Philosophiae Doctor - PhD / This thesis purposes to examine the impact of financial development on health outcomes, health care expenditure and financial protection in health in 46 selected sub-Saharan African (SSA) countries from 1995 to 2014. It also estimates the impact of health care expenditure on health outcomes. The thesis is premised on the hypothesis that health care expenditure is a critical transmission mechanism through which financial development leads to better health outcomes. The health care expenditure channel is conspicuously absent in the literature on financial development and health outcomes; hence the need for this study to fill the gap in the literature. The thesis explores the effects of both depth and access dimensions of financial development on health outcomes, expenditure and financial protection. Throughout the study, financial access is measured by the number of automated teller machines (ATMs) and commercial bank branches per 100 000 people, while financial depth is measured by the proportion of broad money and bank credit to the private sector, to Gross Domestic Product (GDP). The study uses fixed and random effects and the Two-Stage Least Squares estimation approaches. The Generalised Method of Moments (GMM) is also used to estimate the impact of health care expenditure and health outcomes given the absence of valid instrumental variables. The results of the regression analyses show that financial development leads to increased health care expenditure and health outcomes. The analysis also shows that health care expenditure leads to better health outcomes. Additionally, the study indicates that financial development leads to financial protection in health care by reducing out-of-pocket health care expenditure. Well-developed financial systems provide financial protection from the risk of catastrophic health care expenditure and impoverishment resulting from illness. The study shows that health care systems financed through prepaid mechanisms reduce neonatal, infant and under-five mortality rates and increase life expectancy, while those relying on out-of-pocket expenditure have adverse effects on health outcomes.

On October 3rd, 2015, the Consumer Financial Protection Bureau changed the presentation of information within mortgage disclosures such that monthly payments and upfront costs are more salient. Using proprietary bank account data, I document that after closing on the mortgage, treated consumers receiving the re-designed disclosures log in more into their liquid checking accounts, spend less on debit cards and cash, but spend more on credit cards. I argue that the more salient disclosures caused consumers to prioritize having funds to make monthly obligations. Accordingly, I find that liquidity constrained consumers reallocate more of their debit card and cash spending to credit card spending. Other channels related to underestimation of mortgage costs, financial advice, and regulatory enforcement cannot fully explain the results. The reform benefits consumers as they do not accumulate credit card charges despite making more timely mortgage payments. The results collectively demonstrate that modifying information presentation is a low-cost way to change consumers’ behaviors.

The research project intends to investigate the issue of health care accessibility with respect to financial obstacles focusing on the case study of Uganda, where impoverishing effects due to health services utilisation are critical for the population well-being. The thesis consists of three independent chapters aimed to examine multiple aspects which are relevant for health coverage and financial protection. In the first chapter, a political economy perspective is adopted to analyse the country experience of health financing reforms for Universal Health Coverage through a desk review and Key Informant Interviews. In the second chapter, household data from a rural district are employed to explore how the provision of social support through social networks operates at the behavioural level for overcoming barriers to health care utilisation and coping with financial hardship due to health expenditures. The analysis presented in the third chapter relies on a longitudinal household survey to assess the impact of a Community Health Financing pilot program on health expenditures and coping strategies. Overall, the thesis can contribute to the current debate on health coverage in Low- and Middle-Income Countries. On one side, the new evidence based on the collection of primary data and the adoption of innovative methodologies allows to advance the academic knowledge on financial protection. On the other side, the main research findings have the potential to inform policy design and policy making to effectively improve health coverage outcomes in informal settings.

La Couverture Santé Universelle (CSU) vise permettre à chaque individu d’utiliser les services de santé dont il a besoin sans risque de ruine financière ou d’appauvrissement. Bien que le concept de CSU offre un cadre directeur important pour une nation, tous les pays, quel que soit leur niveau de revenu, sont aux prises avec la réalisation ou le maintien de la couverture universelle. Dans ce contexte, générer des preuves sur les expériences des pays et partager les leçons sur les principales contraintes et les choix stratégiques utilisés pour surmonter les barrières techniques serait susceptible de permettre aux pays à revenus faibles ou intermédiaires d’aller de l'avant et de progresser plus rapidement vers la CSU. La thèse propose une analyse comparative de plusieurs instruments politiques, utilisés par cinq cas pays (Niger, Vietnam, Bangladesh, Gabon, France), pour étendre la couverture sanitaire et la protection financière. L’analyse montre que les interventions simples, comme la suppression des frais des utilisateurs (Niger) ou de l'assurance santé à base communautaire (Bangladesh), peuvent accroître l'utilisation des services pour les groupes les plus défavorisés, mais font face à de fortes limitations dans l’atteinte de plus grandes ambitions. Des réformes plus articulées ont démontré des gains importants dans le développement de la couverture santé, mais font également face à des défis pour trouver l'espace budgétaire suffisant (Gabon) et améliorer l’efficience et l'équité du système (Vietnam). Enfin, la thèse analyse les effets de différentes réformes utilisées pour maintenir les gains de la CSU dans des systèmes de santé mûrs, tel que la France. Dans l'ensemble, la thèse a démontré que le menu des réformes vers la couverture universelle est vaste, complexe et perpétuel mais que certains chemins peuvent conduire au succès. / Universal Health Coverage (UHC) is to ensure that everyone can use the health services they need without risk of financial ruin or impoverishment. While the UHC concept offers a powerful framework for a nation, all countries, irrespective of their income level, are struggling with achieving or sustaining universal coverage. In this context, generating evidence about countries’ experiences and sharing lessons on key constraints and strategic choices used to overcome technical barriers would likely enable low-and-middle countries to move forward and make faster progress toward UHC. The thesis provides a comparative analysis of policy instruments used by five selected country cases (Niger, Vietnam,Bangladesh, Gabon and France), to expand health coverage and financial coverage. Analysis shows that single interventions, like user fee removal (Niger) or community-based insurance (Bangladesh), can increase service utilization for the most disadvantaged groups but face strong limitations toward greater ambitions. More articulated reforms have demonstrated significant gains in expanding health coverage but also face challenges in finding the adequate fiscal space (Gabon) and in strengthening system’s efficiency and equity (Vietnam). Finally, the thesis analyzed the effects of different reforms used to sustain gains of UHC in mature health systems, like France. Overall, the thesis demonstrated that the reform agenda for universal coverage is large, complex and perpetual but that certain pathways can ensure success.

La pratique contractuelle des prestataires de services d'investissements s'illustre tant à l'occasion de la fourniture des services d'investissement que lors de montage contractuel issu de la pratique. L'objet de cette étude est de cerner quelles sont les nouvelles règles d'ordre public susceptibles de mettre à mal la sécurité juridique des PSI à l'occasion de cette pratique contractuelle. / Contractual practice of providers of investment illustrates both the provision of investment services and contract assembly created by the practice . The purpose of this study is to identify what are the new public order rules that undermine the legal certainty of PSI during this contractual practice.

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