Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 1 | 12 ORIGINAL RESEARCH Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal Martial Coly Bop 1, Kossivi Akoetey 2, Boubacar Gueye 1, Cheikh Tacko Diop 1, Papa Gallo Sow1, Ouseynou Ka 1, Abdoulaye Diop 4, Fatou Sarr Sow 3 1 Alioune Diop University of Bambey; 2 School of Economics, Clermont Auvergne University; 3 Cheikh Anta Diop University of Dakar; 4 Assane Seck University of Ziguinchor; Corresponding author: Dr Martial Coly Bop; Address: Alioune Diop University of Bambey /Region of Diourbel, Departement of Bambey, Box 54, BAMBEY, Senegal; Email: martialcoly.bop@uadb.edu.sn mailto:martialcoly.bop@uadb.edu.sn Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 2 | 12 Abstract Access to health services is a concern around the world. Different strategies were developed, but Africa’s rate remains the lowest. This article aims to contribute to the population's access to healthcare, and to assess the determinants of the use of mutual health insurance by the population of the Ziguinchor region in Senegal. Methods: The study is transversal and descriptive, carried out from July to August 2018. Through the quota method we defined the number of patients to be interviewed. Thus, by a geographic stratification according to the departments and a second-degree stratification taking into account the staff of the different hospital departments, 392 patients were selected. Results: 73% at the Regional Hospital Center and 27% at the Regional Peace Hospital. Re- sponse rate: 97%, women 60% and men 40%. The enrollment for women (24%) is slightly higher than that for men (21%). Socio-economic factors. The rate of adherence is the highest of for patients with university level, followed by high school; income: the highest rate for patients with a monthly income between 200,000 and 500,000 FCFA, followed by patients with an in- come monthly between 100,000 and 200,000 FCFA. Factors linked to the provision of care: the rate of Mutual Health Insurance adherence follows distances from patients' homes. Concerning the relation to satisfaction, education, distance and information are more determining than adher- ence rate. Recommendations: 1) State: actions on education and distance; 2) Sensitizing the population on mutual health insurance; 3) Urging healthcare providers to reduce waiting times and respect schedules as well as appointments. Keywords: Mutual health insurance, Membership factors, insurance, universal coverage, care services access, healthcare providers, Senegal. Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 3 | 12 Introduction During the colonial period, health care was free for the urban populations (6). Faced with the difficulties of the health system, reorgan- ization was adopted for the partial recovery of costs through the participation of the pop- ulations in care costs. Despite these ac- tions, several constraints remained, including the reduction in access to health care and the weakness of the social security system which only covers a tiny part of the African popula- tions (1). Access to health care and services is a concern around the world. This situation is explained by the multitude of barriers, fi- nancial, geographic and socio-cultural. In Africa, with the end of the welfare state, countries subjected to the rigors of structural adjustment in the 1980s could no longer bear all the costs relating to the provi- sion of care and services to the popula- tion. The low participation of the state in health expenditure generates about 85% of the expenditure borne by patients, resulting in increased expenditure and impoverishment of households. To help people get out of this self-sustaining poverty, situation, initiatives have been taken to improve the health sector and contribute to poverty reduction. How- ever, the finding is less encouraging, and Af- rica remains the continent with the lowest rate of access to health care (8,2%) (1). Thus, the World Health Organization and the United Nations International Children's Re- lief Fund have agreed to help low-income countries to set up a system of pooling health risks to increase health coverage for popula- tions and significantly reduce payment for health services at the fund. In this new impe- tus, many low-income countries, including Senegal, have opted for the establishment of a risk pooling system based on mutual health insurance. Developed in several African countries, it shows low population coverage (2, 7). Several studies have been carried out, particularly in the region of Ziguinchor and Kaffrine in Senegal (3, 4) to identify weaknesses and strengths in the system, to enable leaders to make corrections. We note that in Senegal, more than 80% of the infor- mal sector haven’t joined (5). It’s therefore to contribute to a better knowledge of the sub- ject and provide useful information to public decision-makers that we situate our study, in order to understand the factors likely to strengthen the coverage of mutual health in- surance (MHI) in Africa, in particular, in Senegal. Thus, our objective is to assess the determinants of the use of MHI by the popu- lation of the region. Methods The study was carried out in the Ziguinchor region (three departments, 641,253 inhabit- ants (8) and two level 2 hospitals, Regional