Social health protection through Universal Health Coverage is the aspiration that all people will obtain the quality health services they need while not suffering financially as a result of seeking health care. For the poorest countries, the greatest challenge is not only reaching the people so far not benefiting from quality health services, but also guaranteeing that their financial situation is not worsened by having to pay for the services they receive. In addition, in Low Income countries millions of people do not obtain the health services they need for many reasons – they are unavailable; poor quality; people, particularly the poor, are unaware of their entitlements; people do not trust the health system; or there are financial and non-financial barriers to accessing health services that lead to exclusion.


In Ghana and Tanzania the major challenges are to understand how to increase and sustain coverage, expand the benefits package for people in the informal sector, and ensure effective coverage with services and financial risk protection to the poorest segments of the population. In addition to the need for more funding, it is important for both countries to develop effective approaches to define eligibility criteria and better identify and target the excluded poor, and to ensure that the rights of citizens who are less likely to be covered are properly addressed. This requires health system governance conducive and responsive to all population groups. Yet, governance in health systems design is rarely studied and little is known about how civil society can improve governance and coverage of social health protection.

Social Health Protection in Tanzania

In Tanzania, the National Health Insurance Fund (NHIF) covers only formal public sector employees, while the Social Health Insurance Benefit, provided by the National Social Security Funds, targets people working in the private sector and parastatals. In addition, there are community health funds (CHFs) aimed at covering people working in the informal economy in rural and urban areas, and a number of other micro-insurance schemes targeting different populations in the informal sector. The resulting health insurance structure in Tanzania is thus highly fragmented with many small schemes targeting different segments of the population. As a consequence, the burden of out-of pocket payments is large among the poorest.

Social Health Protection in Ghana

Since 2003, the Government of Ghana has been implementing a single National Health Insurance Scheme (NHIS). The NHIS complements a national strategy to progressively reduce geographic and economic access barriers to health services. However, its coverage is currently only at 34%. A large portion of government subsidy to the scheme is believed to leak to the non-poor, many individuals that are exempt from paying insurance fees still remain unenrolled, losing the benefits of health insurance when they need services, and the proportion of out of pocket health expenditure in total health expenditures has not changed over the last 10 years.


The project will address questions framed by four broad objectives:

  1. To identify who are currently excluded from effective coverage of health services and financial risk protection in the current Ghanaian and Tanzanian social health protection systems, why, and the cost implications of extending coverage with needed services.
  2. To investigate how the poor and vulnerable groups can be better identified and reached to include them in financing protection mechanisms.
  3. To characterize how health systems governance can be improved to support an inclusive social health protection.
  4. To empirically test interventions aimed at improving health system governance, increasing the transparency and accountability of health systems, with regard to their effectiveness in extending social health protection.

Relevance & expected results

The project will have impact at several levels contributing to increase access to higher quality, more accountable and better governed health services in Tanzania and Ghana and ultimately helping to achieve the upcoming health-related Sustainable Development Goals (SDG) targets, which will shortly be released by the United Nations.


The results are expected to reveal opportunities or problems with regard to governance, in particular involving the civil society, in enhancing design and implementation of social health protection. Mechanisms to better identify the excluded population groups – expected to be mainly the most poor –and to improve the governance of the health systems will be tested for effectiveness and implementation feasibility.