AFRICAN

comprehensive understanding of
solidarity in CBHI. Implications of the
study for CBHI policy and for universal
health coverage more widely are discussed
in the next section.
Conclusions
In all three schemes there were serious
contradictions and inconsistencies within
stakeholders’ discourse about solidarity;
and between stakeholders’ discourse about
solidarity on one hand and the target
population’s views and behaviours as
regards solidarity on the other. In practice,
the four dimensions of solidarity (health
risk, vertical equity, scale and source) were
at best only partially mobilized in the
context of CBHI. These contradictions,
inconsistencies and conflicts help
explain the inability of CBHI to expand
coverage. Because solidarity was used
as a catch-all phrase, rarely unpacked
in the way we have done in this paper,
stakeholders were able to continue using
the rhetoric of solidarity, despite the lack
of implementation on the ground.
As such, this study raises a number
of previously overlooked policy and
implementation challenges for expanding
CBHI coverage in Senegal, and perhaps
elsewhere. Policy-makers need to engage
in a more rigorous public discussion of
solidarity as regards CBHI and universal
health coverage policy more widely, in
order to move towards policies which both
resonate with and meet the expectations of
the people they aim to serve.
There is a need to reform CBHI so
that it becomes a coherent solidarity
mechanism, which both provides financial
protection and resonates with local
values concerning all four dimensions of
solidarity. This may involve government
subsidies to cover premiums of all or
of parts of the population. However,
the possibility of low cost-effectiveness
of premium subsidies as compared with
direct payments to providers casts doubt
on this policy option. Therefore, echoing
previous analyses of market-oriented
health sector reforms 37 and consumer-led
financing, 38 alternative or complementary
public sector and/or supply-side financing
policies may be needed in order to
ensure financial protection from the cost
of ill health. These may include health
financing mechanisms which are more
integrated into government systems of
social welfare. 39
From a methodological perspective,
the results suggest that studying values
among stakeholders in multiple case
studies can greatly enhance research
into health financing. Adopting a similar
methodological approach may be a useful
complement to traditional health systems
analysis to understand the challenges
faced by not only CBHI but universal
health coverage policies more widely. p
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AFRICAN HEALTH MONITOR • OCTOBER 2015