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Universal health coverage (UHC), defined as all people receiving access to quality essential health services without fear of financial hardship due to health care costs, has influenced health reforms in many countries. Although UHC has increased worldwide over the last decades, limited access to health care and burdensome health spending persists, especially in sub-Saharan African (SSA) countries. Moreover, COVID-19 has halted progress by disrupting access to essential health services and increasing financial hardship. To move towards UHC—especially since more pandemics are expected to come—a better understanding is needed of how to strengthen health systems with inclusive protection schemes, sustainable financing structures, and resilient governance to leave no one behind. This dissertation examines three aspects of moving towards UHC, focusing on SSA countries, where the most vulnerable population groups live, and where health care resources are particularly limited: the functioning of a mandatory health insurance scheme (chapter 2), the impact of the COVID-19 pandemic on the ability of the health system to provide ongoing essential health services (chapters 3 and 4), and impact of the COVID-19 pandemic on people’s lives (chapters 5 and 6). In chapter 2 (co-authored), we use rich administrative data of the National Health Insurance Fund in Tanzania to provide needed evidence on the usage patterns, cost drivers, and financial sustainability of a mandatory health insurance scheme. This study is the first comprehensive analysis of a mandatory health insurance database for an African country. The results emphasize that people still face barriers to health care access despite being covered and that not all accredited health facilities treat insured patients. Furthermore, the chapter identifies the most used and most expensive health services, highlighting that the cost structure and disease burdens differ substantially from high-income countries (HICs). Lastly, the study estimates that scaling up the insurance scheme to the entire Tanzanian population would not be financially sustainable given the current revenues and cost structure, indicating the need to find ways to increase revenues or decrease costs to make the system financially sustainable. In chapters 3 (co-authored) and 4 (single-authored), we use the case of Ghana to provide evidence on the impact of COVID-19 and the corresponding government interventions on essential health service provision. Based on country-wide monthly administrative data from January 2018 to December 2021 of a set of essential health services aggregated by districts, these are the first two studies that measure the impact for an entire low-and middle-income country (LMIC), over a long period of time, across inter-regional differences and differentiating between the impact of government measures and the pandemic itself. Overall, we find fewer health service interruptions and a faster recovery than expected by the literature; however with a large variation by health service type. For maternal health services and time-critical vaccines, we find no interruption at all. On the contrary, yellow fever vaccinations, services for diarrhea disease, and treatments of road accidents experienced large disruptions. We find that for child routine immunizations in Ghana (chapter 3), fear of COVID-19 early in the pandemic, a short public lockdown, and delayed vaccination outreach campaigns had a substantial impact. The declines in road accidents and diarrhea diseases (chapter 4) are both correlated with the stringency of the government measures in place. The results highlight that the population’s adherence to the mobility restrictions and the general adherence to hygiene and social distancing measures most probably affected people’s behavior, leading to this decline. In chapters 5 (co-authored) and 6 (co-authored), we provide evidence on the impact of COVID-19 on the lives of the most vulnerable people in LMICs, the urban poor. We use the cases of Ghana and South Africa, two of the most COVID-19 affected countries in SSA, and collected three-wave survey panel from April 2020 up to one year later in March 2021. First, we study how the urban poor cope with the pandemic in the short term, during the national lockdowns (chapter 5). We find that the large majority adhered to the government interventions. However, adherence is highly correlated with available resources, such as infrastructure and financial means, knowledge about the interventions, and trust in the government. Thus, costly interventions are only effective if people have the infrastructure, the knowledge and the trust to follow them. Second, we study how the economic and mental health situation among the urban poor developed in the long term, over a year into the pandemic (chapter 6). We find that while the economic situation had recovered again over the course of a year, mental health issues increased and are stagnating. Aside from country-specific reasons for a slow recovery, such as worsened physical health and decreasing trust in government, we find that increasing worries about future income and decreasing knowledge about COVID-19 are the two broad reasons for the mental health stagnation. This dissertation demonstrates that UHC demands strengthening health systems with inclusive protection schemes, sustainable financing structures, and resilient governance to leave no one behind. This research points out several barriers in the process of achieving UHC, providing important implications for academic research as well as for public policy. Chapter 2 demonstrates the need to make the health insurance schemes more inclusive and financially sustainable in order to achieve UHC. Chapters 3 and 4 demonstrate that in the case of Ghana and in the case of the analyzed health services COVID-19 caused no generally overburdened health system. However, as we also identified some highly affected districts, it is needed to put policies in place to target under-served population groups as well as to improve pandemic preparedness to achieve an inclusive and resilient health system. Chapters 5 and 6 demonstrate the need to establish social security systems, improve preventive infrastructure, build up government trust, and strengthening public communication in order to achieve inclusive, sustainable, and resilient UHC—also for future pandemics.

Now that COVID-19 vaccines are slowly being supplied around the world, the demand for vaccinations becomes crucial. A survey in Accra, Ghana, reveals that 70% of the urban poor is willing to receive a vaccine, similar to most high-income countries but lower than for the average Ghanaian and many other African countries. For the 30% who are hesitant about the COVID-19 vaccine, the fear of side effects is the biggest concern. Residents who are well informed about the COVID-19 crisis and those who trust their government are far more likely to demand the vaccine. Just under half of the urban poor would be willing to pay for a vaccine and 30% are for compulsory vaccinations. Misinformation about the vaccination is limited, but lack of knowledge – especially about the roll out of vaccines – is still a challenge., Policy Brief

Ten months after the nationwide school closure due to the Covid-19 pandemic, schools in Ghana reopened in January 2021. A survey of poor urban neighborhoods in Accra shows that 94% of school-aged children are back in school. However, missing one academic year has limited learning for many young Ghanaians. Many students only spent an hour or less on learning during the lockdown, and one out of four did not have any contact with their teachers. Limit-ed access to communication infrastructure and the inability of parents to assist children in their studies profoundly hindered learning at home. Missing school meals deprived children of a healthy diet crucial for further development and growth. Hence, despite most students being back in school in Ghana, the learning loss is huge., Policy Brief