Analysis and Interpretation of the Heterogeneity of Community-Based Health Insurance Attributes and Preferences in Senegal: Evidence from a Discrete Choice Experiment

Background In Senegal, community-based health insurance (CBHI) schemes aim to expand health coverage among informal sector populations, yet enrolment remains suboptimal. This study employs a discrete choice experiment (DCE) to quantify population preferences for CBHI attributes and to simulate uptake under alternative scheme designs. Methods A DCE was conducted with 912 households across the Ziguinchor region using stratified two-stage sampling. The experiment assessed preferences for six CBHI attributes: enrolment unit, benefit package, copayment, transport availability, payment modality, and annual premium. Mixed logit models were applied to estimate the relative importance of each attribute. Policy simulations predicted uptake under various benefit configurations, and subgroup analyses examined preference heterogeneity by income and residence. Results Chronic disease coverage (OR = 61.2; 95% CI: 46.5–81.7), transport availability (OR = 24.3; 95% CI: 17.1–33.1), and flexible payment options (OR = 6.0; 95% CI: 3.9–9.2) were the most influential drivers of enrolment. Significant heterogeneity was observed: rural and low-income households prioritized accessibility and payment flexibility, while high-income respondents showed strong preferences for comprehensive benefit packages and convenience. Notably, their higher willingness to pay suggests the potential for voluntary cross-subsidization, challenging the assumption that CBHI should exclusively target low-income groups. Scenario-based simulations predicted enrolment gains from 76.53% under the baseline DECAM model to 97.81% under a fully optimized model including chronic care, transport support, and adaptive payments. WTP estimates also varied by income and geography, highlighting the need for equity-sensitive premium structures. Conclusions Designing CBHI schemes around user preferences significantly improves predicted uptake and equity. Rather than uniform models, differentiated and preference-aligned insurance designs can drive substantial increases in enrolment and equity. Tailored insurance models that incorporate chronic disease services, address transport barriers, and allow flexible payment modalities are more likely to achieve inclusive enrolment. The inclusion of high-income households offers an opportunity for financial sustainability through cross-subsidization. These results offer actionable insights for Senegal and similar low-resource settings pursuing universal health coverage (UHC) through community-based mechanisms.