[pt] A quarta revolução industrial já está bem próxima do seu ponto de inflexão. As novas tecnologias que, em breve, farão parte das nossas vidas irão impactar a forma como os indivíduos e sociedades se relacionam. A Governança da Saúde Global também precisará se adaptar para absorver essas inovações e o poder que elas terão sobre a agenda de saúde. Avaliar os possíveis impactos sobre os atuais desafios, aumenta a capacidade de se antecipar e incorporar as mudanças. Isso será fundamental para acelerar os processos de fortalecimento e convergência, necessários, em direção à Cobertura Universal da Saúde, até 2030. / [en] The fourth industrial revolution is already very close to its inflection point. The new technologies that will be soon part of our lives, will impact how individuals and societies relate. The Global Health Governance also need to adapt and absorb these innovations and the power it will have on health s agenda. Assess potential impacts on current challenges, increases the ability to anticipate and incorporate these changes. This will be valuable to accelerate processes of strengthening and convergence necessary towards Universal Health Coverage by 2030.

La présente thèse explore, à travers quatre papiers, la possibilité d’étendre le régime d’assurance maladie sociale (SHI) vers la couverture santé universelle (CSU) et ce en présence d’obstacles structurels économiques.Les effets moyens de deux traitements, les deux assurances MHI et MAS, sur l’utilisation des soins de santé (consultations externes et hospitalisations) sont estimés. L’actuel régime d’assurance sociale en Tunisie (SHI), malgré l’amélioration de l’utilisation des soins de santé procurée aux groupes couverts, reste incapable d’atteindre une couverture effective de tous les membres de la population vis-à-vis des services de soins dont ils ont besoin. L’atteinte de cet objectif requière une stratégie qui cible les ‘‘arbres’’ et non la ‘‘forêt’’.Le chapitre deux contourne les principaux obstacles à l’extension de la couverture par l’assurance maladie et propose une approche originale permettant de cibler les travailleurs informels et les individus en chômage. Une étude transversale d’évaluation contingente (CV) a été menée en Tunisie se proposant d’estimer les volontés d’adhésion et les consentements à payer (WTP) pour deux régimes obligatoires présentés hypothétiquement à l’adhésion. Les résultats confirment l’hypothèse selon laquelle la proposition d’une affiliation volontaire à un régime d’assurance obligatoire serait acceptée par la majorité des non couverts et que les WTP révélés pour cette affiliation seraient substantiels. Enfin, dans le chapitre trois, on insiste sur l'’importance de prendre en compte les attitudes protestataires en évaluant la progression vers la CSU. / This thesis explores, in a four paper format, the possibility of extending social health insurance (SHI) schemes towards Universal Health Coverage (UHC) in presence of structural economic obstacles.The average treatment effects of two insurance schemes, MHI and MAS, on the utilization of outpatient and inpatient healthcare are estimated. The current Tunisian SHI schemes, despite improving utilization of healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for needed services. Attaining the latter goal requires a strategy that targets the “trees” not the “forest”.Chapter two gets around major challenges to extending health insurance coverage and proposes an original approach by targeting informal workers and unemployed. A cross-sectional Contingent valuation (CV) study was carried out in Tunisia dealing with willingness-to-join and pay for two mandatory health and pension insurance schemes.Results support the hypotheses that the proposition of a voluntary affiliation to mandatory insurance schemes can be accepted by the majority of non-covered and that the WTP stated are substantial.Finally in chapter three we focus on methodological aspects that influence the value of the WTP. Our empirical results show that the voluntary affiliation to the formal health insurance scheme could be a step towards achieving UHC in Tunisia. Overall, we highlight the importance of taking into account protest positions for the evaluation of progress towards UHC.

