Three essays on health financing in Sub-Saharan Africa

Abstract

In Sub-Saharan Africa (SSA), out-of-pocket health spending constitutes a significant proportion of household expenditures, thereby exposing households to a high risk of impoverishment and potential worsening of already poor health outcomes. This dissertation is a series of three essays on health financing in SSA using quantitative and comparative case study methods. In the first paper, the effects of health shocks on household economic outcomes and the role of health insurance and informal coping strategies in mitigating these shocks was examined using panel data from high-frequency household surveys in central Nigeria. Results suggest that health insurance reduces out-of-pocket health spending and helps protect insured households from engaging in potentially costly informal strategies employed to help smooth consumption during illnesses. These findings provide messaging support for information campaigns on the importance of health insurance. In the second paper, I explore the key determinants of health insurance uptake intention and actual uptake in the context of a community-based health insurance scheme in Nigeria. Findings suggest that social capital enhances both intention and actual uptake. I also find that larger households and younger age groups are less likely to be insured. But while household size and age category appear to matter for actual uptake, they do not matter for uptake intention, explaining to some extent the gap between uptake intention and actual uptake. Results suggest that leveraging community groups in disseminating targeted information about health insurance and policy incentives to encourage full household participation could help reduce this gap. The third paper is a novel application of comparative case study methods to investigate factors that influence the degree of financial risk protection across SSA countries. I find that together- strength of the tax base, government effectiveness, quality of government regulatory function, political stability, economic strength, and government commitment to investing in health- jointly contribute to explaining above-average financial risk protection in SSA. Ultimately, improving financial risk protection across SSA will require not only relevant health system-focused policies, but also the complementary pursuit of improvement in the economic, governance and political domains.