of the civil service scheme and 302,915 in th (...)
- 20 Revue Globale et analyse du système national de protection sociale au Sénégal, 2021, op. cit.
- 21 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de le (...)
- 22 C. Deville, F. Fecher, M. Poncelet, « Les mutuelles de santé subventionnées comme instruments de la (...)
5The social security system in Senegal faces the challenges of the ineffectiveness of its rules, due to a high rate of non-payment of contributions, especially in the informal economy16. The question of its extension is more of a nagging issue insofar as it obliges Senegalese law to aim for a synthesis that is almost impossible. Mandatory health insurance only covers civil servants17 and salaried workers18, who together represent less than 5% of the population19. Less than 11% of the population20 benefit from cover by mutual health organisations, but the system constitutes the key lever in the extension plan. The legal anchoring of the process of extending health cover has soon found itself having to deal with the conflicting perceptions of this type of economy and with conceptual differences, even with regard to the « social mutual fund » category21. The most prevalent conflicts relate to the different sources of law (national, international and community), and they are disrupting hopes of arriving at a simplified approach to the issue. The plurality of actors involved in the process of extending health cover (international donor agencies, civil society, community authorities, public authorities) amounts to an « epistemic community »22 and leads to a conflict of perceptions regarding the purposes and instruments of the extension.
- 23 38 ILO Conventions have been ratified by Senegal, of which 32 are in force. For Convention C102, wh (...)
- 24 See also: the United Nations General Assembly Resolution on Universal Health Coverage urging States (...)
6The intersecting of the social and solidarity economy and the extension of health insurance also raises the more general issue of the social protection floor in developing countries, and is part of Senegal’s agenda to anchor its action in compliance with the international law of the ILO, even though not all the health-related aspects of ILO Convention C.102 have been ratified23. Senegal has, however, acceded to other international instruments dealing specifically with minimum health coverage24. A reflection on the legal instruments of the contextualisation of this issue invites us to measure and examine by the mechanisms by which the social mutual funds can make their involvement part of the extension of health coverage in Senegal.
- 25 Plan to Develop Universal Health Insurance Coverage as part of decentralisation.
7This intersecting of the SSE with the extension of health coverage is re-emphasised by the desire to take a national approach to the decentralisation of health insurance (DECAM)25. The social and popular processes of the extension of health coverage, illustrated by portability between regions or municipalities and family or village registration, bear witness to the search for a social foundation, without which the objective of expansion will be in vain. The question is therefore raised of the public funding of social security, and along with it, the issue of its limits in the face of a debtor State that does not pay.
- 26 C. Deville, F. Fecher, M. Poncelet, « Les mutuelles de santé subventionnées comme instruments de la (...)
- 27 J.-C. Graz, La gouvernance de la mondialisation, Paris La découverte, 2008, p. 107: « To varying de (...)
8The normative and institutional commitment (decentralisation) to the extension of health coverage by instrumentalising the social mutual system, has not produced the expected results. The manifestations of the problem are well known: low contribution rates, very low premiums, very unequal addressing of beneficiaries’ needs, variability in the care offer covered, inadequate quality of the care provided, tensions between mutual organisations and providers, amateurish management26. The formalised approach taken by the public authorities has created a situation of legal syncretism between values drawn from insurance-based social protection, the SSE and OHADA company law. The responses offered by Senegalese law highlight a regime that is caught in a bind between the international standards and their necessary socio-economic and cultural contextualisation27. In spite of a substantial amount of institutional and normative input, a paradox exists in Senegal exists, with a commitment by the State, which is increasing its financial contribution, but which at the same time is disengaging from supervision of the content of the benefits that are offered.
9The decentralisation of health coverage and the promise of a thread of social utility should have made it possible to achieve the recognition of a mutualist specificity. Public financing is a major instrument in the objective of extension but is paradoxically the cause of the failure of the forecasts, and the social momentum sought through administrative decentralisation ignores profound social realities. The State’s commitment to providing a protection floor for healthcare has foundered on the weakness of its intervention on the content of the benefits offered and the backslide in occupational solidarity, at the same time as a too-unified approach to social mutuality has ended up making its adaptation to the different categories concerned by the expansion impossible. The normative arsenal and the data published thus throw some light on a compromise that is unfavourable to the objective of extending health coverage (I) and a compromise that is prejudicial to a fairer and more equitable social protection system (II).
I - A compromise that is unfavourable to the objective of extending health coverage
10The data on mutual health organisations already foreshadows the limits of public financing and decentralisation as instruments for extending health coverage (A). Solidarity, which is so beneficial to social cohesion and public confidence, would have required more flexibility on certain aspects of the governance of the mutual societies. This flexibility is rendered impossible by legislation that imposes an excessive degree of standardisation, and is just as detrimental to the goal of expansion (B).
A - The limits of the instruments of the extension
11The public financing of the extension of health insurance is a source of budgetary tensions, which is already showing the fragility of a system that is vulnerable to both endogenous and exogenous shocks (1). The social anchoring of health insurance, in its extension plan, is also tied to administrative decentralisation which is struggling to latch onto the historical driving forces of socialisation (2).
1 - The paradox of public financing as instrument and limiting factor on the objective of extension
- 28 See in particular: the free care programme for children aged 0 to 5 years; students’ coverage by th (...)
- 29 Namely 1,377,107 beneficiaries for 475,909 members in 2018: Revue globale et analyse du système de (...)
- 30 C. Bec, « La sécurité sociale entre solidarité et marché », op. cit.
- 31 C. Deville, F. Fecher, M. Poncelet, « Les mutuelles de santé subventionnées comme instruments de la (...)
- 32 « Health insurance in low-income countries », OXFAM Briefing paper, p. 6; Plan national de développ (...)
- 33 B. Fonteneau, S. Vaes, J. Van Ongeval, « Toward redistributive social protection? Insight from Sene (...)
- 34 See J.-L. Souchet, « Le mouvement mutualiste dans les évolutions du système de protection sociale f (...)
12In Senegal, public financing of social protection has historically concentrated on social action and assistance28. It has encompassed health insurance with the national Universal Health Coverage (« CMU ») scheme, which is intended to finance 50% of the annual dues of beneficiaries of mutual health organisations for the most disadvantaged strata of the population29. This option, although invaluable for a large segment of the population, still raises questions as to the sustainability of this method of funding: it is a question shared with post-industrial nations30. Delays in the payment of subsidies have seriously upset the financial equilibrium of the organisations concerned, precisely at a time when the level of affiliation is far from substantial31. The budgetary pressures created at State level and for the mutual organisations concerned are in direct contradiction with the forecasts of more extensive cover in the future. The relevance of the approach taken by the public authorities, which is the result of an option chosen when drawing up public policies, is being challenged by the different responses of the actors involved to the question of financing through national solidarity32. This option sets up the deficit as consubstantial with the mutualist system. In Senegal33, as elsewhere, arguments against public intervention are still upheld34.
