Health financing policies in Sub-Saharan Africa: government ownership or donors’ influence? A scoping review of policymaking processes

Lara Gautier, Valéry Ridde

The rise on the international scene of advocacy for universal health coverage (UHC) was accompanied by the promotion of a variety of health financing policies. Major donors presented health insurance, user fee exemption, and results-based financing policies as relevant instruments for achieving UHC in Sub-Saharan Africa. The "donor-driven" push for policies aiming at UHC raises concerns about governments' effective buy-in of such policies. Because the latter has implications on the success of such policies, we searched for evidence of government ownership of the policymaking process. We conducted a scoping review of the English and French literature from January 2001 to December 2015 on government ownership of decision-making on policies aiming at UHC in Sub-Saharan Africa. Thirty-five (35) results were retrieved. We extracted, synthesized and analyzed data in order to provide insights on ownership at five stages of the policymaking process: emergence, formulation, funding, implementation, and evaluation. The majority of articles (24/35) showed mixed results (i.e. ownership was identified at one or more levels of policymaking process but not all) in terms of government ownership. Authors of only five papers provided evidence of ownership at all reviewed policymaking stages. When results demonstrated some lack of government ownership at any of the five stages, we noticed that donors did not necessarily play a role: other actors' involvement was contributing to undermining government-owned decision-making, such as the private sector. We also found evidence that both government ownership and donors' influence can successfully coexist. Future research should look beyond indicators of government ownership, by analyzing historical factors behind the imbalance of power between the different actors during policy negotiations. There is a need to investigate how some national actors become policy champions and thereby influence policy formulation. In order to effectively achieve government ownership of financing policies aiming at UHC, we recommend strengthening the State's coordination and domestic funding mobilization roles, together with securing a higher involvement of governmental (both political and technical) actors by donors.