PPT du webinaire No 1 présenté par Maymouna

1. 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

2. 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

3. Project Overview, Health
Inc Senegal
Project funded by the European Union - 7th Framework Programme
http://www.healthinc.eu/

4. 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

5. 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.

6. Plan Sésame – how it is organized and how
it works
Gov’t of Sénégal
Financing Coordination Purchasing Service delivery
Hospitals
Plan
SESAME
IPRES
State
IPRES (Social
Security for pvt)
Member contributions
Min. of Health
Department of Health
Office of the Elderly
PC
National
Pharmacy
Ministry of
Finance
Taxes
DM
RM
PAF: 70%
IPRES
FNR

7. 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

8. 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

9. Mixed method approach
34 people
60+
46 Actors
Literature review
Pilot household
survey
Household survey
Pilot of semi-
structured interviews
semi-structured
interviews
Enquête ménage
2998
Pilot household
survey
Mapping of actors
Step 1
Focus
groups
Policy recommendations
Mapping of actors Step 2

10. 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

11. Plan Sésame
and the coverage of those 60+

12. 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
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

13. 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
should likely be better informed), 35.2% do
not know about it
The Plan Sesame is a mechanism ill-understood by its supposed
beneficiairies

14. 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.
Sex Educational attainment Place of residence
TotalMen Women illiterate Attended
school
urban Rural
Nbr % Nbr % Nbr % Nbr % Nbr % Nbr % Number %
60+ ill
during
preceeding
2 weeks
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+
hospitalised
in past 12
months
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

15. 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+
Soughthealth
care
Placeofresidence 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

16. 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

17. 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
Beneficiaries
Only 10.5%
of those 60+
Who are the beneficiaries of the Plan
Sésame

18. 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

19. 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)
Coverage

20. 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

21. Are the elderly in Senegal facing social
exclusion?

22. 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

23. 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

24. 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.

25. 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 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
While family may provide help, they spend little time exchanging with

26. 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”

27. 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.

28. Thank you for your attention
Contacts:
Health Inc Sénégal
http://crepos.org/healthinc
Email
health.inc@crepos.org
bamaymouna@yahoo.fr