- 35 Introduced in 2013 and resting « on a vision of a Senegal where all individuals, all households and (...)
- 36 Y. Guichoua, « Solidarité professionnelle et partage des risques parmi les travailleurs informels. (...)
13The extension of health coverage in Senegal is destined to be limited by the limits of public funding in an economic vulnerable to endogenous and exogenous shocks. However, the contributory transfers of the State do contribute to the political legitimation of the health insurance and social security system. The legislation on mutual health organisations, initially designed as a legal instrument, has been overtaken by the State’s political project, which now aligns it with Universal Health Coverage35 as a vector of a fairer and more equitable society given that « economic shocks not covered can plunge non-poor people into poverty »36. The approach is political and instrumental, perhaps even tantamount to political manoeuvring, but it has the advantage of being considered, from the point of view of the impression in the country, as an achievement insofar as it introduces a notion of national solidarity into social security.
- 37 Revue globale et analyse du système national de protection sociale du Sénégal.
14From a totally contribution-based approach imposed on some to a partially contribution-based approach offered to others, the evolution of mutual health organisations will also depend on the raising of living standards in Senegal. Increasing incomes, especially in rural areas and in the informal economy, is surely going to be the only way of reducing the pressure on public financing. Published data shows that « adverse selection » is a fact, driven by low incomes. While the average family in Senegal consists of 5.9 people, it is a surprise to learn that the average size of households registered with mutual health organisations is 2.9 people, members and beneficiaries included. In the larger occupational mutual organisations, the number reaches 5.4 people, thereby establishing the link between membership and level of income37. This sets up a de facto extension mechanism which does not generate competition between protection systems, but does show a regression in the mandatory nature of social security, a sign of backsliding solidarity.
2 - A social anchoring to be reinvented
- 38 Explanatory statement on the Law of 4 June 2003 on mutual health organisations: « Mutual health org (...)
- 39 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de le (...)
- 40 Ibid.
- 41 Plan stratégique de développement des mutuelles de santé au Sénégal, Ministry of Health, July 2004, (...)
- 42 B. Boidin, « Extension de l’assurance maladie et rôle des mutuelles de santé en Afrique : les leçon (...)
15The social and solidarity economy is first and foremost a social economy. Although social and solidarity economy organisations spontaneously began to appear in Senegal over 30 years ago, the government has taken a utilitarian approach to this reality, appropriating their social credibility with the aim of using it to expand health insurance38. The social dynamic is both an end and a means. The legal translation of this necessity appears in the link established between mutual health organisations and decentralisation, a link enshrined as a specific category in public policies through the Plan to Develop Universal Health Insurance Coverage as part of decentralisation (DECAM). If mutual health organisations are the manifestation of Senegal’s wish to maintain an insurance-based approach to health protection, community participation is seen as an active way of involving the population whilst emphasising self-determination39. Decentralisation is supposed to encourage people to « behave more responsibly and with greater attention to prevention »40. The public authorities’ belief in « the strength of the mutual health organisations and their social acceptability »41 deserves to be implemented more fully. The success of the large-scale occupational mutual organisations illustrates the importance of there being a link - here an occupational one - in the goal of integration42.
- 43 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de le (...)
- 44 G. F. Gankpe, E. C. Gankpe, A. N. Baleba, L. Zinzou, C. Messenge, « Les mutuelles de santé reprodui (...)
16In Senegal and Sub-Saharan Africa, the coming together of health care, social protection and the social and solidarity economy should facilitate interactions between the rules and local culture, which is key to learning democracy43. This allows an appreciation of the importance of civil society on this road towards a system that is legitimate because it is sustained and shared. High levels of solidarity within a social group provide an incentive for the members to accept the idea that their contributions also serve others44.
- 45 Art. 12 of Regulation no. 07/2009/CM/UEMOA governing social mutuality within the West African Econo (...)
- 46 Y. Guichoua, « Solidarité professionnelle et partage des risques parmi les travailleurs informels. (...)
- 47 In particular, « Une obligation attachée ou couplée à des bénéfices : obtention de permis d’occuper (...)
17The disadvantage of decentralisation is insufficient portability, but it has the advantage of compliance with the idea of the Republic, unlike systems organised along religious or ethnic lines. Social ties that are too focused on such identities should arouse more reservations45. A certain body of thought points out that in Africa « the chances of seeing initially de-socialised agents spontaneously setting up insurance schemes are low »46. Beyond the issue of administrative decentralisation, other forms of socialisation could be favourable to insurance-based solidarity since they already comprise an element of social solidarity: sports clubs and cultural associations, women’s groups, political parties, subsectors in the informal economy. Proposals relating to the use of the conditionality of certain administrative procedures to incentivise joining a mutual health organisation scheme have not been tried out47.
B - The introduction of a unified legal regime acts as a brake on extension
- 48 M. B. Niang, « Ancrage juridique et perspectives du dialogue social au Sénégal », in P. Auvergnon, (...)
18The Law of 4 June 2003 placed all of the socio-professional categories not covered by mandatory social security on its agenda. This is a single agenda that leaves little room for contextualisation according to occupational or social specificities. This shortcoming, which UEMOA community law has managed to avoid, results in cumbersome processes and ultimately in paralysis. Although it was hoped that public financing and decentralisation would be instruments of the extension of health insurance, their impact on the occupational targets has been very limited. On the one hand, the State subsidies are not intended for this category and, on the other, the link that was supposed to unite hauliers or shopkeepers is not municipal or departmental. The categories of self-employed workers in the formal sector, or even in the informal economy, are sociologically closer to those of salaried workers in the private sector, in terms of ability to pay contributions and capacity for mobilisation, with the appearance of trade unions and federations in the informal sector48.
- 49 Art. 33 of the Regulation.
19It is certainly these groups that the UEMOA has in mind when it provides that « notwithstanding the principle of freedom of membership, it may be decided, by means of a special measure, depending on the professional situation of the members, that membership of a social mutual fund is acquired automatically as a result of belonging to a certain occupational category »49. Article 22 of the Regulation increases the instruments of extension by providing for the possibility of mandatory mutual organisations, that to say whose creation is not left to the discretion of a socio-professional group. The particular nature of social insurance schemes thus requires governance specific to a principle of the social and solidarity economy: freedom of membership. And so interactions between the two categories arise. Mass membership, the guarantee of perfect mutualisation, also leads to denser professional and inter-professional solidarity.
- 50 In particular Rwanda and Ghana. See V. Ridde, A. Asomaning Antwi, B. Boidin, B. Chemouni, F. Hane, (...)
