Social health protection for the poor: Belgium’s support in sub‑Saharan Africa

Abstract

Belgium’s co‑operation, through its development agency Enabel, is supporting nationwide social health protection for people working in the informal economic sector in low-income countries in sub-Saharan Africa. A committed government, ready to subsidise health protection mechanisms, and a sound vision and strategy shared with development partners, are crucial preconditions for success. A national institute for social health protection, combined with decentralised operational units, can ensure the necessary institutional environment for effective health coverage.

This content is part of TIPs In Practice series on poverty and inequalities developed in collaboration with the Development Co-operation Report 2024: Tackling poverty and inequalities through the green transition.  

Challenge

Social health insurance in Africa, often modelled on European systems that focus on formal economic sectors and salary retentions, does not align with the realities of many African countries, especially the poorest, characterised by large informal economies and irregular incomes. This misalignment excludes the most vulnerable populations from traditional social health protection (SHP) models. Community-based health insurance, led by civil society for decades, has shown limited sustainability.

Belgian co-operation through its development agency Enabel is supporting sub-Saharan Africa to develop social health protection systems that address inequalities and financial limitations when accessing quality health care, helping governments to take primary responsibility for protecting their population, while preventing significant health expenditures for the country’s economy.

Approach

Belgium has developed a general social health protection strategy and launched nationwide initiatives in Senegal (2013) and Niger (2021). It extended its efforts to Mauritania in 2022, as part of an EU project.

Belgium’s approach to supporting the development of social health protection systems against inequalities is based on:

• Vision and strategy. The social health protection combines quality service delivery with three protective mechanisms: “classical” health insurance, social assistance and advocacy for patients’ rights. Informal sector workers contribute a modest sum to health insurance, supplemented by government subsidies. For poorer families, the model allows for the government to cover all annual fees, ensuring no one is left behind.

• Institutional arrangements (see Figure 1). The organisation is set up as a single, nationwide, multi-level social health protection institute led by the partner government. The top levels are the regulating bodies with the departmental level comprising the operational units. It has the same pyramidal structure as health services to ensure sufficient supply (health care services) and demand (health protection) at each administrative level. If major conflicts emerge, both sides can escalate to a higher level.

• Strong political commitment and co‑ordination. Partner governments lead the system and establish the necessary national institutions, as well as inter-institutional co‑ordination mechanisms among ministries (e.g. Ministry of Finance, Ministry of Social Affairs and the Ministry of Health).

• Active participation and inclusion. The population is involved through patients’ rights schemes and complaint management mechanisms. Civil society reinforces the dialogue for community mobilisation and maintains a critical eye on the local performance of the health insurance to ensure transparency.

• Gradual implementation. The social health protection scheme was introduced gradually, both geographically and in terms of the coverage package, as its implementation and the reforms required are complex. The social health protection strategy focused initially on the informal economic sector, taking two to four years for Senegal, and about eight years for Niger.

Figure 1. Belgium’s social health protection model implemented in Senegal, Niger and Mauritania

Source: Enabel (2022), Social Health Protection: A path to fight against inequalities.

Results

The following results issue primarily from Senegal, as the initiatives in Niger and Mauritania, although promising, are still too recent to fully analyse.

• Piloting the experience: In Senegal, two departmental health insurance units (piloted by the Senegalese authorities and Enabel from 2013) covered over 400 000 beneficiaries. They target people working in the informal economy, the rural poor and the indigent population.

• Operational setup: In Senegal, a five-person team was responsible for all operational aspects of the social health protection system (e.g. community mobilisation, contracting, invoicing and payments).

• Adhesion fees, co-financing and coverage: The annual adhesion fee was USD 11 per person and the government paid an additional USD 11 for each adherent, thereby subsidising 50% of the income of the social health protection departmental units. In pilot areas, the coverage rate, calculated as the percentage of a given population that has paid its yearly adhesion fee, increased from 4% to 27% between 2013 and 2017. At that stage, Belgium ceased its financial support for the departmental units, as they became financially autonomous through the revenue from the annual contributions. Between 2018 and 2022, coverage increased to 80%, which is the maximum coverage rate expected for a voluntary scheme.

