Introduction

The World Health Organization (WHO) considers diseases Mental illnesses rank 3rd among diseases in terms of prevalence and are responsible for a quarter of disabilities. They affect one in five people every year and one in three if we refer to the prevalence over the entire lifetime [11]. The burden of mental disorders is enormous. Mental disorders Mental disorders are the cause of a considerable personal burden for affected persons and their families and create economic hardship and significant social issues, which affect society as a whole [28]. Lack of economic resources, low economic growth or modest, the constraints imposed on the public sector and the limited capacity to organize, explain why the design of an adequate system of Health financing remains complicated and the subject of considerable debate in developing countries, particularly those with low incomes weak [8]. Faced with this situation, governments are increasingly calling on participation of populations in the management and financing of the sector health. The Ivorian government in particular has undertaken a vast reform of the financing the health sector with a view to increasing accessibility to health care health for the entire population [34]. This involves the implementation of Universal Health Coverage (CMU). It is also worth noting the establishment of several private insurance companies and health insurance companies in several sectors of activity.

Health insurance, whether public or private, is at the heart of the reforms of health financing in low-income countries, to reduce payment direct care. In African countries, its development took place in three waves: from health insurance for the formal sector only, then the micro health insurance targeted the informal sector, finally states have implemented construction site a universal coverage policy [25]. In some cases, these may cover the costs of a hospitalization. A social service attached to almost all establishments public health authorities cited by Professor Koné, in fact offer certain patients free care, or even health insurance which However, generally do not cover psychiatric conditions [38]. Faced with this observation and given the absence of studies relating to care psychiatric and health coverage, we considered it necessary to conduct a study to improve the financial accessibility of populations to psychiatric care services. The main objective of our study was to take stock of the level of medical coverage of psychiatric services by insurance companies and health insurance in Ivory Coast.

2. Methods

Our study is based on a survey conducted in the general management of health insurance companies located in the city of Abidjan, specifically in the communes of Cocody and Marcory. This study took place over a period of four (04) months (August 2018 to November 2018). We conducted an exhaustive survey with a survey form per company. We counted 32 companies (25 health insurance companies and 7 health mutuals). Our study population consisted of medical advisors of health insurance and mutual organizations or an employee likely to provide reliable information (head of the medical or legal department). The inclusion criteria for the survey were: medical advisors and other personnel who had given their consent, insurance companies and social mutuals offering health coverage and finally social mutuals operating in the formal sector.

3. Results

• 3.1 Health insurance companies and the management of psychiatric disorders

Of the 32 companies surveyed, we have 07 mutuals and 25 insurance organizations (insurance companies, insurance intermediaries, reinsurance companies, public health insurance). There were 25 insurance organizations, including 01 public and 24 private.

Figure 1: distribution by type of business

In terms of services, no insurance organization covers consultations, hospitalizations, medications, paraclinical examinations and care (dental, surgical and optical). Only 03 companies covered medical evacuations.

The coverage of psychiatric pathologies is done only by mutual health insurance companies and by no private or public insurance organization. Mutual insurance companies covering chronic psychotic disorders, anxiety disorders, mood disorders and acute and chronic psychotic disorders represent 29% of mutual health insurance companies. No mutual insurance company covered addictive behaviors.

Mutual insurance companies covering psychiatric consultations and hospitalizations represent 29% of health mutual insurance companies. Coverage of psychotherapy and specific paraclinical examinations represent 14% of health mutual insurance companies.

Table 1: Distribution of the share of mutual insurance companies covering benefits in the event of psychiatric disorders

Source: Our surveys, 2018

One (01) private insurance company covered neuroleptics. Antidepressants, anxiolytics, hypnotics, mood stabilizers and substitution treatments were not covered by any organization private insurance. The public insurance body did not cover neuroleptics, antidepressants, anxiolytics, hypnotics, mood stabilizers and substitution treatments.

Mutual insurance companies covering antidepressants,anxiolytics,hypnotics and neuroleptics represented 29% of health insurance.

Figure 2: distribution according to the management of antidepressants,anxiolytics,hypnotics and neuroleptics.