20The UEMOA provisions were adopted six years after the Law of 4 June 2003 came into force, and repeal all earlier contradictory provisions, but have still not been applied. The conclusion is that Senegalese law is inflexible and ill-suited to providing a basis for a multi-pronged approach in the face of the multiple socio-professional categories involved in the plan to expand health insurance. This unfitness, begotten by a legal regime unified to excess, is impeding the prospects of extending health insurance in certain categories, while comparative law studies have shown that some African countries have already succeeded in making membership of occupational mutual schemes mandatory50.
- 51 The World Health Report - Health Systems Financing: The Path to Universal Coverage, WHO, 2010; A. L (...)
21From this point of view, the question of whether to conserve the historical spirit of the social and solidarity economy or to reformulate it is at the centre of the conceptual conflicts between the actors involved. The UEMOA has enshrined the voluntary nature of membership of mutual health schemes in its principles, whilst also allowing for the possibility of mandatory membership reserved for certain occupational categories, whereas the WHO has been saying since 2010 that it will be impossible to achieve universal health coverage with voluntary schemes51. Several analysts consider with regard to mutual health organisations that the success of voluntary schemes is modest at best and even quite poor, and that in some countries they have actually been an obstacle to universal health coverage.
- 52 Ibid.
22Voluntary schemes are thought to produce differentiated social dynamics and to accentuate inequality52:
-
they introduce discontinuity of membership according to age, sex, ethnic origin, religion, marital status, educational level, degree of trust in management, etc.;
-
they seem, according to the statistics, to exclude certain categories, in particular young people, large families, women, people on low incomes, etc.;
II - A compromise that is prejudicial to a fairer and more equitable social protection system
- 54 J. Issa-Sayegh, Le droit sénégalais de la sécurité sociale, NEA, 1982, p. 21; O. Kaufmann, « L’impl (...)
23Institutional unity of health insurance in Senegal is impossible. The circumstances of the creation of the mandatory health insurance system, driven by the victories won by salaried workers54, has generated an institutional organisation that it would be extremely difficult to reproduce as part of the process of extending protection to self-employed categories of workers or non-active segments of the population. The law has created an even greater segmentation of health insurance by multiplying the number of different statuses. It has introduced a divide that is detrimental to solidarity in health insurance (A) and thus illustrates a weakening of the values common to the SSE and social security (B).
A - The dilution of occupational and socio-professional solidarity
- 55 J. Issa-Sayegh, Le droit sénégalais de la sécurité sociale, op. cit., p. 11.
- 56 J.-J. Dupeyroux, M. Borgetto, R. Lafore, R. Ruellan, Droit de la sécurité sociale, op. cit., p. 195 (...)
- 57 P. Chauchard, J.-Y. Kerbouc’h, C. Wilmann, « Droit de la sécurité sociale », op. cit., p. 240.
- 58 C. Vianney, « Une histoire contrastée », Informations sociales, no. 6, 1987, p. 39; P. Batifoulier, (...)
24Beyond its services and financing, the social security system is in fact dependent on an inclusive collective consensus55. Solidarity would seem to be a technique whose purpose is redistribution, without which the notion of a social security system would lose all meaning, and be reduced to a simple mutualisation of the type that exists even in private insurance56. Universality and solidarity are considered to be historically linked57. Social protection therefore exists as a result of the bringing together of people with « quite heterogeneous » abilities to contribute « so as to transfer the surplus resources »58.
- 59 The rates of partial coverage of health expenses are determined by the internal rules of the IPM an (...)
- 60 Institution de Coordination de l’Assurance Maladie Obligatoire (Institution for the Coordination of (...)
25The mandatory health insurance scheme in Senegal implements the solidarity technique and achieves the goal of redistribution by applying a progressive rate of contributions, with high incomes paying more, while providing an identical level of benefits for all the insured and their beneficiaries59. Recently, the ICAMO60 has observed a more active form of solidarity between the health insurance institutions, the Institutions de Prévoyance Maladie (IPMs). A guarantee fund has been set up, funded by contributions from the IPMs, to support organisations in difficulties and introduce inter-professional solidarity among wage-earning workers.
- 61 In 2018, the IPMs provided partial coverage of all medical expenses incurred as a result of non-occ (...)
- 62 Namely coverage of 80% of all medical expenses, including hospitalisation, consultation, examinatio (...)
26The purpose of the IPM is to cover part of the medical, pharmaceutical and hospitalisation expenses incurred by its beneficiaries in Senegal, with the percentages being fixed by its internal rules, but also subject to approval by the Minister in charge of labour relations. The regulations relating to this responsibility determine the beneficiaries (the company’s permanent workers, plus their spouse and dependent children (within the meaning of the family benefits system)). The rates of partial coverage of health expenses are determined by the internal rules, but they must be the same for all beneficiaries61. These rates may vary upwards or downwards according to the results recorded, as long as the increase or decrease is applied consistently and on the same date to all the beneficiaries and remains within the regulatory upper and lower limits. The civil servants’ health insurance scheme is by far the most favourable62.
- 63 To use the words of C. Bec, « La sécurité sociale entre solidarité et marché », op. cit.
- 64 Preamble to the UEMOA Regulation, which refers to « the commitment of all the Member States and the (...)
27The retention of a solidarity and equality-based approach in the mutual health organisation system, completing that which already exists in the statutory and mandatory social security schemes, would have allowed social mutuality to be firmly anchored as a « vector of equal freedom enabling individual freedoms to be tied into the overall social system »63. The aim of reducing inequality and exclusion stated in national and community law64 cannot be achieved without an interlinking of national and socio-professional solidarity. The instruments of solidarity in the mandatory schemes are neutralised in the mutual health schemes by a principle of non-progressive contribution rates. The first paragraph of Article 8 of the Law of 2003 provides that « contributions may be adjusted according to the income of the participating members ». Solidarity through differentiated contributions is therefore not a principle, but simply something that is permitted.
28The link between the first and second paragraphs of the same article allows us to understand that this permission constitutes the basis for the possibility of introducing unequal benefits. In the wording of the first paragraph, « mutual health organisations may not introduce, as far as the levels of benefits and contributions are concerned, any discrimination between members of categories of participating members unless such discrimination is justified by particular situations ». The particular situations the law is referring to are not explicitly defined, but it is likely that a difference in contributions could constitute one such situation. Furthermore, this provision in the Senegalese law appears to have inspired the UEMOA through the Regulation governing social mutuality. Article 36 of the Regulation provides that « participating members are equal in their rights and obligations. However, social mutual funds have the possibility of setting up specific schemes according to the nature of the risks covered and the contributions paid. Contributions may also be adjusted according to the participating members’ ability to contribute ». It is necessary to make a « circular reading » of the provision to understand that the purpose of it is not to establish the principle of non-discrimination, but to introduce permission to provide for different statuses. The adjustment of contributions according to the participating members’ ability to contribute is only an instrument of solidarity when it is accompanied by identical benefits for all members, which is not specified by the text even though its wording does not preclude it.
