Do policies put in place in sub-Saharan Africa to

increase access to health services for socially

excluded groups work?

The example of the “Plan Sésame” in Senegal

Maymouna BA

Summary

Part I: Background

Research topic and objectives

Overview of the Plan Sésame

Analysis framework

Methodology

Part II: Results

The Elderly and the Plan Sésame

The Elderly and social exclusion

Project Overview, Health

Inc Senegal

Project funded by the European Union - 7th Framework Programme

http://www.healthinc.eu/

Research subject

Aging/the elderly little

researched but a growing

population

A number of social prejudices

against the elderly in Africa

Manifestation of increasing

interest in this population =

Plan Sésame in 2006

entry point to do a

health-related study on this

target population group

Questions and research objectives

• Elderly a population especially affected by illness (literature

review and survey)

- Yet most not benefitting from the Plan Sesame, which was

designed to remove financial barriers for them

• Look for other aspects and barriers – political, social, and

cultural?

The health system’s capacity to respond to the needs and

the pressure of this growing population group will be one important

key to its overall performance.

Plan Sésame – how it is organized and how

it works

Gov’t of Sénégal

Financing Coordination Purchasing Service delivery

Hospitals

Pla

n

SE

SA

ME

IPRES

StateIPRES (Social

Security for pvt)Member contributions

Min. of Health

Department of Health

Office of the Elderly

PC

National

PharmacyMinistry of

FinanceTaxes

DM

RM

PAF: 70%

IPRES

FNR

Framework for analysis: social

exclusion

What are the processes of exclusion that inhibit access to

health services for the elderly?

Our working definition of social exclusion is that of the « Social

Exclusion Knowledge Network » (SEKN)* exclusion is a result of

dynamic and mulitdemnsional processes, based on unequal

power relationships. There are often four dimensions:

– Social, Political, Economic and Cultural –

Processes of exclusion exacerbate inequalities in health, thereby

feeding into a continuum of inclusion/exclusion.

*WHO, Commission on Social Determinants of Health, Social Exclusion Knowledge

Network, Understanding and Tackling Social Exclusion, Final Report, February 2008

Analytic Tool: « SPEC by STEPS »

Target population for Plan Sesame: those over 60 years of age

Step1: process and profile analysis following 4 levels of

SPECUninformed

No card

Non-health-seeking

Non-utilisation

Step2: process and profile analysis following

SPEC

Step2: process and profile analysis following

SPEC

Step2: p and p analysis

SPEC

Those >60 informed about Plan Sesame

Those >60 holding a digitial ID card for Plan

Sesame

Those >60 having sought health care

Those >60 having

received health care

Mixed method approach

Enquête ménage 2998

34 >60

46 Actors

Literature review

Pilot household

survey

Household survey

Pilot household

survey

Mapping of actors

Step 1

Pilot of semi-

structured interviews

semi-structured interviews

Focus

groupsPolicy recommendations

Mapping of actors Step 2

Study sites

4 sites selected according to criteria. The analysis looked at all elements

relevant to the study on free care for people >60 years of age

5 criteria for selection :

- urban/rural stratification

- Access to a health post

- Poverty index

- Population size of 60+

- Existence of a hospital

Plan Sésame

and the coverage of those 60+

Results of SPEC

0 10 20 30 40 50 60 70 80 90 100

Ont utilisé Plan Sésame: 21,3% des PA ayant approché services publics de santé

Ont approché services publics de santé: 78,6 des PA ayant approché services santé

Ont approché services de santé: 63,4% des PA ayant CI

Possèdent Carte Identité: 92,7% des PA informées

Informées sur Sésame: 50,3% des PA malades

PA malades: 52,4% des PA

oui

non

60+ who were sick: 52.4%60+ who were sick: 52.4%

Of those sick or injured, 50.3% were

informed about Plan Sesame

Of those informed, 92.7% had ID card

Ye

s

No

Those 60+ sick or injured in 15 days preceeding survey

Of those with an ID card, 63.4% sought health

care

Of those seeking health care, 78.6% went to a

public facility

Of those seeking health care in a public

facility, 21.3% received services under the Plan

Sesame

Information on the Plan Sésame

50.3

64.8

50.7

0

10

20

30

40

50

60

70

PA malades

PA hospitalisées

Ensemble PA

60+ ill

60+

hospitalise

Total 60+

Serious information deficit on the Plan

Sésame:

49, 3% of those 60+ do not know that the

Plan Sesame exists

Even among those hospitalised (who

would likely be better informed), 35, 2% do

not know about it

The Plan Sesame is a mechanism ill-understood by its supposed

beneficiairies

Access to information 1/3

Sociodemographic determinants: gender, educational attainement, place of

residence

•Lesser participation by women in local activities and public meetings.

