Association for Public Policy Analysis & Management

The level of financial risk protection in Sub-Saharan African (SSA) is low, as household out-of-pocket spending constitutes a significant proportion of health expenditure in Sub-Saharan Africa. This study examines contributory factors that influence the degree of  financial risk protection provided by national health financing systems as SSA countries seek to progress towards universal health coverage.

This is a cross-country analysis of the 49 countries in SSA.  Using a mix of comparative and within-case study methodology, namely, Qualitative Comparative Analysis (QCA), Narrative Comparison, and Causal Narrative, I explore the influence of six factors—strength of the tax base, government effectiveness, quality of government regulatory function, political stability, economic strength, and government commitment to investing in health—on  the degree of financial risk protection (defined using a measure of out-of-pocket (OOP) expenditure) across countries in SSA.

Findings from QCA suggest that no single factor meets the necessity and/or sufficiency criteria for deterministic causation. However, together, in all country cases where the 6 causal variables are present in above average levels, financial risk protection is above average; whereas, in all cases where the 6 causal variables are absent, financial risk protection is below average. Further, the use of narrative comparison and causal narratives to explore contradictory causal combinations observed within the QCA truth table suggests that the magnitude of examined causal factors seem to matter as well.

Hence, all the six factors examined are jointly important in explaining above average financial risk protection in SSA countries. The analysis also indicates that both the presence of these factors at above average levels and their magnitude/strength play a role.  

This study represents a novel application of case study methods to cross-national health financing research. It provides evidence against monocausal explanations of financial risk protection and suggests that a combination of different factors contribute to the degree of national financial risk protection. Therefore, policy thrusts to improve financial risk protection will likely only be effective if there is accompanying pursuit of broad-based and sustainable growth in governance and national development.