B - The relegation of the primary goals of the SSE and social security
- 65 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de le (...)
29The extension of health coverage in Senegal has produced a conflict between freedom, solidarity and independent management, principles of the social and solidarity economy that social security struggles to reconcile65. However, the compromise introduced by Senegalese law and the UEMOA Regulation is largely in favour of granting mutual organisations a certain freedom with a sort of authorisation to select the risks covered and benefits provided (1), which leads to the maintaining of the inequalities already observed (2).
1 - The allowance of selection
- 66 J.-L. Souchet, « Le mouvement mutualiste dans les évolutions du système de protection sociale franç (...)
- 67 ILO Convention C102 - Social Security (Minimum Standards), adopted in Geneva on 28 June 1952.
30Avoiding differentiated protection in the country whilst preserving the financial equilibrium of the mutual organisations seems difficult to achieve, both here and elsewhere66. If it is not possible to eliminate inequalities, at the very least a minimum level of protection should be guaranteed so that illness ceases to be synonymous with poverty and so that social security can be a means of breaking the intergenerational cycle of poverty. ILO Convention C.102, whose provisions on minimum standards for the coverage of medical care have not been ratified, nevertheless constitutes an essential standard for our era, which should be fully ratified by Senegal67.
- 68 Art. 22 of Law no. 2003-14 of 4 June 2003 on mutual health insurance organisations: « The articles (...)
- 69 Out of a sample of 81 mutual health organisations, a large majority (58) covered only small risks w (...)
31The legal instruments which, under Senegalese law, allow the selection of risks and persons as well as a very low level of benefits, are identified by the freedom to set the level of contributions and benefits enshrined in the articles of association or adopted by a general meeting68 of the mutual organisation. Such provisions authorise the mutual organisation to provide the cheapest care, but for common conditions with a high probability of occurrence, whilst avoiding those that are rarer and require more expensive benefits such hospitalisation and serious or chronic conditions69. The cost of the insurance, the search for savings and the financial equilibrium of the organisations concerned transform accounting and financial realities into essential factors in the search for compromises.
- 70 M. Gauchet, Le nouveau monde, Gallimard, « sciences humaines » collection, Paris, 2007, p. 458. The (...)
- 71 Articles 79 to 94 of Regulation no. 07/2009/CM/UEMOA governing social mutuality; Implementing Regul (...)
32In addition to the political and ideological limits (neo-liberal theories)70 and structural limitations (modest budgets of African States) there are also contingencies specific to governance and management. It is worth taking a closer look at the importance of the provisions on oversight and sanctions71 that apply to mutual organisations, as this reveals how their financial viability has become a value competing with those that are intrinsic to social security and the social and solidarity economy.
- 72 Conférence Interafricaine des Marchés d’Assurance (Inter-African Conference on Insurance Markets)
33What still seems to create a difference between mutual health organisations and private insurance is the presence of a supervisory body overseeing the former, although, in many respects, it is not that different from that of the CIMA’s72 Regional Commission for Insurance Supervision.
- 73 See in particular Art. 27 of the UEMOA Regulation governing social mutuality: « social mutual funds (...)
34The 2003 law places mutual health organisations under the supervision of the Ministry of Health, but the oversight concerns only accounting and financial aspects73. The compromise between freedom and responsibility should prevent the mutual organisations from losing their specificity by giving them a particular identity, even while a minimum social agenda is imposed upon them. A mitigation of the (overly) uniform nature of the legislation would have allowed for more contextualisation on the voluntary or mandatory nature of membership or on the level of solidarity. The excessive amount of space taken up by the law and its disengagement from the social responsibility aspect have led to a verticalisation and recentralisation of decision-making on the aspects where more freedom would have been desirable (voluntary or mandatory nature of membership of occupational mutual schemes with the aim of encouraging more people to join those schemes). The distinctive values of mutuality, applied to social security, should come through more clearly with a densification of human-centric and quality-focused criteria.
- 74 « The health benefits of the CMU are precarious and not guaranteed, including for members who have (...)
- 75 Art. 21 of the Regulation.
- 76 P. Batifoulier, V. Duchesne, A.-S. Ginon, « La construction d’un marché éduqué de l’assurance santé (...)
35The very liberal option taken by Senegalese lawmakers on the content of the mutual health organisations’ benefit packages74 runs contrary to the approach defined by the eight Member States of the UEMOA. This approach is based on a different reading of the relationship between social mutuality and solidarity. The provision for mandatory mutual schemes, imposed by administrative decisions75 as well as the possibility of requiring mandatory membership in certain occupational categories are options in community law that Senegalese law would do well to adopt. Only provisions of this kind are liable to give rise to a viable compromise that enshrines the « idea that the State and the market are not opposing forces »76.
2 - Persistence of inequality and exclusion
- 77 See the table entitled « Description de caractéristiques du modèle de mutuelles dans le projet de D (...)
36Inequalities in the Senegalese health insurance system are consubstantial with the creation of the system almost fifty years ago, with differentiated levels of benefits for civil servants and salaried workers. These inequalities were in no way alarming as they did not call into question the basic right to health coverage. The way the Senegalese system has developed has accentuated the presence of category-based solidarity, which goes against the notions of national solidarity and cohesion. The 2003 law and the administrative practices that it generated have exacerbated the phenomenon. The action taken by the public authorities to combat very low levels of benefits has been incentive-based. In practice the CMU and the DECAM encourage mutual health organisations wishing to be benefit from State support to give up their prerogatives on setting the level of the contributions and the healthcare package offered. But, even seen from this angle, the social mutuality system still falls down on quality. Non-coverage of chronic conditions continues, thereby excluding the seriously ill from the health coverage system77. The sources of inequality are not only to be found in public financing, but also in the lack of a will to establish real solidarity, for these inequalities subsist even in the category that does not receive government subsidies.
- 78 G. F. Gankpe, E. C. Gankpe, A. N. Baleba, L. Zinsou, C. Messenge, « Les mutuelles de santé reprodui (...)
- 79 M. Borgetto, « La solidarité, l’égalité et la responsabilité face aux transformations de l’Etat pro (...)
37The extension of health insurance coverage is driven by a desire to reduce inequalities, not eliminate them, by offering a minimum level of healthcare, which, for this very disadvantaged segment of the population, must look like a « luxury ». This perverse effect of any attempt to extend the systems of coverage is a phenomenon that is shared with other African States78 and authors based outside the continent regularly describe it79.
- 80 In 2020, only 18% of people were up to date with their contributions and fewer than 40% of benefici (...)
