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: BackgroundResearch topic and objectivesOverview of the Plan SésameAnalysis frameworkMethodologyPart II: ResultsThe Elderly and the Plan SésameThe Elderly and social exclusion

Project Overview, Health Inc Senegal

Project funded by the European Union - 7th Framework Programmehttp://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 S

ES

AM

E

IPRES

StateIPRES (Social

Security for pvt)Member contributions

Min. of HealthDepartment of HealthOffice of the Elderly

PC

NationalPharmacy

Ministry of Finance

Taxes

DM

RM

PAF: 70%IPRESFNR

 

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 SPEC

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

Non-health-seeking

Non-utilisation

No card

Uninformed

Mixed method approach

19

34 people

60+46

Actors

Literature review

Pilot household survey

Household survey

Pilot of semi-structured interviewssemi-structured interviews

Enquête ménage 2998

Pilot household survey

Mapping of actorsStep 1

Focus groups

Policy 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 fee exemptions 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

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

0 10 20 30 40 50 60 70 80 90 100

nonnon concernés

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

Of those sick or injured, 50.3% were in-formed about Plan Sesame

Of those informed, 92.7% had ID card

Yes

No

Those 60+ sick or injured in 15 days preceding survey

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

Of those with an ID card, 63.4% sought health care

Information on the Plan Sésame

Se-ries1

0

10

20

30

40

50

60

70

50.3

64.8

50.7

PA malades

PA hospital-isées

Ensemble PA

60+ ill

60+ hospi-talised

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 should 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 attainment, 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.

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+

Access to information 3/3Status 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% 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 (34% of 60+, even though health post = 1st care seeking level;

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

BeneficiariesOnly 10.5% of those 60+

Who are the beneficiaries 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+ said 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) “ The Plan Sésame, its nothing”  (person over 60)

Coverage

Overall negative perceptions of the Plan Sésame

Today the Plan Sésame has a negative association

This despite being considered also 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 those still 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 salaried workers. - 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 health coverage

“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….

…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 solidarity 83.7% 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 their grandparents. Just look at how many young people on the bus stay in their seats when there are elderly passengers standing up: this was unthinkable several years back.

Less emotional support leads to lonelinessAbout 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

While family may provide help, they spend little time exchanging with the elderly in the household

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