Hospital Center (RHC) and Peace Hospital (PH) in Ziguinchor. The information col- lected from the nursing services of the two structures enabled us to estimate the annual number of patients for the RHC at 63,756 and 43,206 for the PH. The study was cross-sec- tional and descriptive. The study population consisted of patients from hospitals, who are concerned with community-based health care services and coming from the region. Any pa- tient at the Hospital who agreed to be inter- viewed was included in the study. How- ever, any patient with limitations in respond- ing or with a disability during the survey pe- riod or under the age of 18 or over 60 or re- ceiving a Health insurance institution or budget charge was excluded from the study. Sampling and sample size The units in the sample were only patients from members and non-members of the MHI coming from all departments in the region for treatment. The quota method was used to de- fine the number of patients to be interviewed, Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 4 | 12 according to the administrative departments and to the different hospital ser- vices. First, we did a geographic stratifica- tion according to the three departments of the region: the quotas of patients to be inter- viewed depended on the size of the popula- tions in each department (Table 1). Table 1: Distribution of the population according to the departments Table 2: Distribution of patients in hospital departments 2016-2017 Départements Population Ajusted population (11%) Ziguinchor 330 112 293800 Bignona 318 478 283445 Oussouye 64 850 57717 Total 713440 634962 Regional Hospital Hospital of Peace Services 2016 2017 Average 2016 2017 Ave- rage MEDECINE 2961 3525 3243 2961 3525 3243 SURGERY VICERAL 886 574 730 886 767 827 SURGERY ORTHO 1927 1669 1798 1927 1667 1797 SAU 10918 12143 11531 10918 12137 11528 MATERNITY 7671 6981 7326 7671 6981 7326 ORL 2187 2148 2168 2187 2148 2168 CARDIO- LOGY 560 465 513 560 495 528 STOMATO- LOGY 1265 1327 1296 1265 1327 1296 OPHTALMO- LOGY 5724 7239 6482 5724 7239 6482 PHYSIOTHE- RAPY 465 439 452 465 439 452 CRAO 530 368 449 530 347 439 RADIO- LOGY 7524 7454 7489 1322 2361 1842 LABORA- TORY 18856 17325 18091 2975 3207 3091 DERMATO- LOGY 2126 2254 2190 2126 2255 2191 Total 63600 63911 63756 41517 44895 43206 Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 5 | 12 Second, we did a second-degree stratification taking into account the staffing levels of the different departments of the two hospi- tals. The number of patients to be inter- viewed in the different departments was de- fined according to the number of patients in each department (Table 2). To avoid duplica- tion, we have only presented data on the number of consultants. To determine the sample size, we set a margin of error of 5% and a confidence level of 95%. In the frame- work of our study, the parent population is known and according to the theorem of the centered and reduced normal distribu- tion, when a random sample of size is not greater than 30, the distribution of the sample follows a normal distribution N of mean p and standard deviation σ (p) with σ (p) = √𝑝 ∗ [(1 − 𝑝)]/𝑛 . Assuming the as- sumption of the sample with replacement, we have: t * L with t the confidence rate that we establish at 95% and L the margin of error set at 5%. The formula for the size of the sample was thus obtained: 𝑛 = 𝑡2 × 𝑝(1 − 𝑝) 𝐿2⁄ , p being the rate of adhesion of the population to MHI in the region. According to the re- gional agency for universal Disease coverage (ACMU) of Ziguinchor, it would be 39.9%. According to calculations, the mini- mum sample size is 369. At this figure, we weighted by adding a 10% margin to account for non-responses or recording errors. The sample size was estimated to be 405. Variables studied The literature review helped to choose the variables cited below. The socio-economic determinants were composed of sex, marital status, level of education, socio-professional status, association membership and income of the patients. Demographic determinants consisted of household size and patient age. The determinants linked to the use of mutual health insurance were represented by mem- bership in a mutual health insurance, the rea- sons for membership, for non-membership in MHI, the means of information on MHI, the perception of members for MHI, preference for membership in MHI and respect for the medical pyramid. Regarding services, the de- terminants related to the distance from the nearest health center, the competence of care providers, satisfaction with care, inequalities in relation to care and the waiting period. Data collection Data collection was carried out during the pe- riod from July to August 2018. We used the sphinx software for the design, layout and ad- justments of the questionnaire. After design- ing the questionnaire, we had to train a total of eight people to collect the data. During the training, we translated the questionnaire into the local language, followed by a field test on patients not concerned by the survey, includ- ing patients from the entry office. This test step of the questionnaire allowed us to inter- view around 20 patients and correct short- comings on the questionnaire, including the order of the questions and the way in which the answers were recorded. It