•Difficulty for illiterate to receive and understand information given to them by

public authorities (72% des PA)

•Weak media exposire (the main information mechanism for Plan Sesame) in rural

areas : 86.9% of urban 60+ listen to the radio versus 79.1% of those in rural areas.

86.4% of urban 60+ watch TV versus 27.68% of rural.

Sex Educationalattainment Placeofresidence

TotalMen Women illiterate Attendedschool

urban Rural

Nbr % Nbr % Nbr % Nbr % Nbr % Nbr % Number%

60+ illduringpreceeding2weeks

Yes 433 58,7 339 42,5 507 44,1 265 68,5 456 59,1 316 41,3 772 50,3

No 305 41,3 459 57,5 642 55,9 122 31,5 315 40,9 449 58,7 764 49,7

Tot 738 100,0 798 100,0 1149 100,0 387 100,0 771 100,0 765 100,0 1536 100,0

60+hospitalisedinpast12months

Yes 89 74,8 58 53,7 101 59,4 46 80,7 75 65,2 72 64,3 147 64,8

No 30 25,2 50 46,3 69 40,6 11 19,3 40 34,8 40 35,7 80 35,2

Total 119 100,0 108 100,0 170 100,0 57 100,0 115 100,0 112 100,0 227 100,0

Access to information 2/3

Main reasons for low utilisation of

health services by 60+:

Cost: 1st reason given by 57.1% of

those sick or injured, and of 74.2%

of those requiring hospitalisation

Self-medication: 17.1% of those seeking

care

Distance from health facilities: physical

access more difficult for those living

in rural areas where 54% said the

closest health center was too far to

reach on foot versus 30.3% of urban

dwellers

Health service quality: long waiting

times discourage those 60+ from

seeking care

Health facilities (3rd source of information)

BUT don’t spread information widely due

to low utilisation by 60+

Service utilisation by those 60+

Sought health

care

Place of residence Total

urban rural Eff %

Yes 59,1 57,3 894 58,2

No 40,9 42,7 642 41,8

Total 100 100 1536 100

Access to information 3/3

Status of retirees from the formal sector

Those having retired from formal sector employment are better informed

about the existence of the Plan Sésame than those having always worked

in the informal sector

“Its those from the IPRES and the FNR who got the message because

they are educated, they are in organisations where information circulates

and they know how it works.” (Stakeholder)

Lobbying from associations of retired persons for better

medical coverage

Process grew out of these assocations of retirees whose members were the

urban educated

60+ who are informed

60+ who live close to health services: 92.1% des of the non-users of health posts live +30 mn from hospital

versus 53.1% of those who got care

60+ with access to hospital (and yet health post = 1st care seeking level; (34% of 60+) 66.7% of households are -30mn from a health post

In summary, urban, male, educated retirees from the formal sector

“Those over 60, it’s a slogan than people say, but the people over 60 who live in Dakar who are formal civil servants and intellectuals who have networks and family will get far more out of this opportunity than someone over 60 who lives in the village, who never went to school, and who may not have access to the same kind of information.”

Health system actor

Beneficiaries

10,5% of those 60+

The beneficiairies of the Plan Sésame

Weak points with the Plan Sésame 1/2

Communication: No communication plan was developed due to a lack of

financial and human resources

Main source of information was “parents, friends, and neighbors”

Targeting/ No restrictions were put on either the categories of the population

of 60+ or the services to be covered

Financing/ Modest – irregular funding

Management/ No plan for monitoring or audit at an institutional level – no

focal point for the Plan Sesame designated in health facilities

Electoral motivation at launch of Plan?

May explain the haste in its implementation

Weak points of the Plan Sésame 2/2

Different regions and different facilities had different coverage

practices.

Many health facilities readjusted the coverage they provided under

the Plan

- Limited it to clinical services only

- Excluded costly services

- Simply refused to provide services

53.9% of those 60+ think the Plan Sésame does not work and 40%

of those having used services under the Plan were only partially

covered.

“The Plan Sésame has put hospitals out of business”

(Stakeholders)

“The Plan Sésame, its only talk” (person over 60)

Coverage

Overall negative perceptions of the Plan Sésame

Today the Plan Sésame has a negative association

This despite being considered also a noble, generous, altruistic and showing solidarity

Bringing to mind several quotes:

“In Africa, the death of an elderly person is like a library that

burns to the ground” Amadou Hampaté Ba

“Mag mat naa bàyi ci am rèew” Kòcc Barma

Are the elderly in Senegal facing social

exclusion?

