In sub-Saharan Africa, a health problem can still plunge an entire family into poverty. Without adequate social protection, households finance their own healthcare, often at the cost of heavy sacrifices. Given this reality, mutual health organisations, and more specifically community-based mutual health organisations, are an essential lever for ensuring sustainable and equitable access to healthcare. However, they must be given the means to play their role to the full.

Today, less than 20% of the African population has access to health-related social protection. And in sub-Saharan Africa, 94% of the poorest and 97% of those living in extreme poverty are not covered or are inadequately covered (World Bank, 2025). A very large proportion of healthcare financing is therefore borne directly by households, exposing them to a significant risk of poverty.

Behind these figures are human beings and everyday realities that are unimaginable to Westerners: a father who hastily sells part of his harvest to pay for medicine to cure his son, knowing full well that there will not be enough food for the rest of the family. Or an expectant mother in labour praying that her family will raise the money needed for the caesarean section that will save her and her child.

A goal not yet achieved

So what about African social protection systems? Today, the overall goal is to achieve universal health coverage (UHC), meaning that everyone has access to health services without facing financial hardship. UHC is one of the targets that countries around the world set themselves when they adopted the United Nations Sustainable Development Goals (SDGs) for 2030 in 2015.

However, it must be acknowledged that there is still a long way to go. For more than 20 years, Louvain Coopération has been fighting for access to healthcare in Benin, Togo and Burundi. It does so through the development and structuring of mutual health insurance schemes at municipal and regional level, but also through political advocacy, aimed at convincing governments to invest in this fundamental issue. Despite some significant progress, there are still many obstacles. Pascal Ndiaye, a specialist in social protection in health, helps us to understand.

LC: One of the major challenges facing African mutual health organisations is financial self-sufficiency. Is this achievable?

PN: Yes, a mutual society can be self-sufficient, but there are challenges and conditions for this self-sufficiency that support structures such as Louvain Coopération must absolutely explore, otherwise it will always be dependent on external aid. Today, mutual societies depend on three sources of income. The first is membership fees, which are used primarily to finance healthcare. To maintain these contributions, it is necessary to offer attractive healthcare that truly meets the needs of members. The second source is the state, which plays a key role in regulating prices: if the cost of services and medicines is not stabilised, and if their supply is not guaranteed, this affects the mutual insurance company's cash flow. The State must also bear the risk, i.e. it must put in place prudential mechanisms to intervene in the event of difficulties and ensure the continuity of services, as it is responsible for protecting its population. Finally, the third source is technical support, which is provided by technical and financial partners, NGOs, etc. The self-sufficiency of mutual societies therefore requires a balance between these three pillars.

LC: A crucial issue is the involvement of governments. Is there political will to invest in access to healthcare?

PN : I think that governments are maturing in their thinking. This is a momentum that needs to be seized. Some time ago, governments wanted nothing to do with mutual societies. Some tried to develop systems on their own but realised how complex it was, especially at the operational level. More and more governments are realising this complexity and want to bring mutual societies back into the game. We should welcome interesting initiatives from governments, such as subsidising contributions (sometimes by half), covering certain serious illnesses, integrating free healthcare policies (such as covering pregnant women and children under 5), integrating vulnerable people, and so on. And all this via mutual insurance companies. The problem is that mutual insurance companies are not always ready.

LC: What is African mutuals lacking in order to fulfil their role on a larger scale?

PN : Clearly, professional management. Mutual societies need to be led by people capable of strategic thinking that will lead to self-sufficiency. This means raising the level of training for mutual society staff. We are in an era of professionalisation, because the challenge is to achieve a situation where, as in Belgium, the state delegates the management of health insurance to mutual societies. And states are not going to invest money in mechanisms that do not have control over the engineering of health insurance, a technical and demanding field in which to maintain viability.

LC : Is training mutualist staff partly the role of NGOs?

PN : NGOs are useful throughout this system in terms of training. They already train mutual fund managers, but we need to go one step further and prepare mutual funds to play an important role in UHC. It is essential that there be strategic thinking and that NGOs organise themselves to support mutual funds in a highly structured manner so that this capture by the state takes place under the best possible conditions. Belgian NGOs have a good approach in terms of synergy. They make a lot of individual efforts to support the mutualist movement, but this approach needs to be better developed in order to produce the expected impact.

LC : The reduction in subsidies for Belgian NGOs will force them to make choices, and perhaps to stop supporting mutual health organisations...

PN : Yes, and I say this to all those who support them: now is not the time to abandon social protection. Because if we want to make a difference in agroecology, entrepreneurship... in all other areas, we need to protect people. Good health increases productivity; this has been proven and is very easy to understand. Without social protection in health, other projects are meaningless.