- 81 J.-F. Draperi, quoted by S. Ctin-Marx and M. Helly, « Le projet de l’économie sociale et solidaire (...)
- 82 P. Batifoulier, V. Duchesne, A.-S. Ginon, « La construction d’un marché éduqué de l’assurance santé (...)
- 83 Ibid.
38The unease generated by the low rates of membership of the mutual health organisations80 and the weakness of the benefits offered raises questions about the real explanations for this situation. They are cultural, no doubt economic, but also legal. Concerning the way forward to achieve greater solidarity and more dynamic actions, two routes deserve to be examined in more depth. Policies incentivising mutual health organisations to offer more substantial care packages more focused on solidarity and social responsibility should be continued and strengthened. The linking of the social and solidarity economy to health insurance should work to influence the « market rules so that the market becomes more oriented towards the public interest, more inclusive and equitable »81. The pursuit of the goal of the « minimum health benefit basket » should be accompanied by limits on rates, coverage ceilings, reimbursement rates, maximum prices for healthcare services, etc. A harmonisation of copayments for consultations with health professionals, medicines and medical tests must also be part of the effort to achieve a mandatory level of coverage. The tools of such an « education »82 of the system, which will involve the approval of a set of « more responsible specifications », « responsible contracts » or « responsible, solidarity contracts », have been tried and tested elsewhere and have produced significant effects83.
- 84 Rapport évaluation finale du programme d’appui de la micro assurance santé au Sénégal, CTB, Agence (...)
39Continuing the incentive policy remains a transitional option which can contribute to solving the issue of the difference between benefits, but will not provide the answer to the financing issue in the face of expenses that have become unsustainable for the State. A more far-reaching reform that goes beyond incentive policies is urgently needed. The excessively light-touch leadership provided by the public authorities, which reflects the co-existence of different visions at national level, has led to a « lack of debate on major strategic issues and a failure to develop national policies and orientation documents »84. The future of the extension of health insurance, combined with the conservation of solidarity, equality and equity as indicators of the humanism of the health insurance system, depends on a willingness to mobilise the ability to contribute of the liberal professions, other self-employed people, large-scale traders and entrepreneurs to fuel inter-professional and national solidarity.
40Bringing these professions into the system by introducing mandatory mutual schemes in the different occupational categories of the formal and informal economy, is the only way of funding the mutuality system and supporting the State’s efforts in favour of the most disadvantaged. The ability of these categories to contribute must be mobilised if any system based on solidarity is to play its redistributive role.
41A campaign of awareness-raising on the need for such measures will be necessary, but the State must not waiver in its determination to implement them. Once the mandatory mutual health schemes have been set up, the goal of effectively enrolling the persons targeted will constitute the second stage of the process. Incentivising self-employed people to join en masse could be based on a policy of making certain tax and social benefits conditional upon doing so: obtaining a NINEA (company ID number), registration with the RCCM (Trade and Property Credit Register), tendering for public procurement contracts, etc. are all instruments the State could use to encourage self-employed people to join. The creation of a solidarity fund between the mutual health organisations should complete the solidarity link as part of the extension of health insurance.
42Extending health insurance in Senegal with the ultimate goal of achieving universal health coverage will require a firm, sustained commitment from the State, but also - and this will be of equal importance - a popular and then national realisation of the necessity of the approach, without which there can be no social and solidarity economy.
Notes
1 The first mutual health insurance scheme in Senegal was created in 1989 in a village called Fandene. See J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de leurs acteurs », Revue internationale de l’économie sociale, no. 345, July 2017, p. 69
2 Explanatory statement on Law no. 2003-14 of 4 June 2003 on mutual health organisations: « mutual health organisations are a modern, promising instrument for developing the health insurance system in particular, and beyond that, for contributing to improving the health of the population. The proof can be found in the spontaneous and progressive development of the mutualist system in Senegal », JORS (Official Gazette of the Republic of Senegal) no. 6110 of 5 July 2003, p. 675 ff; completed by Decree no. 2009-423 of 27 April 2009 implementing Law no. 2003-14. See also J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de leurs acteurs », op. cit.
3 In particular the assistance and insurance programmes of the Universal Health Coverage (Couverture Maladie Universelle, CMU) system overseen by the CMU Agency (Agence de la CMU) (Decree no. 2015-21 of 7 January 2015 creating the National CMU Agency (Agence Nationale de la CMU), even though the oversight of mutual health organisations dates from a law of 2003.
4 « Plan stratégique de la Couverture Maladie Universelle 2013-2017 », Ministry of Health and Social Action, 2013, p. 19: « [mutual health organisations] are, in view of the current level of coverage and the scale of the informal and rural sectors of the economy in the country, the only ones that have the potential to cover the majority of the Senegalese population ». See also the « Plan stratégique de développement des mutuelles de santé au Sénégal », Ministry of Health, July 2004, p. 25: « La force des mutuelles de santé est leur acceptabilité sociale ».
5 African Union Social Policy Framework adopted in 2008; Harmonisation framework for the technical, financial and institutional governance of social security bodies; Multilateral Convention on Social Security of the Inter-African Conference on Social Insurance (CIPRES); Supplementary Act of the Economic Community of West African States (CEDEAO) relating to the General Convention on Social Security; Regulation no. 07/2009/CM/UEMOA governing social mutuality within the West African Economic and Monetary Union (UEMOA); Implementing Regulation no. 2/2011/COM/UEMAO of 31 August 2011 laying down the modalities and procedures for the constitution, approval and registration of social mutual funds and their overarching structures; Implementing Regulation no. 3/2011/COM/UEMOA on the prudential rules that must govern the financial resources of social mutual funds; Implementing Regulation no. 3/2012/CM/UEMOA adopting the social mutual funds’ chart of accounts within the UEMOA; Bamako Initiative; etc.
6 According to the World Bank, development depends directly on individuals’ ability to overcome the risks that must be anticipated and calculated by individuals: see the World Development Report « Risk and Opportunity, Managing Risk for Development », World Bank, 2013; the World Health Report « Health Systems Financing - The path to universal coverage », WHO, Geneva, 2010; the Declaration of Alma-Ata signed at the International Conference on Primary Health Care, 1978: primary health care « requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation… ».
7 See in particular: Law no. 2021/017 of 30 April 2017 on social mutuality in the Republic of Guinea; Organic Law no. 17/02 of 8 February 2017 laying down the fundamental principles relating to mutuality in the Democratic Republic of the Congo; Law no. 2008-10 of 30 April 2008 establishing the general regime applicable to mutual health organisations in the Republic of the Niger; the Mutual Health Organisations Code in Mali; Law no. 060-2015 introducing a universal health insurance system in Burkina Faso.