also allowed us to determine together with the trained agents, a clear and concise message on the definition of MHI, the interest and the ac- ceptance to participate in the study that was transmitted to patients who were not mem- bers or who have never heard of MHI, and also determine the interview time. Data processing and analysis We used the sphinx software to enter and codify the data. After the entry, we did a de- tailed proofreading, and we corrected the anomalies observed in the data- base. Then, the Stata software helped in the statistical analysis of data on socio-economic Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 6 | 12 and demographic characteristics, the use of MHI and the provision of care. To deepen the analyzes in order to identify the factors re- lated to the adhesion and use of MHI, we car- ried out an econometric modeling. The varia- ble to be explained is adherence to MHI. It is made up of the yes modality if the patient is a member of an MHI and the no if not. The de- pendent variable being a binary qualitative variable with two modalities and the explan- atory variables are either qualitative or quan- titative. The logistic model was chosen for the data analysis. As the study is cross-sec- tional, this method allowed us to compare in- dividuals with each other. To do this, we used the following logistic regression equation: Logit𝑦𝑖 = 𝛼 + 𝛽j𝑥𝑖j + 𝜀𝑖: 𝑦𝑖 is the dependent variable for individual i in the sample. Here it represents MHI membership and is a binary qualitative variable with 1 if the patient is a member of a MHI and 0 if not; 𝜶 is the con- stant that explains the random part of MHI membership; 𝛽j represents the effect of an explanatory variable j in the model, i.e. the effect of determinants on MHI adherence; 𝑥𝑖j represents the explanatory variable j for an individual i of the model; 𝜺𝒊 represents the er- ror term. In order to capture all the possible effects of the explanatory variables, we ad- justed the model. Therefore, we performed the Chi-square goodness-of-fit test. Results In total, we surveyed 392 patients from the various hospital departments and depart- ments in the region, including 73% surveyed at the RHC and 27% surveyed at the PH. Compared to pre-established esti- mates, we recorded a response rate of 97%. Socio-economic characteristics of patients The results of the survey showed that women made up 60% of the sample compared to 40% of men. The enrollment rate for women was slightly higher than for men. In the sam- ple, married patients were predominantly represented, followed by single people. In contrast, the membership rate was higher among divorced people who represented only 7% of the total sample (Table 3). Patient demographics In our sample, the average household size was 10 people and a maximum of 30 people for larger families. The patients interviewed had in their families on average two children under 5 years old and on average two people over 60 years old. The average age of the pa- tients was 34 years. Factors related to the use of MHI The results of our survey of patients in hospi- tals in the region showed a 23% adherence rate. Regarding patients who had no health coverage, 53% said they had never heard of universal or community health coverage. Of those patients who had heard of it at least once, 67% said they did not have clear infor- mation about the enrollment pro- cesses, prices, location, and content of the program. The remainder said they did not trust MHI because some pharmacies and health centers would refuse members' diaries; or that they found the procedures too long or that «the program is no longer moving for- ward because the State is no longer providing funding» (Table 4). The MHI encountered difficulties related to late payments of state subsidies, which lim- ited their functioning and activities. They have a major problem related to the lack of staff. The voluntary staff in charge of the management of the MHI incurred exorbitant expenses related to travel and catering which were not reimbursed by the MHI. Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 7 | 12 Table 3 : The socio-economic characteristics of the patients surveyed Characteristics Member Non Member Total Sample Sexe Female 24,15 75,85 60,46 Male 20,92 79,08 39,54 Marital status Single 15,38 84,62 33,16 Partner 0 100 0,26 Divorced 30,77 69,23 6,63 Married 27,03 72,97 57,4 Vidower (Vidow) 10 90 2,55 Level of Study No 13,64 86,36 16,84 Koranic School 25 75 10,2 Primary 15,56 84,44 11,73 Secondary 24,39 75,61 42,35 University 31,08 68,92 18,88 Socioprofessionnal Status Farmer/Breeder 26,47 73,53 8,67 Artisan 7,69 92,31 3,32 Other 22,22 77,78 11,48 Trader 20 80 27,3 Employee(private) 36,11 63,89 18,62 Student 18,92 81,08 18,88 Household 17,39 82,61 11,73 Associative Mem- bership In the past 27,5 72,5 11,8 No 20,16 79,84 38,35 Yes 28,14 71,86 49,85 Patients Income Under 30 15,52 84,48 29,59 30-60 24,46 75,54 14,54 60-100 26,56 73,44 3,06 100-200 28,07 71,93 35,97 200-500 33,33 66,67 16,58 Over 500 0 100 0,26 Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 8 | 12 Table 4: Factors related to the use of MHI Characteristics Freq. Percent Member of a MHI No 300 77.12 Yes 89 22.88 Reasons for no belonging to MHI Other 137 46.60 Don’t Know the MHI 157 53.40 Reasons for non-MHI membership