Perceptions et utilisation de la Couverture Maladie Universelle (Plan Sésame) par les personnes âgées à Dakar (Sénégal), impacts sur les dépenses de santé liées au diabète et à l’hypertension

Perceptions and use of Universal Health Coverage (Plan Sésame) among the elderly in Dakar (Senegal), impacts on health expenditure related to diabetes and hypertension

Introduction/rationale. In 2006, the Senegalese government set up a health coverage programme for people aged 60 and over - the Plan Sésame - to provide free medical care in all the country’s public health facilities. This scheme has been integrated into the Universal Health Coverage (CMU) promoted from 2013. The objective of the study was to describe and analyse the knowledge and representations of professionals and users about health coverage and the Plan Sésame, the use of the scheme by the elderly, to evaluate the amount of medical expenses incurred during a routine medical consultation for the monitoring of their illness (hypertension and diabetes), and to calculate the out-of-pocket expenses related to the consultation.

Material and methods. Study conducted between July 2020 and October 2021 in two public health facilities in Dakar. Mixed approach: 1/ qualitative study by semi-directive interviews, informal interviews, observations and field diary with 35 people selected according to a reasoned choice procedure with the aim of diversifying gender, age, social status, therapeutic itineraries for 23 people (including 12 women, ages between 60 and 85 years), and professional activities for 12 health actors; 2/ quantitative cross-sectional study by questionnaire of 225 people (including 141 women) aged 60 and over; we calculated the total cost of the consultation and associated prescriptions (complementary examinations and medicines) as well as the remaining medical expenses (out-of-pocket) and the cost of transporting patients. This is a descriptive exploratory study of a non-representative sample of the elderly population in Senegal.

Results. The health professionals interviewed supported the principle of health coverage, but most of them had limited and sometimes imprecise knowledge of the existing schemes and the methods of access or the services covered. Their point of view about the consequences of the Plan Sésame on their practice reveals some contradictions: some complain about the increase in workload, the criticism is extended to all the free schemes which would have a negative impact on daily practice because of the increase in the number of consultations which would be linked to abuse by patients.

The interviews highlight the heterogeneity of the knowledge of elderly people about the health coverage intended for them, even though the Plan Sésame has been in place for over ten years. The interviews clearly show that the use of the health coverage system by the elderly depends closely on the information they have and their ability to use it, both for women and men. There is a close link between the level of social integration of people and their use of health coverage: the most socially integrated people are those who know how to use CMU services best. The use of health coverage by the elderly appears to vary according to the individual.

Although Plan Sésame is defined as part of a national strategy, its implementation varies according to the health structures and the periods; in the two study sites, the range of services covered by Plan Sésame is very limited, so the coverage provided by Plan Sésame is only partial: between 30 and 50% of the medical costs; the remaining cost of a consultation for elderly patients with hypertension and/or diabetes varies between 24,000 and 28,000 CFA francs.

These amounts must be put into perspective with the resources available to people. Statistical studies published in 2021 report that in Senegal the average daily expenditure is 1,390 CFA francs/person/day; and that almost 38% of the population lives on 913 CFA francs/person/day, which is the poverty line calculated in 2019. Thus, the average out-of-pocket expenses for a follow-up consultation for hypertension, diabetes or a combination of the two diseases represent 15 to 30 days of daily expenditure. While the vast majority of elderly people in Senegal do not have a retirement pension, health expenses are therefore borne by their relatives. Within households, medical expenditure for the elderly competes with basic needs, particularly food, which usually take up more than half of household resources. This indispensable family support places the elderly in a situation of total dependence.

Conclusions. In 2021, Plan Sésame does not yet allow for completely free care for the elderly. However, its application, even partial, has resulted in a real reduction in health care costs for the elderly. Its use remains limited due to inconsistent application by most health structures. Its impact is insufficient in view of the amounts that users have to pay in a context of social and economic vulnerability. These observations reinforce the need to work on reducing the price of medical services and strengthening the UHC, in order to improve the equity and performance of the system, and to make it fully functional in all health structures.

Perceptions et utilisation de la Couverture Maladie Universelle (Plan Sésame) par les personnes âgées à Dakar (Sénégal), impacts sur les dépenses de santé liées au diabète et à l’hypertension

Introduction/justification. En 2006, l’État sénégalais a mis en place un programme de couverture maladie pour les personnes âgées de 60 ans et plus – le Plan Sésame – devant permettre de fournir une prise en charge médicale gratuite dans toutes les structures sanitaires publiques du pays. Ce dispositif a été intégré dans celui de la Couverture Maladie Universelle promue à partir de 2013. L’objectif de l’étude était de décrire et analyser l’utilisation des dispositifs de couverture en santé en 2020, par les personnes âgées, d’évaluer le montant des dépenses médicales engagées à l’occasion d’une consultation médicale pour le suivi de leur maladie (hypertension artérielle et diabète), et de calculer les restes à charge liés à la consultation.

Matériel et méthodes. Enquêtes réalisées entre juillet 2020 et octobre 2021, dans deux structures sanitaires publiques dakaroises. Approche mixte : 1/ étude qualitative auprès de 35 personnes sélectionnées selon une procédure de choix raisonné : 23 personnes âgées (dont 12 femmes), et 12 acteurs de santé ; 2/ étude quantitative transversale par questionnaire auprès de 225 personnes (dont 141 femmes) âgées de 60 ans et plus. Nous avons calculé le coût total de la consultation et des prescriptions associées ainsi que le reste à charge des patients. Il s’agit d’une étude exploratoire descriptive auprès d’un échantillon non représentatif de la population des personnes âgées du Sénégal.

Résultats. L’enquête met en évidence l’hétérogénéité des connaissances des personnes âgées sur la couverture sanitaire, alors que le Plan Sésame est en place depuis plus de 10 ans. Les personnes les mieux insérées socialement sont celles qui savent le mieux utiliser les services de la CMU. Les professionnels de santé adhèrent au principe de la couverture maladie, mais la plupart ont des connaissances limitées sur le dispositif. La mise en œuvre du Plan Sésame apparaît variable selon les structures sanitaires ; la couverture fournie par le Plan Sésame n’est que partielle : entre 30 et 50 % des coûts médicaux ; le reste à charge lié à une consultation pour les patients âgés présentant une HTA et/ou un diabète varie entre 24 000 et 28 000 XOF (francs cfa).

Conclusions. En 2021 le Plan Sésame ne permet pas encore une totale gratuité des soins pour les personnes âgées, cependant son application se traduit tout de même par une réelle baisse des dépenses de santé des personnes âgées. Ces observations confortent la nécessité de travailler à la réduction du prix des prestations médicales et au renforcement de la CMU, afin d’améliorer l’équité et la performance du dispositif.