Ethiopia has two stories to tell: a fast progress and unfair distribution of the gains in child health care. Despite Ethiopia’s achievement in meeting MDG4, wealth-related mortality inequality increased by 1.5 for every 1,000 live births between 2000 and 2011. Two major dividing lines contribute to child health inequality in Ethiopia: place of residence and wealth status. Lack of proper studies on health inequality policy making is affecting the comprehensiveness and quality of inequality reduction in Ethiopia. This study wished to assess child health inequality and policy factors that affect progress in inequality reduction. Accordingly, the study explored policy-makers’ attitude and interest; policy contents, and institutions to make recommendations that promote child health equity in Ethiopia. The research is mainly a qualitative policy research. Conducted between 2013 and 2017, it was design based on health policy researching and health inequality theories. The researcher conducted semi-structured interviews among health policy makers; policy analysis; and a review of the literature. Twenty policy-makers, 15 policy documents, over 350 literatures were selected through purposing and theoretical open sampling methods. Data was synthesised and analysed with ATLAS.ti 7.1.4 through applying the tools of critical interpretive synthesis and ground theory. The study found that Ethiopia is in an early state of recognizing and intervening against health inequalities. The quality and level of knowledge is mixed and gets reduced as one goes far from the centre. Consensus is still growing on the major underlying causes of child health inequalities in Ethiopia. Most of the policy makers focus on down-stream factors than broader determinants of health. Wealth inequality is less discussed and intervened than geographical inequalities. The production of a new Plan of Action can helped to resolve the challenges of lack of detailed approaches that can help reduce the gap in Ethiopia. However, the content of the health policy documents is not comprehensive and based on global lessons. Policy makers from the central government in Ethiopia tend to reject the use of redistribute justice intervention as policy options. There were multiple reasons including: fear of sustainability, ethics and effectiveness were used to reject these interventions. However, leaders from DRS and DPs broadly support the proper adaption of these interventions. The recent surge of interest to address health inequalities is mainly led by small groups from the top leaders. The engagement of the middle level leaders, Developing Regional States (DRSs), civil society and development partners has been limited. The relation between different institutes is very important in the Ethiopian federal state to reduce inequality. Without an improved level of awareness; change in attitude; broader engagement of citizens; use of independent data source and review of resource distribution Ethiopia’s progress towards Universal Health Coverage in 2030 could get delayed. Finally, this research provided a list of recommend interventions that Ethiopia might take in its plan, to narrow down health inequalities among children by 2030. / Health Studies / D. Litt. et Phil. (Health Studies)

Doctorat en Santé Publique / info:eu-repo/semantics/nonPublished

Aid is an important topic in development sector current discussions are polarised thereby creating a need for further research. This essay assesses the role that Malawi and Zambia plays in realising its development outcomes including in the area of health. There is a need to appreciate the variables that contribute to the inability of most countries in sub-Saharan Africa to finance their domestic expenditure related to healthcare. In this situation, foreign aid which has received marked interest by scholars over the past decade and is used to supplement incomes of developing countries like Malawi and Zambia. Debate on the effectiveness of aid is polarised, while highly concerned scholars see aid as ineffective and a contributor to the poor performance of economies in developing countries, others see it as essential in the achievement of development outcomes. This thesis explores the extent to which development assistance contributes to dependency in Malawi and Zambia. It further examines the link between aid and the Malawian and Zambian health sectors. The study similarly considers the role of development assistance for health in realising outcomes related to maternal health in line with SDG 3.1. By identifying two countries in sub-Saharan Africa, this essay underscores the similarities between Malawi and Zambia analysed through a historical context, health systems structures, child and maternal mortality rates and health programme models. The essay concludesthat social, political and economic barriers present challenges in financing healthcare in Malawi and Zambia. Aid contributes to dependency in the study countries.

Bibliography: leaves 268-317 / The challenge of accessing affordable healthcare services in the developing countries prompted the promotion of community-based health insurance (CBHI) as an effective alternative. CBHI has been implemented in many countries of the South over the last three decades for the purpose of improving access and attaining universal health coverage. However, the sudden stoppage of a CBHI programme in rural Nigeria raised a lot of concerns about the suitability of the health financing scheme. Thus, this thesis examines the stoppage of the CBHI programme in rural Kwara, Nigeria. Premised on the health policy triangle as a conceptual framework, mixed methods approach was adopted for data collection. This involved 12 focus group discussions, 22 in-depth interviews, 32 key informant interviews and 1,583 questionaires. The study participants were community members, community leaders, healthcare providers, policymakers, international partner, health maintenance organisation officials and a researcher. Findings revealed that transnational actors relied on various resources (e.g. fund and ‘expertise’) and formed alliances with local actors to drive the introduction of the programme. As such, the design and implementation of the policy were dominated by international actors. Despite the sustainability challenges faced by the programme, the study found that it benefitted some of the enrolled community members. Though, even at the subsidised amount, enrolment premium was still a challenge for many. The main reasons for the stoppage of the programme are a paucity of fund and poor management. The stoppage of the programme, however, signified a point of reversal in the relative achievements recorded by the CBHI scheme because community members have deserted the healthcare facilities due to high costs of care. In view of these, the thesis notes that short-term policies often lead to temporary outcomes and suggests the need to repurpose the role of the state by introducing a long-term comprehensive healthcare policy – based on the reality of the nation – to provide equitable healthcare services for the citizenry irrespective of their capacity to pay. / Sociology / D. Phil. (Sociology)