Around 150 million people annually suffer financial catastrophe as a result of bearing health expenses globally (WHO 2010). Health financing is not only about mobilizing resources to run health services required, but to do it in such a way that payments made do not create expenses that are catastrophic for the individual. An important part of the health financing discussion over the last decade or so has therefore been focused on the effects that Social Health Insurance (SHI), Development Assistance for Health (DAH) and other alternative domestic financing options have on reducing the detrimental impact that out of pocket payments (OOP) can have on especially the poor. From an equity perspective OOP are regressive and lead to a higher level of households facing catastrophic payments for health care (Ke et al. 2003). Additionally, the impact of even low user fees on access to health care has been well researched and shown to prevent access to necessary health services, especially among the poor and most needy. Exemption mechanisms have also proven to be difficult to manage and operationalize (Carasso, Palmer & Gilson 2010). Women and girls in poor countries are more commonly marginalized as they often have no or little disposable income. Additionally, coping strategies for paying health services can sometimes involve taking girls out of school to enable the mother to earn money by doing piecework. This is the essential rationale for the general movement in health financing towards free health care at the point of delivery (Robert &Ridde 2013). Those in the lowest income quintiles in African countries are often most affected. It is only when direct payments for health fall below 15 20% of Total Health Expenditure (THE) that the incidence of financial catastrophe and impoverishment fall to negligible levels.

The international policy direction is towards systems that also from a financial perspective allow for universal access to health services and which are financed mainly from government revenue and through compulsory contributions (WHO 2010). The current trend in many low income countries is to introduce SHI as an additional means of collecting and pooling revenue. Ethiopia and Zambia are examples of countries coming from a tradition of essentially tax financing who are now pursuing SHI, while South Africa has a financing background where private insurance, especially for the privileged few, stand for a significant share of financing health services (Government of South Africa 2011). One limitation with SHI is that it traditionally only covers the part of the population that is formally employed, which in most low income countries is a very limited part of the population and usually not the poorest. As evidence suggest that poverty is one of the strongest negative determinants of health (reference) equity aspects such as (i) how well health systems manage to provide access to services for the poorest, and (ii) if finance in itself is a barrier to access are key issues to investigate.

The proposed project would explore how SHI has been introduced in a selection of countries in Sub-Saharan Africa (SSA). Apart from describing the process for introduction, the contents of the schemes and their coverage, the project would focus on exploring how the different schemes have catered for different population groups, both in terms of enrollment and in terms of access to services.

From an epistemological perspective, and using the scale presented by Easterby-Smith, Thorpe & Jackson (2012, p 25) the project would build on constructionism but with some positivist influences. The study would describe a number of cases on how SHI has been introduced in a number of countries, but would also use search for data from household surveys and National Health Accounts to explore how SHI has affected both access to care and financing of health systems.