Economic activity

41.8% of 60+still work, sometimes until they are quite old (14% of thosestill working > 75 years old)

Reasons given for still working:

- Large family to support (68.1of 60+=CM)- Children unemployed- No pension (73.6%) – or inadequate pension for previously salariedworkers.- No assets, livestock, or land (76.6%)

Negative impact on the capacity of those 60+ to pay for health services = only 13% of those 60+ who were ill actually benefited from healthcoverage

“The doctor is good, but his treatment is expensive. When one is old and no longer working, when one’s son is not working, how can one seek health care and also make sure the family can eat at the same time? If you can’t even feed your family, you don’t have the means to seek care.” (person 60+)

Low levels of material and financial resources

Levels of social integration

Good level of

cultural and

community

participation….

Sex Place of residence

Male Female Urban Rural Total

Participation in local activities Going to the main square 51,4 0,0 39,8 59,7 51,4

Going to the mosque or to church 88,2 54,7 69,3 75,7 72,6

Participating in reading the Coran 85,7 0,0 81,5 88,4 85,7 No particiation in any activity 36,9 57,3 57,5 34,5 45,8

Participation in religious activities 58,0 36,5 35,5 61,2 48,6 Participation in community activities 20,0 9,8 11,3 19,6 15,5

Participation in political activities 6,5 2,3 2,9 6,3 4,7 Participation in sports 2,1 ,3 1,9 ,6 1,3

Holding a religious or administrative function Yes 16,0 4,2 8,7 12,2 10,5

No 84,0 95,8 91,3 87,8 89,5

Village/neighborhood chief 26,3 3,5 8,9 31,0 22,1 Imam, pastor or priest 19,5 0,0 15,3 17,9 16,9

Association manager 20,3 47,4 33,1 20,1 25,3 Rural or municiapl counsellor 10,0 7,0 17,7 3,8 9,4

Social relations and networks Close relations with neighbors 97,6 97,4 95,8 99,1 97,5

Visits from parents (often or sometimes) 94,2 92,0 90,9 95,4 93,2 Visits to parents (often or sometimes) 78,0 60,9 69,3 70,7 70,0

Existennce of special friends 85,9 84,0 76,5 93,1 85,0 Ability to get around/travel (often or

sometimes) 61,9 45,7 60,9 48,1 54,3

…but weak social

participation

60% of 60+ belong to no

association

Only 10.5% have a

position of responsibility

Those 60+ have

little influence in

their communities

Family support remains the most important,….

86.4% report they are in a household where someone takes daily care of

them. (Children: 42.9%, Spouse: 38%)

….especially in cases of illness….

Material support and help when ill come from family and not neighbors or

friends

…but is this crumbling due to poverty?

Do the young help you ?

“Not to my eyes. It may be because they don’t have the means since

times are hard. If you have no means, you can’t be expected to help

others. Families are big and there just aren’t enough resources.”

The situation is similar with networks for social solidarity83.7% say they have never received assistance from an NGO or

association.

Steady decline in the status of those 60+

• Diminishing power within the family

• Less respect and consideration from youth

• Lessened ability to weigh in on the crisis in values within Senegalese

society

◦ I would say that the situation for the elderly is getting worse; they are

not as respected as they used to be…I had great respect for my

grandparents compared with that which my own children have toward

thier grandparents. Just look at how many young people on the bus

stay in their seats when there are eldery passengers standing up: this

was unthinkable several years back.

Less emotional support leads to loneliness

About 2 in 5 (39.9%) of those 60+ who were interviewed admited to

being lonely, despite more than 90% of households having at least 5

members.

Increasing marginalisation within the family

Getting old….

Can be a difficult and painful time:

-lack of means,

-Onset of illness

-Lack of respect and consideration from society; especially from youth,

- difficulty accessing public services: administrative hassles and

corruption, lack of adapted infrastructure, physical frailty (making getting

around and long waits especially difficult), virtual non-existence of any

geriatric or gerontological services

“One gets older faster when one is poor or one suffers due to family

problems. Poverty is the worst; when one adds suffering, it makes us

even older.”

“When you get old, you may participate in life, but you are no longer

associated with life.”

“When one gets old, the only thing left is death”

Conclusions

There are social, political, economic, and cultural dynamics

that turn people over 60 into second-class citizens who are

increasingly marginalised…

Is this process going to result in social exclusion?

…This situation, compounded by weak systems of social

assistance and protection limits their access to public

services, including health care.

It is essential to put in place better policies of inclusion.

Thank you for your attention

Contacts:

Health Inc Sénégal

http://crepos.org/healthinc

Email

health.inc@crepos.org

bamaymouna@yahoo.fr