• Real protection and quality health care: The percentage of health care costs covered by the social health protection insurance in Senegal is 85-95%, with the patient paying the remaining sum (5-15%). Despite the COVID‑19 pandemic, access to quality health care increased by an average of 60%. As patients pay less, they are more likely to use the services.

Lessons learnt

• Leaving no one behind and the role of the international community: social health protection implementation is feasible in low-income countries, even in the informal economic sector, if the partner country takes ownership of its responsibilities and receives adequate support from international providers.

• There is an opportunity to enhance coherence by collaborating behind a unified nationwide social health protection model and reduce aid fragmentation. The health financing landscape is too fragmented with diverse initiatives that are not embedded in partner systems and limit effectiveness (e.g. partial free health care, community-based health insurance and voucher systems for pregnant women).

• Government-led and inclusive process: The partner country assumes the lead as a co‑ordinator and norm setter, with the objective of establishing a nationwide system. Stakeholders, such as civil society and the private sector, should be involved from the outset of the process, while ensuring alignment with national policies.

• Short-term financing with long-term goals: Development co-operation providers can support schemes with initial investments on a temporary basis (e.g. two first years) for the running costs of the operational units. This can be followed by further assistance in the development of a nationwide social health protection system.

• Social mobilisation: The population is highly motivated and solidarity within communities can become significant if they perceive concrete government commitments such as subsidies, the comprehensiveness of insurance coverage, transparency of fee-paying systems, and improved performance of health facilities. The quality of health care service delivery remains a crucial aspect in motivating people to adhere to a health insurance scheme.

Further information

Enabel (2022), Social Health Protection: A path to fight against inequalities, https://www.enabel.be/app/uploads/2022/11/Pro_soc_Sante_Ed2_EN_Web.pdf.

Ridde et al. (2022), Factors that foster and challenge the sustainability of departmental health insurance units in Senegal, International Social Security Review, https://doi.org/10.1111/issr.12300

Bossyns, P, F. Ladrière and V. Ridde (2018), Une assurance maladie à grande échelle pour le secteur informel en Afrique subsaharienne : Six ans d’expérience au Sénégal rural 2012 – 2017, Studies in Health Services Organisation & Policy, Vol 34, https://horizon.documentation.ird.fr/exl-doc/pleins_textes/divers19-06/010075821.pdf.

Waelkens, M-P et al. (2017), “An in-depth investigation of the causes of persistent low membership of community-based health insurance: a case study of the mutual health organisation of Dar Naïm, Mauritania”, BMC Health Services Research, Vol 17, p.535, https://doi.org/10.1186/s12913-017-2419-5.

Soors, W., F. Dkhimi and B. Criel (2013), “Lack of access to health care for African Indigents: a social exclusion perspective”, International Journal for Equity in Health, Vol 12, p.91 https://doi.org/10.1186/1475-9276-12-91.

Defourny, J. and J. Failon (2011), “Factors Influencing Enrollment in Community-Based Health Insurance Programs”, Mondes en développement, 153, 7-26, https://doi.org/10.3917/med.153.0007.

OECD resources

OECD (2024), Development Co-operation Report 2024: Tackling poverty and inequalities through the green transition, OECD Publishing, Paris, https://doi.org/10.1787/357b63f7-en. 

OECD (2020), OECD Development Co-operation Peer Reviews: Belgium 2020, OECD Development Co-operation Peer Reviews, OECD Publishing, Paris, https://doi.org/10.1787/026f1aad-en.  

OECD (2001), Poverty Reduction, The DAC Guidelines, OECD Publishing, Paris, https://doi.org/10.1787/9789264194779-en. 

To learn more about the Belgium’s development co-operation: 

OECD, “Belgium”, in Development Co-operation Profiles, OECD Publishing, Paris, https://doi.org/10.1787/58873fc4-en. 

See more In Practice examples from the Belgium here: https://www.oecd.org/development-cooperation-learning?tagkey+partner=belgium#search.