Sociodemographic Inequalities in Health Insurance Ownership among Women in Selected Francophone Countries in Sub-Saharan Africa

Abstract

In sub-Saharan Africa, improving equitable access to healthcare remains a major challenge for public health systems. Health policymakers encourage the adoption of health insurance schemes to promote universal healthcare. Nonetheless, progress towards this goal remains suboptimal due to inequalities health insurance ownership especially among women. In this study, we aimed to explore the sociodemographic factors contributing to health insurance ownership among women in selected francophone countries in sub-Saharan Africa. Methods. This study is based on cross-sectional data obtained from Demographic and Health Surveys on five countries including Benin ( $n=\mathrm{13,407}$ ), Madagascar ( $n=\mathrm{12,448}$ ), Mali ( $n=\mathrm{10,326}$ ), Niger ( $n=\mathrm{12,558}$ ), and Togo ( $n=\mathrm{6,979}$ ). The explanatory factors included participant age, marital status, type of residency, education, household wealth quantile, employment stats, and access to electronic media. Associations between health insurance ownership and the explanatory factors were analyzed using multivariate regression analysis, and effect sizes were reported in terms in average marginal effects (AMEs). Results. The highest percentage of insurance ownership was observed for Togo (3.31%), followed by Madagascar (2.23%) and Mali (2.2%). After stratifying by place of residency, the percentages were found to be significantly lower in the rural areas for all countries, with the most noticeable difference observed for Niger (7.73% in urban vs. 0.54% in rural women). Higher levels of education and wealth quantile were positively associated with insurance ownership in all five countries. In the pooled sample, women in the higher education category had higher likelihood of having an insurance: Benin ( $\text{AME}=1.18$ ; 95% $\text{CI}=1.10$ , 1.27), Madagascar ( $\text{AME}=1.10$ ; 95% $\text{CI}=1.05$ , 1.15), Mali ( $\text{AME}=1.14$ ; 95% $\text{CI}=1.04$ , 1.24), Niger ( $\text{AME}=1.13$ ; 95% $\text{CI}=1.07$ , 1.21), and Togo ( $\text{AME}=1.17$ ; 95% $\text{CI}=1.09$ , 1.26). Regarding wealth status, women from the households in the highest wealth quantile had 4% higher likelihood of having insurance in Benin and Mali and 6% higher likelihood in Madagascar and Togo. Conclusions. Percentage of women who reported having health insurance was noticeably low in all five countries. As indicated by the multivariate analyses, the actual situation is likely to be even worse due to significant socioeconomic inequalities in the distribution of women having an insurance plan. Increasing women’s access to healthcare is an urgent priority for population health promotion in these countries, and therefore, addressing the entrenched sociodemographic disparities should be given urgent policy attention in an effort to strengthen universal healthcare-related goals.