Mutual insurance companies covering mood stabilizers represented 14% of health insurance companies. Substitution treatments are not covered by any mutual insurance company. To this end, our investigations show that the drugs used in psychiatry were on the exclusion list of 94% of the companies surveyed (see table 2), which could explain why they were not covered by insurance companies.

• 3.3 Factors behind the failure to cover psychiatric illnesses and their medication by health insurance companies

To identify the main factor that would be at the root of the non-coverage of mental illnesses by public, private and mutual health insurance companies, 5 key hypotheses were raised and verified with health insurance managers. These include, among others, the lack of knowledge of mental illnesses, a consensus between insurance companies, the existence of a law justifying the non-coverage, the rarity of mental illnesses and finally the high cost of the coverage of mental illnesses as the main factor in the non-coverage of mental illnesses. Among these elements, the consensus between health insurance companies was the main factor in the non-coverage of mental illnesses with 75% of the responses as shown in Table 3.

Table 3: Distribution of responses from medical advisors on the different factors which are the basis for the failure to treat mental illnesses

Source: Our surveys, 2018

Insurance companies have mutually agreed not to cover mental illnesses in favor of other chronic diseases such as diabetes, cardiovascular diseases and strokes. In addition,Lack of awareness of mental illnesses and the high cost of treating mental illnesses respectively represent only 9% of the factors for non-treatment. The rarity of mental illnesses would in no case be an important factor in non-treatment since it represents only 3%.

After investigations, we were given open responses from medical advisors to explain the failure of insurance companies to cover mental illnesses.

Medical advisor 1: "Within the framework of health insurance, there are self-funded schemes such as mutual insurance companies. In this case, the structure is its own insurer and most often covers psychiatric care."

"It is much more of a commercial choice because the outcome of the psychiatric pathologies remain difficult to determine”.

Medical advisor 2: “Since mutual insurance is social, compromises are sometimes necessary, hence the management of exceptional cases.”

“Psychiatric pathologies are taken into account if it is proven that they are following trauma or an accident or any other event identified”.

4. Discussion

Our study focused on 32 companies including 25 insurance organizations (insurance companies, insurance intermediaries, reinsurance companies, public health insurance) and 07 mutual health insurance companies, respectively 78% and 22% of the companies surveyed. The documents collected from the companies showed that certain criteria had to be met to benefit from health insurance, including age and professional activity. Age was an important criterion because to benefit from health coverage from private insurance organizations, subscribers had to be under 59 years old for most companies and beneficiaries (legal child) under 21 years old. The choice of this age group could be explained by the fragile health of the elderly which could cause losses for companies and the age of majority according to article 488 of the civil code of Côte d'Ivoire which is 21 years old. This criterion made a large proportion of patients suffering from psychiatric disorders subscribers given the predominance of young adults in this population as shown by the studies of Djo Bi [13] and Koudou [21] who in their studies found a clear predominance of the age group of 25 to 34 years with respectively 29.8% and 32.6%. Djo Bi [14] found in Another study shows a predominance of subjects between 26 and 35 years old, i.e. 33.6% of subjects surveyed. Other international studies have highlighted a predominance of young adult populations.

This is the case of Abdoulaye [1] in Mali who found 40% of subjects between 25 and 34 years old. These data show that these patients given their ages should themselves subscribe to private health insurance and pay the insurance premium. The other important criterion was the professional activity which was the very basis of membership in the mutual insurance companies surveyed. This criterion excluded a large part of people suffering from mental disorders because they are unemployed as Djo Bi [13], [14] found in these two studies more than a third or 37.5% and 36.9% of patients suffering from psychiatric disorders who were unemployed. In a Tra Bi study [35] found 31.4% of unemployed people in first place.

Generally, mentally ill people, who are poorly accepted by society, have difficulty integrating into the world of work. Mental illness would explain the fact that these patients are unemployed and dependent on their families. This would mean that a large proportion of patients suffering from a psychiatric illness cannot take out private health insurance or join a mutual health insurance company. It should be noted that only 10 to 15% of the population benefits from health coverage in Côte d'Ivoire, mainly in urban areas and among workers in the formal sector [2], [6].

