Financial protection in health care across the West African Economic and Monetary Union: a multidimensional analysis

Abstract

BACKGROUND: As in much of Africa, the heavy reliance on out-of-pocket payments for health care in West African Economic and Monetary Union (UEMOA) countries exposes households to financial risk. We aimed to measure the level of financial protection in health-a core dimension of universal health coverage-by integrating financial hardship and barriers to financial access; assess equity in financial protection; and evaluate the effectiveness of financial protection mechanisms, with a focus on health insurance. METHODS: In this multidimensional analysis, we analysed repeated cross-sectional data from the Harmonised Household Living Conditions Survey (EHCVM) for all eight UEMOA countries in 2018-19 and 2021-22. To measure the level of financial protection, we constructed a composite indicator of financial protection combining forgone care for financial reasons; catastrophic health expenditure (CHE; >10% of household budget); and impoverishing health expenditure (IHE; relative to national poverty lines). To examine inequalities in financial protection, we used concentration indices to assess household socioeconomic characteristics. To estimate the associations between health insurance and forgone care, as well as between insurance and health expenditures, we used inverse probability of treatment weighting with 18 covariates, including age, sex, education level, economic activity, reason for care need or illness, disability status, and wealth quintile. FINDINGS: The EHCVM covered 119 189 households (736 902 individuals) across the two time periods. In 2021-22, 54 645 696 (39·8%) people across the UEMOA did not have financial protection, ranging from 32·6% (Niger) to 50·3% (Guinea-Bissau). Relative to 2018-19, financial protection worsened in six of the eight countries. Components of the composite indicator included forgone care for financial reasons, which affected 10 028 269 (7·3%) people, and financial hardship, affecting 52 751 775 (38·4%) people. 13 631 980 (9·9%) people reported CHE and 47 742 509 (34·8%) reported IHE; these categories are not mutually exclusive. In both time periods, medicines accounted for more than 50% of health spending in most countries; among households with CHE, medicines share often decreased in favour of outpatient or inpatient care (by <13·7 percentage points; p<0·0001). Forgone care was highest for individuals with ophthalmic needs (11·9% in 2021-22), exceeding those with non-communicable diseases (5·7%). Insurance coverage reduced from 6·8% to 5·7% (p<0·0001) and remained concentrated among wealthier populations (ie, pro-rich; concentration indices 0·29-0·65). Insurance was associated with reduced odds of forgone care (country-specific odds ratios ranged from 0·03 [95% CI 0·00-0·15] to 0·90 [0·86-0·95]) and a reduced budget share of health spending among households with coverage (reductions of 30·1-68·7%; p<0·0001). INTERPRETATION: Our findings suggest that absence of financial protection in the UEMOA is four times higher than conventional estimates, confirming the inadequacy of standard indicators in African contexts. The paradox of effective yet minimal and pro-rich insurance coverage substantiates the failure of contributory models in informal economies. These findings call for adopting indicators that integrate financial access barriers, massively increasing public financing through non-contributory fiscal approaches, and ensuring the inclusion of essential medicines in protection mechanisms. FUNDING: None. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.