Universal Health Coverage for the Poor and Informal Sector in Africa: A Health Financing Policy Analysis

Background:In their pursuit of Universal Health Coverage (UHC), a challenge African countries face is extending health coverage to the poor and informal sector. This group accounts for a significant proportion of the population in most African countries, yet there is a wealth of evidence documenting their low health coverage and a contrasting paucity of data available to inform financing policy reform. This thesis intends to collect and apply data to this challenge, redressing this paucity and generating evidence on policies that support a fair, progressive realization of UHC.

Methods:I used a policy surveillance methodology to transform the text of health financing laws and policies into quantitative and qualitative data for analysis. I surveyed the 47 countries of the World Health Organization AFRO region with a codebook consisting of 28 questions relating to the coverage of the poor and informal sector. I answered questions using publicly available, country level documents. I used the data to (i) identify prevailing financing policies that provide health coverage to the poor and informal sector and (ii) present a comparative case analysis examining associations between health financing policies and essential health service coverage.

Results:Health insurance and user fees are predominant UHC financing approaches in Africa. 45 of 47 countries (96%) have health insurance policy and 34 countries (72%) have policy enforcing user fees. To help the poor and informal sector overcome these financial access barriers, countries use exemptions and subsidies. Of the 45 countries with health insurance, 18 (40%) exempt or subsidise premiums for the poor. Of the 34 countries with user fees, 18 (53%) exempt and/or subsidise user fees for the poor. Of the 41 countries with health service packages, 19 countries (46%) provide the health services for free. In general, there is a lack of targeted financing mechanisms for the informal sector.

Conclusions:Extending coverage to the poor and informal sector is a challenge within the broader context of expanding UHC in Africa. This study provides a comprehensive overview of financing policy solutions from within the continent and lays the foundation for further analyses to clarify what reforms work best.