The only alternative for people suffering from psychiatric disorders to benefit from health coverage could be the CMU, which is a mandatory national social protection system against the risk of illness and whose main objective is to guarantee all populations residing in Côte d'Ivoire access to quality health care. The CMU in Côte d'Ivoire provides a system for the indigent which is subsidized by the state, this system would take care of the mentally ill in public structures, for well-defined pathologies. In our study, insurance organizations, whether private or public, did not cover any psychiatric pathologies.

Chronic psychotic disorders, acute psychotic disorders, anxiety disorders, mood disorders are covered by 02 mutual insurance companies, or 29% of social mutual insurance companies. Addictive behaviors are not covered by any mutual insurance company. The documents collected from companies showed that psychiatric pathologies are excluded by these companies and therefore not covered. This situation could be explained by the lucrative nature of private insurance organizations, which would probably have carried out market studies that do not would not guarantee benefits. This alarming finding in our study would be related to the stigma attached to psychiatric disorders. According to a Medical Advisor: "Since mutual insurance is social, compromises are sometimes necessary, hence the coverage of exceptional cases"; and this could be justified by the principle of mutual aid which remains one of the foundations of a social mutual insurance. Any mutual insurance could therefore cover one of its members suffering from a psychiatric pathology as an exceptional measure. The CMU which is currently in its phase of extension to the entire population and which could be the only health coverage that most people suffering from mental disorders can benefit from does not cover psychiatric care. There would therefore be exclusions in this health coverage which calls itself "universal".

Yet in other countries the public sector is the guarantor of psychiatric care. This is the case in Gabon where psychiatric pathologies are part of the list of 30 Long-Term Conditions (ALD) giving rise to a reduction in the co-payment to 10% instead of 20% for the Mandatory Health Insurance (AMO) [27]. In Ghana, treatment of mental health problems in public hospitals is free and is funded by the Ghana Health Service. Technically, all services are free to the Ghanaian public, but some minimal fees are charged to help run the hospital. New patients are required to pay 04 Ghana cedis (415 FCFA) for a hospital record, an identification card and some forms. Patients are also asked to pay about 80 pesewas (81 FCFA) for their medication, which can cost up to 400 Ghana cedis (41,600 FCFA) [17]. Morocco has also solved this problem by introducing psychiatric care into basic health care and ensuring that this care is free [30]. In France, mental health benefits from coverage for all, thanks to a highly developed public service [33]. This is also the case in South Korea where the average cost of treatment for insured patients, 65% of the expenses are covered by health insurance [23]. These measures in favour of the mentally ill are alternatives to direct payment which show that economic accessibility to psychiatric care is a real public health problem throughout the world. The public service could therefore be the solution to this problem. In Ivory Coast other fringes The most vulnerable sections of the population have already benefited from measures reducing the problem of direct payment through targeted free care for children aged 0 to 5 and free caesarean sections in public centres.

In our study, no private or public insurance organization covered medical services: consultations, hospitalizations, psychotherapies, paraclinical examinations in the event of psychiatric pathologies. Psychiatric consultations and hospitalizations were covered by 02 health insurance companies, i.e. 29% of health insurance companies. Psychotherapies and paraclinical examinations were covered by 01 health insurance company, i.e. 14% of mutual insurance companies. This low rate of coverage of psychiatric services could be explained by the exclusion of psychiatric pathologies themselves and of all services related to them by the majority of companies. The non-coverage of certain services by public insurance is sometimes little known to the population, as in Mali where the study by Keita [20] showed that 78.7% of patients were not aware of the medical acts not covered by charge by Compulsory Health Insurance (AMO). Other African states outside of Ghana, Gabon and Morocco mentioned above are committed to covering these services.

The Nigerian government has committed to integrating mental health services into primary care, as has Kenya [16], [19]. In South Africa, public sector mental health care is funded by national tax revenues, which are allocated to the national department of health [26]. In France, the cost of hospitalization in a psychiatric hospital and consultations in private psychiatry is covered by social security [33]. Among the 25 insurance organizations surveyed, 01 covered medications used in psychiatry, but these were only neuroleptics which were covered by 01 private insurance in certain cases such as neuropathic pain according to the Medical Advisor. This would lead some doctors to change the diagnosis so that patients suffering from mental disorders benefit from these medications. Antidepressants, anxiolytics, hypnotics and antipsychotics were covered by 02 mutual social insurance companies, or 29% of mutual insurance companies. Thymostabilizers were covered by 01 mutual insurance company, or 14% of mutual insurance companies. Substitution treatments were not covered by any of the 32 companies surveyed.