8 X. Itcaina, « Economie sociale et solidaire », Dictionnaire des politiques territoriales, 2020, p. 187. In it the author quotes J.-F. Draperi and D. Castiel: « The new social economy, or social and solidarity economy, is being asserted through new citizens’ initiatives, in particular in the areas of solidarity, environmental protection and the creation of news services ».
9 Art. 2 of the Orientation Law of 4 June 2021 on the social and solidarity economy, JORS (Official Gazette of the Republic of Senegal) no. 7450 of 21 August 2021.
10 Art. 1 of Law no. 2003-14 of 4 June 2003 on mutual health insurance organisations: « A mutual health organisation is a non-profit group of persons which, mainly through the contributions of its members, proposes to carry out, in the interests of those members or their families, welfare, mutual assistance and solidarity actions in particular to cover all or part of health care provision (…). Mutual health organisations are bound by the following mutualist principles: solidarity, freedom, democracy and independence ».
11 J.-L. Laville, « Economie et solidarité. Esquisse d’une problématique », L’économie solidaire. Une perspective internationale, Paris, Fayard, 2013, 2nd ed, p. 9.
12 P. D. Rousseau, « Malaise dans l’économie sociale et solidaire », SER Etudes, 9/2020, p. 57.
13 C. Bec, « La sécurité sociale entre solidarité et marché », Revue Française de Socio-économie, 2020, special issue.
14 J.-P. Chauchard, J.-Y. Kerbouc’h, C. Wilmann, « Droit de la sécurité sociale », LGDJ, 7th ed, p. 95: « Whereas social security is mandatory and tightly regulated by the State, mutuality is marked by freedom of membership for any individual wishing to arrange additional protection ».
15 The State employees’ and customs and armed forces mutual organisations top up the civil servants’ health scheme, which covers 80% of certain costs.
16 In 2015, a national survey carried out using the Annual Labour Declaration (DASMO) revealed that IPMs only covered 35% of the population of identified salaried workers. J. Issa-Sayegh, Le droit sénégalais de la sécurité sociale, Nouvelles Editions Africaines, 1982, p. 21; J.-J. Dupeyroux, M. Borgetto, R. Lafore, R. Ruellan, Droit de la sécurité sociale, 14th ed., 2001, p. 59.
17 Civil servants’ health care expenses are partially covered by the national budget. Retirement pensions are paid by the National Retirement Fund (FNR).
18 Salaried workers in the private and public sector and civil servants only benefit from social security as part of mandatory schemes (Social Security Code, Law no. 73-37 of 31 July 1973, JORS (Official Gazette of the Republic of Senegal) no. 4308 of 4 August 1973, p. 1564. The Law of 30 April 1975 on social welfare institutions extended coverage to health risks and pharmaceutical expenses and the Order of 9 March 1978 created the nation pension institution, the Institut de Prévoyance Retraite du Sénégal (IPRES).
19 In 2018, there were 459,338 insured and beneficiaries of the civil service scheme and 302,915 in the mandatory salaried workers’ scheme, namely a total of 762,253 persons out of a total population of over 16 million: Revue Globale et analyse du système national de protection sociale au Sénégal, ILO, January 2021.
20 Revue Globale et analyse du système national de protection sociale au Sénégal, 2021, op. cit.
21 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de leurs acteurs », op. cit. According to the author: « We are attempting to demonstrate that a single institution, the mutual society, may be justified by different principles to give it meaning, which leads to significant coordination problems between actors (…). The systems of representation in the mutual sector are diverse and the apparent consensus on the form adopted in the Law conceals power relationships that are being challenged ».
22 C. Deville, F. Fecher, M. Poncelet, « Les mutuelles de santé subventionnées comme instruments de la Couverture Maladie Universelle au Sénégal », Rencontres des études Africaines en France, July 2018.
23 38 ILO Conventions have been ratified by Senegal, of which 32 are in force. For Convention C102, which defines and establishes the minimum standards for the 9 branches of social security, Senegal has only ratified parts VI to VIII on employment injury and illness benefits, family benefit and maternity benefit. Senegal has also ratified Convention C121on employment injury and illness benefits and Convention C183 on maternity protection. The country has also acceded to ILO Recommendation no. 202 on social protection floors adopted in 2012, which advocates the vertical and horizontal extension of social cover by « national strategies for the extension of social security ».
24 See also: the United Nations General Assembly Resolution on Universal Health Coverage urging States to fund their health system via fair and inclusive mechanisms; the United Nations General Assembly Resolution of 6 December 2012 on Universal Health Coverage.
25 Plan to Develop Universal Health Insurance Coverage as part of decentralisation.
26 C. Deville, F. Fecher, M. Poncelet, « Les mutuelles de santé subventionnées comme instruments de la Couverture Maladie Universelle au Sénégal », op. cit.; Stratégie Nationale de Financement de la Santé (SNFS) pour tendre vers la couverture sanitaire universelle au Sénégal, Ministry of Health and Social Action, 2017.
27 J.-C. Graz, La gouvernance de la mondialisation, Paris La découverte, 2008, p. 107: « To varying degrees, societies must find differentiated responses to establish the limits and renouncements necessary to constitute social ties within the restrictive framework of life ».
28 See in particular: the free care programme for children aged 0 to 5 years; students’ coverage by the Centres des œuvres universitaires (student welfare bodies); free care for disadvantaged over-sixties (73,202 beneficiaries in 2018); full health care coverage for disabled people (19,637 beneficiaries in 2018); 100% coverage of the costs of caesarean sections; coverage of the costs of dialysis; etc.
29 Namely 1,377,107 beneficiaries for 475,909 members in 2018: Revue globale et analyse du système de sécurité sociale au Sénégal, ILO, 2021.
30 C. Bec, « La sécurité sociale entre solidarité et marché », op. cit.
31 C. Deville, F. Fecher, M. Poncelet, « Les mutuelles de santé subventionnées comme instruments de la Couverture Maladie Universelle au Sénégal », op. cit.
32 « Health insurance in low-income countries », OXFAM Briefing paper, p. 6; Plan national de développement sanitaire 2009-2018, Dakar, Ministry of Health and Social Action, 2013, p. 29 : « The low level of development of mutual health organisations in the country is linked in part to the low level of involvement of the key stakeholders in setting up mutual health organisations (…). Weak support from central government and local authorities for community mutual health organisations has not so far allowed the mutual health organisations to be turned into relays for extending health risk cover. The low level of support from the public authorities and the modest contributions have obliged most mutual organisations to offer packages of benefits that are not very attractive to their members ».
33 B. Fonteneau, S. Vaes, J. Van Ongeval, « Toward redistributive social protection? Insight from Senegal and Morocco », quoted by V. Ridde, A. Asomaning Antwi, B. Boidin, B. Chemouni, F. Hane, L. Tourer, « Les défis des mutuelles communautaires en Afrique de l’ouest », in V. Ridde, Vers une couverture sanitaire universelle en 2030 ? Reforme en Afrique sub saharienne, Edition Science et Bien Commun, 2021.
