Analyse de l’implantation du régime d’assurance maladie universelle (RAMU) au Bénin : obstacles et facteurs facilitants

The Republic of Benin took the initiative in 2011 to set up a universal health insurance scheme (UHIS). Its objective was to improve the accessibility of quality health care to the entire population of Benin. As no evaluation of the process had been carried out, the purpose of this study was to analyze the implementation of UHIS. To do this a synthetic, mixed, predominantly qualitative research, via a documentary review and semi-structured interviews (implementation managers, healthcare providers, target population) was made. Four health zones (multiple case study) were selected from the 6 pilot zones concerned by the implementation. The level of analysis corresponds to the peripheral level of the health pyramid. A total of 31 semi-structured interviews were conducted, including 07 in the Cotonou VI health zone, 07 in the Porto-NovoSèmè-podji-Aguégués health zone, 07 in the Bassila health zone, 08 in the Nikki-Kalalé-Pèrèrè health zone and 02 at the National Agency of Health Insurance. A content analysis, vertical and transverse, of the collected data was done manually according to the deductive and inductive logic. The following results were obtained. The pilot project was spread over 3 years (2012 to 2015) and officially ended in December 2015. The expansion phase of the implementation has not started and the degree of implementation is relatively low (low membership rate i.e. less than 1% of the Benin population, non-operational organizational structure marked by unavailability of resources and a non-functional process in some cases). The obstacles that could explain this situation were numerous: the strong politicization of the process, precipitation in implementation with an absence of legislative framework during implementation, strong centralization of the process, lack of communication between the different actors, resulting in a climate of mistrust between them, the lack of involvement of all the main actors, particularly health mutual in the process of developing and implementing UHIS, communication and awareness-raising modalities that were inadequate and unsuitable for each social category, shortage of staff at the level of implementers and care providers, lack of trained and qualified providers, lack of motivation of providers and non-reimbursement of benefits. There were a few facilitating factors: political stability, genuine political commitment, the ability to mobilize resources by the State, financial packages offered and the perception of the concept of universal health insurance by all actors. Overall, there were more obstacles than factors facilitating the implementation of the UHIS in Benin and the implementation in terms of membership and operationality of the organizational structure is still in its beginning stage. It should be noted that several approaches to relevant solutions have been objectified. This study should therefore contribute significantly to the improvement of UHIS implementation strategies in Benin.

Keyphrases: Obstacles, Universal health insurance, UHIS, Implementation, Facilitating factors, Benin