Proceédures too long 2 1.52 To desist 1 0.76 Pharmacies refuse notebooks 2 1.52 Lack of information 88 66.67 Lack of confidence 30 22.73 Lack of means 3 2.27 Program stopped 5 3.79 In progress 1 0.76 Means of information on MHI Other 17 12.98 Mass awareness 13 9.92 Member of MHI 28 21.37 The Medias 27 20.61 A relative 46 35.11 Perception des Membres aux MHI Good 99 84.62 Bad 4 3.42 Very good 14 11.97 Preferred membership modes of members of MHI Individual 10 8.70 Family 99 86.09 (Associative) group 6 5.22 Respect for the medical pyramid No 21 36.21 Yes 37 63.79 Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 9 | 12 Factors related to the provision of care Patients with a health center less than two kil- ometers from their homes have the highest adherence rate, followed by patients who have a health center between 2 and 5 kilome- ters from their homes and patients whose homes are more than 10 kilometers from a health center are not members of the MHI. Most of the patients surveyed admit that healthcare providers are in control of their job and therefore competent. Patients who think healthcare providers are very competent show a higher rate of 44% membership while those who think providers have no skills are not members of MHI. Likewise, the majority of respondents are satisfied with the treat- ments received. The results of econometric modeling have shown that the presence of people over the age of 60 in the household has a significantly negative impact on MHI membership. With regard to overall satisfac- tion, the majority of patients surveyed de- clared that they were not satisfied; 55% of them say that the waiting times are too long and that they are not well received (Table 5). Table 5: Factors related to the provision of care Characteristics Member Non Member Total Sample Distance to the nearest health center Under 2 26,58 73,42 56,89 ]2-5] 19,33 80,67 38,78 ]5-10] 7,69 92,31 3,32 ]10-20] 0 100 0,51 Over 20 0 100 0,51 Health care provider skills No skills 0 100 1,81 Moderately competent 17,86 82,14 14,51 Competent 16,07 83,93 58,55 Very competent 44,33 55,67 25,13 Satisfaction with care Yes 23,33 76,67 84,87 No 20,69 79,31 15,13 Inequalities in relation to care Yes 29,25 70,75 28,57 No 21,51 78,49 71,43 Timeout Short 38,46 61,54 3,34 Normal 28,57 71,43 41,39 Too long 17,84 82,16 55,27 Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 10 | 12 The results of the estimations showed that neither the income, nor the association mem- bership, nor the presence of children in the household, nor the age of the patients, nor the satisfaction linked to the treatments received nor the aforementioned waiting times have significant impact on MHI membership. Re- garding the level of study, the estimations carried out have shown a significant effect of the secondary level of education on the ad- herence to the MHI. Patients who have a level of secondary education have a 195% chance of adhering to the MHI, in contrary to patients who don’t have any level of study. Likewise, the estimates of the results from the logistic regression and the robustness model have shown that variables such as household size, the presence of elderly peo- ple in the household, the perception that indi- viduals have on MHI and their self-confi- dence, and the respect of the long procedures to receive care have a significant impact on the adhesion to the MHI. The significantly positive impact of the size of the household on the membership in the MHI companies shows that the larger a household, the more it adheres to MHI. Finally, the result of our data analyzes showed a significantly negative ef- fect of adherence to the medical pyramid on MHI adherence. This means that the more re- strictions there are in the procedures to be fol- lowed in order to receive care, the less the members have free choice of treating physi- cians and the less they adhere to the MHI. In addition, some patients felt that the posts and health centers are full of poor skills and can worsen their health in the event of illnesses that would require strong skills or emergen- cies. These results, little known in the litera- ture, constitute a particular contribution of this study (Table 6). Table 6 : Logistic Regression Logistic regression Number of obs = 332 LR chi2(6) = 230.76 Log likelihood = -71.316718 Prob > chi2 = 0.0000 Pseudo R2 = 0.6180 AppartenenceMS2 Odds Ratio Std. Err. z P>|z| [95% Conf. Interval] Pyramidmedical .1125208 .0543078 -4.53 0.000 .0436922 0.2897759 TailleMenage 1.143535 .0461296 3.32 0.001 1.056604 1.237618 ConfianceMS 8.769468 4.12697 4.61 0.000 3.48652 22.0574 personneAgee .3468341 .1663387 -2.21 0.027 .1354855 .8878728 NiveauSecond 2.957122 1.42276 2.25 0.024 1.151677 7.592902 PerceptionMS 56.59515 29.61976 7.71 0.000 20.29049 157.8578 cons .000432 .0005158 -6.49 0.000 .0000416 .0044867 Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 11 | 12 Discussion The shortcomings identified in the context of our work are of three types: representative- ness bias, information bias and judgment bias. According to the literature, depending on the nature of the questions asked, the an- swers of those in favor can tend to be those of biased actors (9), which can generate judg- ment biases. To this end, it would imply cau- tion in interpreting the results across the