RT Journal Article
SR Electronic
T1 Examining the level and inequality in health insurance coverage in 36 sub-Saharan African countries
JF BMJ Global Health
JO BMJ Global Health
FD BMJ Publishing Group Ltd
SP e004712
DO 10.1136/bmjgh-2020-004712
VO 6
IS 4
A1 Edwine Barasa
A1 Jacob Kazungu
A1 Peter Nguhiu
A1 Nirmala Ravishankar
YR 2021
UL http://gh.bmj.com/content/6/4/e004712.abstract
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.