34 See J.-L. Souchet, « Le mouvement mutualiste dans les évolutions du système de protection sociale français », Vie sociale, 2008, no. 4, p. 104. The author summarises the neoliberal approach that he is challenging as follows: « The WHO’s well-being and quality of life approach finds its dynamics thwarted by the commodification-based approach of the IMF and the WB ».
35 Introduced in 2013 and resting « on a vision of a Senegal where all individuals, all households and all communities benefit from universal access to quality promotional, preventive, curative and rehabilitation health services without any form of exclusion », Ministry of Health and Social Action, 2013, p. 9.
36 Y. Guichoua, « Solidarité professionnelle et partage des risques parmi les travailleurs informels. Une étude de cas à Abidjan », Presses de Sciences Po, 2007, no. 43, p. 191.
37 Revue globale et analyse du système national de protection sociale du Sénégal.
38 Explanatory statement on the Law of 4 June 2003 on mutual health organisations: « Mutual health organisations are a modern, promising instrument for developing the health insurance system in particular, and beyond that, for contributing to improving the health of the population; Regulation no. 07/2009/CM/UEMOA governing social mutuality within the West African Economic and Monetary Union (UEMOA); « The need to set up, with the full participation of the populations of the Member States, a social risk management policy (…) ».
39 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de leurs acteurs », op. cit.
40 Ibid.
41 Plan stratégique de développement des mutuelles de santé au Sénégal, Ministry of Health, July 2004, p. 25.
42 B. Boidin, « Extension de l’assurance maladie et rôle des mutuelles de santé en Afrique : les leçons de l’expérience sénégalaise », Revue de l’Institut d’économie politique, 2012, p. 47: « The lorry drivers’ scheme was set up based on this category’s past experience in terms of mutual assistance, solidarity and social control practices ».
43 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de leurs acteurs », op. cit.
44 G. F. Gankpe, E. C. Gankpe, A. N. Baleba, L. Zinzou, C. Messenge, « Les mutuelles de santé reproduisent-elles les inégalités de santé au Benin ? », Santé publique, 3/2018, vol. 30, p. 389.
45 Art. 12 of Regulation no. 07/2009/CM/UEMOA governing social mutuality within the West African Economic and Monetary Union: « Voluntary and non-discriminatory membership consists of a voluntary act of participation in a social mutual organisation not based on sex, race, nationality, political or religious affiliation ».
46 Y. Guichoua, « Solidarité professionnelle et partage des risques parmi les travailleurs informels. Une étude de cas à Abidjan », op. cit.
47 In particular, « Une obligation attachée ou couplée à des bénéfices : obtention de permis d’occuper, registre de commerce, NINEA, accès au micro crédits, distribution de semences… », Stratégie nationale de financement de la santé pour tendre vers la couverture sanitaire universelle (SNFS), Ministry of Health and Social Action, 2017, p. 28.
48 M. B. Niang, « Ancrage juridique et perspectives du dialogue social au Sénégal », in P. Auvergnon, C. Kenoukon, Dialogue social dans l’espace OHADA et ailleurs dans le monde, L’Harmattan, 2018, p. 221.
49 Art. 33 of the Regulation.
50 In particular Rwanda and Ghana. See V. Ridde, A. Asomaning Antwi, B. Boidin, B. Chemouni, F. Hane, L. Tourer, « Les défis des mutuelles communautaires en Afrique de l’ouest », op. cit.
51 The World Health Report - Health Systems Financing: The Path to Universal Coverage, WHO, 2010; A. Letourmy, A. Pavy-Letourmy, « La micro-assurance de santé dans les pays à faible revenue », AFD, 2005, p. 26; B. Fonteneau, S. Vaes, J. Van Ongeval, « Toward redistributive social protection? Insight from Senegal and Morocco », op. cit. G. F. Gankpe, E. C. Gankpe, A. N. Baleba, L. Zinzou, C. Messenge, « Les mutuelles de santé reproduisent-elles les inégalités de santé au Benin ? », op. cit.
52 Ibid.
53 Ibid.: « By making membership mandatory, more people could benefit from social protection » because, according to the authors, the current system « can even contribute to reproducing inequalities in the health care field ».
54 J. Issa-Sayegh, Le droit sénégalais de la sécurité sociale, NEA, 1982, p. 21; O. Kaufmann, « L’implantation et l’évolution du droit de la sécurité sociale en Afrique francophone au sud du Sahara », op. cit., p. 267.
55 J. Issa-Sayegh, Le droit sénégalais de la sécurité sociale, op. cit., p. 11.
56 J.-J. Dupeyroux, M. Borgetto, R. Lafore, R. Ruellan, Droit de la sécurité sociale, op. cit., p. 195: « It is then up to the community to re-establish, through specific institutions, a social bond undermined by market forces »; R. Pelet, « Régimes, branches et fonds de la sécurité sociale », RDSS, 1/99, p. 13: « By extension, (…) it [the notion of a social security system] also supposes the implementation of solidarity between members of a given group in the face of the risks that the law designates, as social security is based on an idea of redistribution ».
57 P. Chauchard, J.-Y. Kerbouc’h, C. Wilmann, « Droit de la sécurité sociale », op. cit., p. 240.
58 C. Vianney, « Une histoire contrastée », Informations sociales, no. 6, 1987, p. 39; P. Batifoulier, V. Duchesne, A.-S. Ginon, « La construction d’un marché éduqué de l’assurance santé : une réorientation de la solidarité ? », Revue de l’IRES, 2021, p. 21; J. Issa-Sayegh, Le droit sénégalais de la sécurité sociale, op. cit., p. 11: « We can only talk of a social security system if the protection against social risks is organised collectively and specifically ».
59 The rates of partial coverage of health expenses are determined by the internal rules of the IPM and are the same for all the beneficiary members. These rates may vary upwards or downwards according to the results recorded as long as the increase or decrease is applied in a uniform manner: Order no. 9176 of 31 July 1976 establishing the standard model for the internal rules of the IPMs and the package of benefits covered.
60 Institution de Coordination de l’Assurance Maladie Obligatoire (Institution for the Coordination of Mandatory Health Insurance)
61 In 2018, the IPMs provided partial coverage of all medical expenses incurred as a result of non-occupational illness by the worker and their beneficiaries at rates ranging from 50 to 80%.
62 Namely coverage of 80% of all medical expenses, including hospitalisation, consultation, examinations and tests in public and approved private healthcare facilities: Revue globale et analyse du système national de protection sociale du Sénégal.
