This article is part of the following series: Health for all? Critical perspectives on Universal Health Coverage
“Health for All?” critically explores global moves towards Universal Health Coverage and its language of rights to health, equity, social justice and the public good. Highlighting emerging ethnographic and historical research by both young and established scholars, the series explores the translations and frictions surrounding aspirations for “health for all” as they move across the globe. The series is edited by Ruth Prince.
My research is on efforts to establish a social protection floor in Senegal. The idea of a social protection floor is not new, however it was formalised in policy in 2012 when the International Labour Organisation (ILO) adopted its Social Protection Floor Recommendation. This sets out a minimum guarantee for states to aspire to: that ‘over the life cycle, all in need have access to essential health care and to basic income security which together secure effective access to goods and services defined as necessary at the national level.’ Social security linked to formal employment in Senegal dates back to the post-war years, however in a country where informal workers and the rural economy make up around 80% of the population, the more recent expansion of social protection for this sector – in Senegal as in many countries across Africa and the Global South – is significant. The necessity for social protection for this population has been laid bare in the current COVID-19 pandemic. My research was carried out – and this piece conceived – before the pandemic; however at the end I reflect further on Senegal’s experience of COVID-19 and how it might shape things to come.
In 2017-18 I carried out fieldwork in Dakar, where I looked at two key government programs at the heart of Senegal’s vision: the bourse familiale (PNBSF), a conditional cash transfer program allocated to 300,000 of the poorest families nationwide and Couverture Maladie Universelle (CMU), Senegal’s version of Universal Health Coverage (UHC), both introduced in Senegal in 2013. Cash transfers, which were first seen in Latin America in the 1990s, are now so widespread they have been described by some as ‘21st century welfare,’ while UHC was adopted as part of the Sustainable Development Goals in 2015. I studied the infrastructure and bureaucracy of these two programs and carried out ethnographic research with beneficiaries of them. Part of my work was to look at how existing, or informal, forms of distribution intersect with more formal government programs and policy and to this end I lived in a relatively poor area of the city, in a ‘quartier populaire,’ where I followed modes of distribution amongst families, the community and in local politics.
In this piece I draw on my research on mutuelles de santé to explore some of the early struggles to implement CMU. Mutuelles are organisations that provide health insurance to members and are formed on the basis of an ethic of mutual aid, solidarity and collective pooling of health risks. There is a strong tradition of mutuelles in Francophone West Africa and the first mutuelle in Senegal, Fandène mutuelle in Thiès, was created in 1989. By the turn of the millennium there were around 30, and by the late 2000s, around 130 across the country. In its early years, Senegal’s Universal Health Coverage (CMU) programme incorporated existing mutuelles as well as created hundreds of new ones, so that there now exists at least one in every municipality nationwide (some 676 across 552 municipalities). They vary in size, ranging from a few hundred to a few thousand, largely depending on how long they’ve been established and their institutional capacities. In 2019 around 2.6 million people were enrolled in community health mutuelles out of a total national population of 15 million. The CMU has also created several socio-professional mutuelles, serving those who share in the same type of work rather than live in the same geographical location. Mutuelles cover 80% of health centre and hospital costs and 50% of the costs of speciality medicines, while the patient pays the remainder. There are, however, limitations and exceptions. Chronic illnesses, for example, are not yet included as they are deemed too costly, and hospital fees are covered for a period of up to seven days. CMU figures claim to have increased overall coverage of the population from 20% in 2012 to 49.6% in 2018, and its objective is to reach 75% coverage in 2021.
The bourse familiale and CMU were launched in 2013 by President Macky Sall’s government a year after it was elected to power. These programs – the government’s ‘grands projets’ – sit within Senegal’s development plan, the Plan Sénégal Émergent (PSE) and indicate a strong political will for the expansion of social protection in the country. Indeed, the government’s plans are ambitious. To use its own words:
‘Dominant economic theory would argue that… before distributing, we must first produce. But the PSE has opted for a bolder, more demanding, even risky approach: to produce and at the same time redistribute.’
