Analysis and interpretation of the heterogeneity of community-based health insurance attributes and preferences in Senegal: evidence from a discrete choice experiment.

introductionCommunity-based health insurance (CBHI) schemes have been widely promoted to improve financial protection and expand access to healthcare in low- and middle-income countries (LMICs), particularly among populations working in the informal sector who lack access to formal health insurance. In Sub-Saharan Africa, CBHI has been implemented as part of broader efforts to advance universal health coverage (UHC), yet enrolment often remains low. In Senegal, CBHI schemes aim to expand insurance coverage among informal sector populations, but participation remains limited and uneven across geographic and socioeconomic groups. Evidence on how specific insurance design attributes influence enrolment decisions remains scarce. This study examines population preferences for CBHI attributes and their implications for scheme uptake.

methodsA discrete choice experiment (DCE) was conducted with 912 households in the Ziguinchor region using a stratified two-stage sampling approach. First, communities were selected across rural and urban areas. Second, households were randomly selected within each selected community. Lists of households were obtained from local administrative records, and respondents were randomly chosen from these lists. Interviews were conducted with household heads or adult household representatives. Prior to the main survey, the questionnaire and choice tasks were pilot-tested with a small sample of households to ensure clarity and comprehension. Mixed logit models were used to estimate preferences for six CBHI attributes, and policy simulations predicted enrolment under alternative scheme designs.

resultsChronic disease coverage (OR = 61.2; 95% CI: 46.5-81.7), transport availability (OR = 24.3; 95% CI: 17.1-33.1), and flexible payment options (OR = 6.0; 95% CI: 3.9-9.2) were the strongest determinants of enrolment. Significant heterogeneity in preferences was observed across population groups. Compared with urban households, rural households placed greater importance on transport availability and flexible payment mechanisms. Similarly, compared with high-income households, low-income households showed stronger preferences for flexible payment options, while high-income respondents preferred more comprehensive benefit packages. Scenario simulations predicted enrolment gains from 76.53% under the baseline DECAM model to 97.81% under an optimized scheme including chronic disease coverage, transport support, and flexible payment options. Willingness-to-pay also varied across income groups and locations.

conclusionsDesigning CBHI schemes around user preferences significantly improves predicted uptake and equity. Rather than uniform models, differentiated and preference-aligned insurance designs can drive substantial increases in enrolment and equity. Tailored insurance models that incorporate chronic disease services, address transport barriers, and allow flexible payment modalities are more likely to achieve inclusive enrolment. The inclusion of high-income households offers an opportunity for financial sustainability through cross-subsidization. These results offer actionable insights for Senegal and similar low-resource settings pursuing universal health coverage (UHC) through community-based mechanisms.