63 To use the words of C. Bec, « La sécurité sociale entre solidarité et marché », op. cit.
64 Preamble to the UEMOA Regulation, which refers to « the commitment of all the Member States and the Union to fighting poverty ». The orientation law on the social and solidarity economy establishes, in Article 19, the conditions for benefiting from « Social and Solidarity Economy » accreditation: « To provide, by its activities, support for people in vulnerable situations due to their economic and social situation: workers, users, customers, members or beneficiaries of that company » and « to contribute to the fight against health;, social, economic, educational and civic exclusion and inequality or to the maintaining and strengthening of territorial cohesion ».
65 J. Alenda-Demoutiez, « Les mutuelles de santé au Sénégal face aux difficultés de coordination de leurs acteurs », op. cit.: « The Senegalese mutualist convention is stretched between two main reference standards according to our study; that of private insurance on the one hand, via an instrumental vision, and a reference standard based on the values of the social and solidarity economy on the other ».
66 J.-L. Souchet, « Le mouvement mutualiste dans les évolutions du système de protection sociale français », Vie sociale, 4/2008, no. 4, p. 103.
67 ILO Convention C102 - Social Security (Minimum Standards), adopted in Geneva on 28 June 1952.
68 Art. 22 of Law no. 2003-14 of 4 June 2003 on mutual health insurance organisations: « The articles of association establish: - the obligations and benefits of the participating members or their family »; Articles 19 and 42 of the UEMOA Regulation governing social mutuality.
69 Out of a sample of 81 mutual health organisations, a large majority (58) covered only small risks while 23 mutual health organisations covered bigger risks such as hospitalisation and surgery in hospital settings (« Plan stratégique de développement des mutuelles de santé au Sénégal », Ministry of Health, 2004). See also the « Plan stratégique de développement de Couverture Maladie Universelle au Sénégal, 2013-2017 », Ministry of Health and Social Action, 2013.
70 M. Gauchet, Le nouveau monde, Gallimard, « sciences humaines » collection, Paris, 2007, p. 458. The author talks about the theories that are « attempting to align the overall functioning with the rules of the economic side, which are supposed to provide the optimum formula for the collective dynamic ».
71 Articles 79 to 94 of Regulation no. 07/2009/CM/UEMOA governing social mutuality; Implementing Regulation no. 2/2011/COM/UEMAO of 31 August 2011 laying down the modalities and procedures for the constitution, approval and registration of social mutual funds and their overarching structures; Implementing Regulation no. 3/2011/COM/UEMOA on the prudential rules that must govern the financial resources of social mutual funds, establishing the conditions of organisation and intervention of the Guarantee Fund, clarifying the modalities relating to the control of social mutual funds and determining the procedures for taking safeguarding measures, administrative sanctions and the withdrawal of accreditation by the competent administrative authorities; Implementing Regulation no. 3/2012/CM/UEMOA adoption of the social mutual funds’ chart of accounts within the UEMOA.
72 Conférence Interafricaine des Marchés d’Assurance (Inter-African Conference on Insurance Markets)
73 See in particular Art. 27 of the UEMOA Regulation governing social mutuality: « social mutual funds have an obligation (...) to produce and submit annual reports (technical, ethical and financial report) to the social mutuality administrative body and to the members ».
74 « The health benefits of the CMU are precarious and not guaranteed, including for members who have paid their dues », Revue globale du système de protection sociale au Sénégal, op. cit.
75 Art. 21 of the Regulation.
76 P. Batifoulier, V. Duchesne, A.-S. Ginon, « La construction d’un marché éduqué de l’assurance santé : une réorientation de la solidarité ? », op. cit., p. 21.
77 See the table entitled « Description de caractéristiques du modèle de mutuelles dans le projet de Décentralisation de l’assurance Maladie (DECAM) Sénégal », quoted by I. Seck, A. T. Dia, O. Sagna, « Déterminants de l’adhésion et de la fidélisation aux mutuelles de santé dans la région de Ziguinchor (Sénégal) », Santé publique, 2017, p. 105.
78 G. F. Gankpe, E. C. Gankpe, A. N. Baleba, L. Zinsou, C. Messenge, « Les mutuelles de santé reproduisent-elles les inégalités de santé au Benin ? », op. cit., p. 389: « The impact of mutual health organisations, as they currently operate, therefore remains marginal and can even contribute to a reproduction of inequalities in health care ».
79 M. Borgetto, « La solidarité, l’égalité et la responsabilité face aux transformations de l’Etat providence », in C. Bec, G. Procacci (dir.), De la responsabilité solidaire. Mutations dans les politiques sociales d’aujourd’hui, Syllepse, Paris, 2003, p. 48; R. Bigot, E. Daudey, S. Haibian, « Note de synthèse du CREDOC», September 2014, no. 11; A.-S. Ginon, « L’assurance maladie ; quelle place pour le marché ? », in M. Borgetto, A.-S. Ginon, F. Guiomard (dir.), Quelle(s) protection(s) sociale(s) demain ?, Dalloz, Paris, 2016; R. Lafore, « La CMU, un nouvel îlot dans l’archipel de l’assurance maladie », Droit Social, January 2000, p. 24; D. Tabuteau, « Une rationalisation inachevée du financement de la sécurité sociale », RDSS, 2nd part, 2016, p. 134.
80 In 2020, only 18% of people were up to date with their contributions and fewer than 40% of beneficiaries were paying their own contributions: V. Ridde, A. Asomaning Antwi, B. Boidin, B. Chemouni, F. Hane, L. Tourer, « Les défis des mutuelles communautaires en Afrique de l’ouest », op. cit.
81 J.-F. Draperi, quoted by S. Ctin-Marx and M. Helly, « Le projet de l’économie sociale et solidaire : fonder une économie capitaliste. Entretien avec Jean-François Draperi », Mouvements, Qui est le patron des associations ?, 2015, p. 38.
82 P. Batifoulier, V. Duchesne, A.-S. Ginon, « La construction d’un marché éduqué de l’assurance santé : une réorientation de la solidarité ? », op. cit.
83 Ibid.
84 Rapport évaluation finale du programme d’appui de la micro assurance santé au Sénégal, CTB, Agence belge de développement, 2012, p. 12.
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Mohamed Bachir Niang, « The role of the social and solidarity economy in the extension of health insurance in Senegal », Revue de droit comparé du travail et de la sécurité sociale, 4 | 2022, 110-127.
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Mohamed Bachir Niang, « The role of the social and solidarity economy in the extension of health insurance in Senegal », Revue de droit comparé du travail et de la sécurité sociale [En ligne], 4 | 2022, mis en ligne le 15 décembre 2023, consulté le 12 mai 2026. URL : http://journals.openedition.org/rdctss/4697 ; DOI : https://doi.org/10.4000/rdctss.4697
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