Ambitious plans are accompanied by ambitious spending promises and year after year the government has broken budgetary records. Of course, plans for redistribution rely heavily on international donors. A country historically successful at attracting external finance, Senegal has gained significant financial backing; at the end of 2018, it raised three times the amount initially sought during its second major funding appeal for the PSE development plan in Paris.
Early achievements of the CMU reflect this, notably the creation of a national agency in 2015, the Agence CMU to oversee its implementation and the huge expansion of mutuelles themselves. Beyond this institutional setup, however, money has often been slow to follow. The budget itself was the subject of much debate in 2018, the year I carried out my fieldwork. In a year declared an ‘année sociale’ with a Presidential election taking place early the next year in February 2019, debate centred on whether it was a ‘social’ budget or a ‘campaign’ budget. Moreover, the 4,000 billion CFA (£5.2 billion; EUR6.1 billion) heights reached in the 2019 Finance Bill gave cause for concern. Eventually the Finance Minister made a ‘mea culpa,’ admitting that budgetary tension identified by the International Monetary Fund (IMF) was at least in part due to the government’s choice of social policy. Within this nascent context of political ambition and financial constraint, then, I point to some of the challenges that emerge in the early years of CMU in Senegal.
Low enrolment and Funding gaps
Mutual health insurance and free policies (gratuité) are the two main axes of the CMU and the two main avenues through which the government has promised money to health mutuelles. Mutual health insurance rests on the idea that the CMU will work on the ‘law of the big number’ (loi de la grand nombre), a common refrain amongst those involved in the implementation of the CMU, whereby each person contributes 3,500 CFA (£4.80, EUR5.30) a year to enrol and the government matches this amount. While appealing to deeply embedded cultural values of solidarity in its vision for mutual health insurance and encouraging the population to ‘bokk’ – Wolof for being a part of, belonging, participating, sharing, or having in common – enrolment rates have so far been low. These ‘classic’ enrolments make up just over one third of all those so far enrolled in the community mutuelles.
The larger proportion is made up of those who receive the bourse familiale cash transfer and the disabled. Under the other main axis of the CMU, free policies (gratuité), the government has committed to taking on these categories of the population, as well as children aged 0-5, the elderly and the costs of certain healthcare services including caesareans and dialysis. (Care for some illnesses like HIV and TB is already free in Senegal through existing arrangements). Government subventions – or contributions – are, however, often lacking and late. During my fieldwork, the government provided just 25% of the sum initially promised for those receiving the bourse familiale that year.
Taken together, then, mutuelles are often strained due to the limited contributions from classic enrolments which are used to cover the health costs of those receiving the bourse familiale, pending government funds. Comments like ‘dafa doy war’ (it’s strange, surprising, or striking in Wolof) from those working in mutuelles in response to taking on people for free can begin to undermine the principal of gratuité. The president of one mutuelle told me ‘free policies kill value’ (la gratuité tue la valeur) and held the view that everyone should contribute, if only a small amount, to adhere. Some mutuelles went as far as to temporarily stop taking on those who received the bourse familiale. Significant financial and management burden falls on the health mutuelles themselves. Most are forced to look elsewhere for resources and are encouraged to carry out income-generating activities and to seek out partnerships with associations, NGOs and other organisations.
In the absence of government subsidies, existing modes of distribution like patronage fill some of the gaps. Perhaps the most high-profile example of this is when singer, businessman, and occasional politician Youssou N’Dour gave 75 million CFA (£100,000, EUR115,000) to the cultural actors mutuelle (MNSAC), a figure topped by the government a few months later with a cheque for 100 million CFA (£135,000, EUR150,000). Similar gestures in smaller ways were common at the local level. The mutuelle in the area I lived received 2 million CFA (£2,700, EUR3,000) from the town hall. Another local politician enrolled 1,000 school students as part of CMU élève. Another important local figure signed up talibé (child disciples who live in koranic schools) at his expense. Voluntary contributions are repeated throughout Senegal and might range from £10 to £1,000, from local wealthy or otherwise significant people, to sign up those in the neighbourhood who are unable to afford the fee, reflecting cultural and Islamic practices of giving, charity and solidarity.
