Patronage, partnership, voluntarism: Community-based health insurance and the improvisation of universal health coverage in Senegal.

The turn towards Universal Health Coverage (UHC) in the past decade raises the question of the role of the state, following years of state withdrawal and a fragmented approach to public health. Senegal introduced its version of UHC, Couverture Maladie Universelle (CMU) in 2013 and this paper explores early efforts to fund it through the establishment of community-based health insurance (CBHI). The paper draws on ethnographic research at mutual health organisations, or mutuelles de santé as they are commonly referred to in francophone countries, which manage CBHI. The research was carried out as part of broader doctoral fieldwork on poverty and social protection in the capital, Dakar, in 2017-18. Responding to recent calls for the move away from the voluntary nature of CBHI with government subsidies and the professionalisation of management, this paper considers the financial strain that mutuelles were under. By drawing on the concept of 'improvisation' as it has come to be employed in recent ethnographies of health infrastructure in contexts of scarcity, the paper attends to the ways in which mutuelles and the voluntary workers that run them sought alternative forms of support, with a particular focus on patronage and partnership. I argue that what might appear to be very minimal gestures of support and material investment serve to maintain a sense of hope and potential in CMU, one however that is fragile and potentially unsustainable.