re- gion. Studies on the determinants of MHI ad- hesion and use are few and lack of available data (10). The few rare studies that have ad- dressed the subject are unanimous on a num- ber of factors such as: education, lack of communication and low household in- come. In our study, the results showed that adherence is progressive depending on the level of study. These results are similar to the one carried out in Ziguinchor (3) which claims to have found a significant link be- tween the level of education of the head of household and membership in the MHI. Also, as patients' income increases, so does their willingness to pay MHI premiums. Education has a significant impact on health. It enables highly educated people to have a high socio-economic status, improves entrepreneurial capacities (11). Thus, people with a high level of education would be likely to have health coverage and by extension, to join more in the MHI. Like education, ac- cording to the literature (10, 4), income is a key variable in the factors of MHI adherence. In contrast, in other work (2, 12), the authors have shown that they found no significant as- sociation between income and MHI member- ship. Demographics also play an important role in MHI membership. Household size and the presence of elderly people in the house- hold have a significant impact on MHI mem- bership. The significantly positive impact of household size on membership in MHI shows that the larger a household, the more it ad- heres to MHI. Conversely, the presence of people over the age of 60 in the household has a significantly negative impact on MHI membership. This result is confirmed by the study carried out in the Ziguinchor region (3). It could no doubt be explained by the establishment of free pro- grams of the State for the latter. The almost free care for people over 60 years old would prevent them and those around them from joining the MHI. In order for there to be con- sistency between the free programs put in place and the health coverage program by the MHI, a partial subsidy for the care of the lat- ter would make the two programs more equi- table and would prevent individuals, espe- cially older, to anticipate not to join the MHI. Then, the state could put in place a pol- icy of gradual subsidies in favor of large fam- ilies. One of the main factors which would constitute a brake on adhesion identified through this study is the lack of infor- mation, which has also been identified in cer- tain works (3, 2). Thus, MHI, through their unions departments, should organize more mass awareness sessions in public places, in the media and more in private than public training centers. The study did not identify a significant impact between factors related to the provision of care services and adherence to MHI, as some studies suggest (1, 3, 13). This would undoubtedly be linked to the embryonic state of the start of the MHI sys- tem in Senegal. In contrast, the patients sur- veyed raised huge issues that need to be ad- dressed to support the process towards MHI maturity. The results of the study showed that the MHI adherence rate also tracks distances from patients' homes. These results are sup- ported by various studies (12, 3) of house- holds which indicate that low adherence is linked to the distance between the household and the health center and the residence in ru- ral areas. This study examining factors re- lated to MHI adherence and use, admittedly had its limitations such as representativeness Bop MC, Akoetey K, Gueye B, Diop ChT, SOW PG, Ka O, Diop A, Sow FS. Evaluation of determinants of the use of health mutuals by the population of the Ziguinchor region in Senegal (Original research). SEEJPH 2021, posted: 25 April 2021. DOI: 10.11576/seejph-4380 P a g e 12 | 12 © 2021 Coly et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bias, information bias and judgment bias, but also had advantages. It could provide a broader knowledge of the functioning of the MHI in Senegal and help to identify the fac- tors which would constitute a hindrance to the membership of the MHI in the region. It also provided useful information to help local policy makers and mutual managers to im- prove the operating system of MHI for greater membership. Indeed, our study has shown that the factors which would consti- tute a brake on the adhesion and the use of the MHI are essentially the lack of infor- mation, the income, the education, the large size of households and the presence in house- hold of persons over 60 years of age. Conclusions Mutual health insurance is a topical issue in the health systems of African countries to- day. This initiative is taking on an unprece- dented scale in the journey of building a re- silient health system in Africa. Although the health risk coverage system through the MHI in Senegal is still in a state of initiation and requires more monitoring, it has solid foun- dations and considerable advantages that could serve as a reference model for other countries on the continent. Recommendations: 1) State actions on education and distance; 2) Sensitizing the population on mutual health insurance; and 3) Urging healthcare provid- ers to reduce waiting times and respect schedules as well as appointments. ____________________________________________________________________________