Receiving money via such routes is beneficial, sometimes vital, for the mutuelle, and a convergence of formal and existing informal modes of distribution might strengthen programs like the CMU. However, this process can also be exclusionary. As a government program, the CMU is often politicised, leading to significant variation in the capacities of mutuelles. Buildings themselves are one indication of this. The local mayor in the area I lived, for example, was a member of the Parti Socialiste (PS) which is part of the ruling Benno Bokk Yakaar (BBY) coalition, and funded the renovation of an entire building for the community mutuelle with the help of a North-South partnership with Belgium. It has separate offices for the treasury, secretary, president (an indication of the bureaucratic set up) and even a ticket office (guichet). In fact, it has too many rooms and one upstairs is rented out to ‘fêtières’ (those who work at fetes or parties) to store their huge pots. Other mutuelles I visited were less equipped; one doubled up as a computer room in a school, others had rooms within hospitals or health centres or community centres. Alongside this direct support of mutuelles, moreover, politicians often choose, or ‘target’ their own supporters to enrol, thereby perpetuating existing exclusions amongst the general population.
The experience of ‘mutualistes’ – those working in the health mutuelles themselves – further reveals tensions manifest in an under-funded government project seeking to lean on and cultivate cultural values. Alongside my fieldwork at community mutuelles I followed the setting-up of the informal sector mutuelle, one of the socio-economic mutuelles that were more recently introduced. Early meetings held by its CIM (Comité d’Initiative Mutualiste), a committee put in place to establish a mutuelle, revolved around the problem of having no money. Without funding they could not initiate the activities necessary to attract subscriptions and thereby meet the Agence CMU’s quotas that were required to be officially recognised as a mutuelle. One meeting resulted in all those present getting up from around the table and putting forward their green 5,000 CFA notes (£6.70, EUR7.60). This public gesture again resonates with cultural modes of giving money and there was a strong sense that if they all come together (nekk benn), in solidarity (bokk) they will be stronger (am doole). While these are precisely some of those values the CMU seeks to harness, here they exist alongside a more general frustration with the government (many in this group had links with unions) and a sense that they should not waste their time waiting for it.
All those who work in the mutuelles are voluntary and unpaid and their ambivalence about this work was clear. While there was a sense of sacrifice and vocation, for some there were limitations to the pride they felt. A mutualiste in Yoff put it plainly: ‘too much voluntary work kills voluntary work.’ Efforts to address this and professionalise health mutuelles are in motion. One concrete step in this direction was the introduction of paid managers; however, at the time of my fieldwork these salaries were yet to be received. One mutualiste commented on the fact that during the same period that these payments were withheld, the Agence CMU had employed promotion officers (agents de promotion), each with a regular salary, reflecting skewed funding priorities.
The Agence CMU is planning to adopt more major strategic reforms to address some of these challenges. Most relevant here are institutional changes, whereby the risk pool will be ‘raised’ to the departmental administrative level. Benefits of this include a larger risk pool making community mutuelles more financially viable as well as the departmental units having paid employees to take on some of the management burden. It will be interesting to see the effect this institutional reform has. It will no doubt improve the capacities of the mutuelles; a pilot study estimating that the enrolment rate rose from 2.4% to 25% gives one indication of this. However, just as institutional achievements stood out in the early establishment of the CMU, in the years that follow it remains vital that funding follows suit.
At a general assembly for the restructuring of the regional union of health mutuelles in Dakar the outgoing president opened her report with a quote from Bernard Werber’s Empire of the Ants: ‘We must not think about the objective to be achieved, we must only think of moving forward. It’s by advancing that we reach the objective, or that we double these objectives without even realising it.’ That the CMU is relatively new in Senegal and that it will take time to establish is a widely held view. The director of COSAS, a civil society coalition that works to evaluate health policies in Senegal, for example, suggested it would take forty or fifty years to put in place properly and that we can’t hope for miracles now. In the meantime, it is vital to pay attention to both the challenges and opportunities that arise. The CMU sits within the broader vision of Senegal’s development plan: ‘of an Emergent Senegal in solidarity, backed by our cultural convictions and the right to social security.’ Such political will embedded within cultural values is encouraging, however without the money to follow, difficulties risk becoming engrained.
