Additional file 1: of The extra cost of comorbidity: multiple illnesses and the economic burden of non-communicable diseases

Estimating the cost of chronic diseases in the presence of a comorbidity. (PDF 354 kb

Child Income Appropriations as a Disease-Coping Mechanism: Consequences for the Health-Education Relationship

<p>This paper analyses the relationships between HIV/AIDS and education taking into account the appropriative nature of child income. Using a theoretical model, we show that considering remittances from one’s child as an insurance asset can reverse the usual negative relationship between disease prevalence and educational investment. This prediction confirms the results of an empirical study conducted on data compiled from the Demographic and Health Survey (DHS) database for 12 sub-Sahara African countries for children aged between 7 and 22-years-old. Using regional HIV prevalence as a measure of health risk, we find that the ‘sign of the slope’ between health risk and the enrolment of children is not constant. Splitting the data based on expected remittance patterns (for example rural versus urban), we obtain that the effect is most likely driven by household characteristics related to child income appropriation.</p

Impact on adherence of dispensing exact quantities required.

<p>Impact on adherence of dispensing exact quantities required.</p

Level of membership score according to confidence (low, medium, high) in the current health system.

Note: Fig 2 shows that the more confidence respondents have in the health system, the more likely they are to join the insurance.</p

Operationalization of the seven dimensions of acceptability.

Operationalization of the seven dimensions of acceptability.</p

Descriptive statistics of adherence to treatment.

<p>Descriptive statistics of adherence to treatment.</p

Level of membership score according to confidence (yes/no) in the government as for the management of CBHI.

Note: Fig 1 shows that there are more respondents in favour of voluntary than mandatory membership.</p

STROBE statement.

With the low adherence to voluntary mutual health insurance, Senegal’s policymakers have sought to understand the feasibility of compulsory health insurance membership. This study aims to measure the acceptability of mandatory membership in community-based mutual health insurance (CBHI) and to understand its possible administrative modalities. The study consists of a national survey among a representative population sample selected by marginal quotas. The survey was conducted in 2022 over the phone, with a random composition method involving 914 people. The questionnaire measured the socio-economic characteristics of households, their level of acceptability concerning voluntary and compulsory membership, and their level of confidence in CBHIs and the health system. Respondents preferred voluntary (86%) over mandatory (70%) membership of a CBHI. The gap between voluntary and compulsory membership scores was smaller among women (p = 0.040), people under 35 (p = 0.033), and people with no health coverage (p = 0.011). Voluntary or compulsory membership was correlated (p = 0.000) to trust in current CBHIs and health systems. Lack of trust in the CBHI management has been more disadvantageous for acceptance of the mandatory than the voluntary membership. No particular preference emerged as the preferred administrative channel (e.g. death certificate, identity card, etc.) to enforce the mandatory option. The results confirmed the well-known challenges of building universal health coverage based on CBHIs—a poorly appreciated model whose low performance reduces the acceptability of populations to adhere to it, whether voluntary or mandatory. Suppose Senegal persists in its health insurance approach. In that case, it will be essential to strengthen the performance and funding of CBHIs, and to gain population trust to enable a mandatory or more systemic membership.</div

Preferred administrative channel for enforcing systematic membership for those in favour of the strategy.

Preferred administrative channel for enforcing systematic membership for those in favour of the strategy.</p

Characteristics of respondents (n = 914).

With the low adherence to voluntary mutual health insurance, Senegal’s policymakers have sought to understand the feasibility of compulsory health insurance membership. This study aims to measure the acceptability of mandatory membership in community-based mutual health insurance (CBHI) and to understand its possible administrative modalities. The study consists of a national survey among a representative population sample selected by marginal quotas. The survey was conducted in 2022 over the phone, with a random composition method involving 914 people. The questionnaire measured the socio-economic characteristics of households, their level of acceptability concerning voluntary and compulsory membership, and their level of confidence in CBHIs and the health system. Respondents preferred voluntary (86%) over mandatory (70%) membership of a CBHI. The gap between voluntary and compulsory membership scores was smaller among women (p = 0.040), people under 35 (p = 0.033), and people with no health coverage (p = 0.011). Voluntary or compulsory membership was correlated (p = 0.000) to trust in current CBHIs and health systems. Lack of trust in the CBHI management has been more disadvantageous for acceptance of the mandatory than the voluntary membership. No particular preference emerged as the preferred administrative channel (e.g. death certificate, identity card, etc.) to enforce the mandatory option. The results confirmed the well-known challenges of building universal health coverage based on CBHIs—a poorly appreciated model whose low performance reduces the acceptability of populations to adhere to it, whether voluntary or mandatory. Suppose Senegal persists in its health insurance approach. In that case, it will be essential to strengthen the performance and funding of CBHIs, and to gain population trust to enable a mandatory or more systemic membership.</div