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Enabling Universal Health Coverage in Sub-Saharan Africa: Implications and Learnings from Uganda



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Universal health coverage (UHC), defined by the World Health Organization as all individuals having access to health services they need, of sufficient quality, without suffering financial hardship is important to improve population health, particularly for vulnerable populations. Across Sub-Saharan Africa (SSA), advances towards UHC are still limited. This thesis aimed to strengthen the evidence base on UHC in SSA, by focusing on Uganda and examining its readiness for a sustainable UHC model. Objectives included synthesising the existing knowledge base on health financing mechanisms for UHC in SSA, determining how UHC is framed within Ugandan national health policy documents, exploring the relationship between health insurance and sociodemographic factors, and investigating the perception and values of key stakeholders in UHC, particularly health care workers and policymakers in Uganda.

Quantitative and qualitative methods of the mixed methodological approach involved a systematic review of UHC health financing mechanisms in SSA, national health policy content analysis and 2016 Uganda Demographic and Health Survey analysis. This was complemented by a stakeholder analysis of primary data at international, regional, and national level that included email survey techniques, 30 semi-structured interviews, and a focus group discussion about stakeholder perceptions and values of UHC. The theoretical approach of both the qualitative and quantitative data analysis was guided by the Walt & Gilson (1994) Policy Triangle Framework, an interaction between content, context, processes, and actors.

The systematic review revealed a high dependency of donor funding to support health care expenditure among SSA countries, with a need for an increased proportion of domestic financing and enhanced accountability measures to achieve UHC. There was an absence of detailed budget and monitoring and evaluation plans needed to implement UHC in policy documents. Demographic survey analysis showed that among the low proportion (1.4%) of individuals with health insurance, coverage widened with increasing wealth and education levels. Findings of the poisson regression analysis suggested a significant positive association between health service utilisation and age, marital status, wealth, and knowledge of health insurance. A high level of importance of UHC in Uganda was found among stakeholders, with key recommendations centred on communication, organisation, power, and trust.

Summarising these diverse findings provides new insights into the complexities around delivering UHC in low-income settings. Despite the high attributed importance given to UHC by all stakeholders, this research highlights the critical need for better communication of UHC targets to improve understanding across relevant communities and institutions. Furthermore, increased domestic financing, transparent budget plans and strong accountability measures are essential to ensure health coverage reaches lower socio-economic groups. Higher education levels were positively associated with health insurance coverage, indicating the importance of education in health promotion. Therefore, the next steps for implementation must include a communication strategy based on these findings to widely disseminate the existing UHC Roadmap to all stakeholder groups from policy to grassroots level. Beyond an inclusive approach of reaching vulnerable population groups, strategies for the future national health insurance scheme need to incorporate the improvement of education services for empowerment. Analysis of stakeholder perceptions highlights that safeguarding trust among the population through transparency and honesty in metrics and progress, awareness of local cultural sensitivities, provision of quality and timely health services, and investment of health care workers through fair renumeration will be essential to ensuring success of a multisectoral systems approach of UHC in Uganda.





Brayne, Carol
Parkes-Ratanshi, Rosalind


Africa, Global Health, Health Systems, Uganda, Universal health coverage


Doctor of Philosophy (PhD)

Awarding Institution

University of Cambridge
Mary Euphrasia Mosley, Sir Bartle Frere & Worts Travel Fund College Darwin Fund