Senegal was the second country in sub-Saharan Africa to register positive cases of coronavirus and implemented a state of emergency on 23 March 2020, bringing in a curfew between 8pm and 6am and enforcing social distancing measures. As elsewhere around the world, the socio-economic effects of the pandemic are unprecedented; it is estimated that Senegal’s GDP will fall from 6.8% to less than 3%. To stem its impact, the government established ‘Force COVID-19,’ a response and solidarity fund which will be endowed with 1 trillion CFA (£1.3 billion; EUR 1.5 billion). It is to be financed by the state and ‘bon volonté’ (good will), receiving contributions from individuals, the private sector and development partners and has attracted funds from a wide array of benefactors already. As well as support for the health sector and other sectors hardest hit, out of this fund, the government allocated 69 billion CFA (£92.3 million; EUR 105 million) for food provisions for the most vulnerable households and later announced that it would pay all water and electricity bills for a two-month period for those families in need.
The government has promised that 1 million families will receive the provisions, representing around eight million Senegalese, or half of the national population. The first to receive it will be those already registered as vulnerable through the safety net system, including those receiving the bourse familiale cash transfer and others registered on the National Single Registry (RNU) which contains further data on poor and vulnerable households. Subsequent households will be selected through community targeting. A senior economist at the World Bank states that the safety net program is ‘front and centre’ in the government’s mind for responding to COVID-19 and that it was discussing scaling up cash transfers as part of an emergency response. 
In the immediate term, COVID-19 makes clear the importance of social safety nets for responding to ‘shocks’ and Force COVID-19 demonstrates Senegal’s ability to raise large sums, reflecting modes of solidarity described in the bulk of this piece. In Macky Sall’s address to the nation on 3 April, the eve of Senegal’s 60th Independence Day – for which there was no ceremonial parade this year – he proclaimed, “I want to say to everyone that the state will not abandon you.” The longer-term sustainability of financing social protection, however, continues to pose a challenge. Right at the beginning of Macky Sall’s first term he set out a vision for an ‘Autonomous Universal Social Protection Fund’ (CAPSU) with the idea that it would manage the financing of programs like the bourse familiale and CMU. So far this has not materialised. A fund like Force COVID-19 perhaps sets a precedent in this direction.
Anna Wood is a PhD student in Social Anthropology at the University of Cambridge. She is interested in emergent forms and politics of distribution in the context of contemporary poverty. Anna received her MSc in Social and Cultural Anthropology from University College London.
 Here I use the name Couverture Maladie Universelle (CMU), as this is the name the government has given the program. There is however debate over its name and a strong call for it to be called Couverture Sanitaire Universelle (CSU), to emphasise the broader dimensions of health.
 Lavinas, L. 2013. ‘21st Century Welfare’ in New Left Review, 84, 5-40.
 A definition drawn from: ‘The Contribution of Mutual Health Organisations to Financing, Delivery, and Access to Health Care: Synthesis of Research in Nine West and Central African Countries,’ Chris Atim 1998: 2.
 Deville, C. et al. 2018. ‘La Couverture universelle en santé au Mali et au Sénégal en 2018,’ Working Paper, CEPED, 40, 18.
 Finance Bill 2019: 6 (https://www.sec.gouv.sn/sites/default/files/Projet_De_Loi_Des_Finances_2019_1.pdf).
 The Equal Opportunities Card (Carte d’Égalité des Chances) provides financial assistance for people with disabilities.
 Daff, B. M. et al. 2020. ‘Reforms for financial protection schemes towards universal health coverage, Senegal’ in Bulletin of the World Health Organisation, 98, 100-108.
 ‘Il ne faut pas penser à l’objectif à atteindre, il faut seulement penser à avancer, c’est à force d’avancer, que l’on atteint ou que l’on double ses objectifs sans mêmes s’en apercevoir.’
 …a vision politique d’un « Sénégal émergent dans la solidarité » adossée à nos convictions culturelles et au droit à la sécurité sociale…’ (SNPS 48).
 Thomas Bossuroy, Senior Economist at the World Bank speaking in a socialprotection.org webinar on ‘The Adaptive Social Protection Program in Sahel,’ 2 April 2020.
 In French: Caisse Automone de Protection Sociale Universelle.
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