In our study, the drugs used in psychiatry were from the list exclusion of 30 companies, or 94% of the companies surveyed. Exclusions are part of the insurance contract and are not covered by the company. But according to a medical advisor interviewed: "Psychiatric pathologies are covered if it is proven that they are the result of trauma or an accident or any other identified event." This would mean that a hospitalization for example for "behavioral disorder following a road accident" would be covered by his company. But in reality what care could exist without that of these drugs? They are essential in the drug management of psychiatric care.

This is why in South Africa the national list of essential medicines includes antipsychotics, anxiolytics, antidepressants. Psychotropic drugs are available in psychiatric hospitals (100%), followed by psychiatric care units in general hospitals (96%), and outpatient mental health facilities (88%) [26]. In Djibouti, the drugs and care provided during psychiatric hospitalization are the responsibility of the Ministry of Health. Thus, patients in psychiatric wards benefit from completely free care. The population has access to essential psychotropic drugs but only when they are treated in hospital; patients must obtain their own drugs when they are treated as outpatients [22].

Several factors were mentioned during our study. Among them, the lack of knowledge of mental illness and its rarity, which were not the cause according to the people surveyed. This could be explained by the choice of our study population, which consisted of medical advisors who, during their basic training at the faculty of medicine, received courses in psychiatry and completed internships in psychiatric hospitals, and therefore had knowledge of psychiatric pathologies. But it should be remembered that they are not the decision-makers. The care provided is already defined by the companies. We looked for a legal basis for this non-care, more than half of the people surveyed, or 69%, did not know if there was a law or an article justifying this non-care and no one said they knew of one. This would mean that there would be no legal or judicial basis.

The cost of treating psychiatric pathologies had also been mentioned, but was not in question according to the majority of respondents, i.e. 53%. In Ivory Coast, the latest price list in force since January 1, 2019 in CI, psychiatric consultations in private clinics are the most expensive and cost 20,000 FCFA. In France, Health Insurance estimates, for the year 2011, at 22.6 billion euros the health expenses associated with them, i.e. the second expense item behind one-off hospitalizations and ahead of cardiovascular pathologies or diabetes [24]. The cost of treating psychiatric care would therefore have a high cost but this cost would not be the cause of the non-treatment according to our study but could limit access to care given the lack of health coverage for the majority of patients and the poor level of treatment by these companies.

The most mentioned factor was consensus. This could be explained by the way these companies (mutual insurance and private insurance) operate, which almost all have the same general conditions and offer almost similar care. According to a medical advisor: "It is much more a commercial choice because the outcome of psychiatric pathologies remains difficult to determine." This would probably be the frequent relapses as shown by the Koudou study [20] in Ivory Coast, which found 81.9% patients surveyed who had a personal psychiatric history. Elsewhere Saliou Salifou et al [32] in Togo showed 34.4% of patients with a personal psychiatric history. But one might wonder whether the outcome of pathologies such as typhoid fever, peptic ulcer or bacterial pneumonia are not difficult to determine, yet they are all taken care of. In reality, do we know the outcome of a pathology? Indeed, if this commercial choice is due to frequent relapses or the chronic nature of certain mental illnesses, one could wonder why other chronic conditions such as high blood pressure (HTA) and diabetes are taken care of and not mental illnesses. This would be a stigmatization of mental illness by the health system and even the public who are supposed to take care of it. cares for the mentally ill without exclusion.

Conclusion

The coverage of mental illnesses by health insurance companies in Ivory Coast is almost non-existent. In the public and private sectors, mental illnesses are excluded from any form of social insurance. Thanks to mutual insurance companies, certain benefits and certain medications are taken into account. However, 2 out of 7 mutual insurance companies included among the 32 insurance companies manage to relieve people living with mental illness or epilepsy. Despite the arrival of Universal Health Coverage, mental illness insurance remains a decoy. Mental illnesses, in addition to being isolated from other illnesses, still suffer from institutional discrimination linked to the many myths and doubts that have always been built.

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