PT  - JOURNAL ARTICLE
AU  - Edwine Barasa
AU  - Jacob Kazungu
AU  - Peter Nguhiu
AU  - Nirmala Ravishankar
TI  - Examining the level and inequality in health insurance coverage in 36 sub-Saharan African countries
AID  - 10.1136/bmjgh-2020-004712
DP  - 2021 Apr 01
TA  - BMJ Global Health
PG  - e004712
VI  - 6
IP  - 4
4099  - http://gh.bmj.com/content/6/4/e004712.short
4100  - http://gh.bmj.com/content/6/4/e004712.full
SO  - BMJ Global Health2021 Apr 01; 6
AB  - Introduction Low/middle-income countries (LMICs) in sub-Saharan Africa (SSA) are increasingly turning to public contributory health insurance as a mechanism for removing financial barriers to access and extending financial risk protection to the population. Against this backdrop, we assessed the level and inequality of population coverage of existing health insurance schemes in 36 SSA countries.Methods Using secondary data from the most recent Demographic and Health Surveys, we computed mean population coverage for any type of health insurance, and for specific forms of health insurance schemes, by country. We developed concentration curves, computed concentration indices, and rich–poor differences and ratios to examine inequality in health insurance coverage. We decomposed the concentration index using a generalised linear model to examine the contribution of household and individual-level factors to the inequality in health insurance coverage.Results Only four countries had coverage levels with any type of health insurance of above 20% (Rwanda—78.7% (95% CI 77.5% to 79.9%), Ghana—58.2% (95% CI 56.2% to 60.1%), Gabon—40.8% (95% CI 38.2% to 43.5%), and Burundi 22.0% (95% CI 20.7% to 23.2%)). Overall, health insurance coverage was low (7.9% (95% CI 7.8% to 7.9%)) and pro-rich; concentration index=0.4 (95% CI 0.3 to 0.4, p<0.001). Exposure to media made the greatest contribution to the pro-rich distribution of health insurance coverage (50.3%), followed by socioeconomic status (44.3%) and the level of education (41.6%).Conclusion Coverage of health insurance in SSA is low and pro-rich. The four countries that had health insurance coverage levels greater than 20% were all characterised by substantial funding from tax revenues. The other study countries featured predominantly voluntary mechanisms. In a context of high informality of labour markets, SSA and other LMICs should rethink the role of voluntary contributory health insurance and instead embrace tax funding as a sustainable and feasible mechanism for mobilising resources for the health sector.Data are available in a public, open access repository.