Ibou Dieye

Dissertation Title: "Countdown to 2030: Essays on Universal Health Coverage in Developing Countries"

Sub-Saharan Africa (SSA) bears a disproportionate share of the world’s health burden. Women and children remain two of the most critical target groups for intervention. SSA accounts for about 60 percent of global under-five deaths and roughly 70 percent of maternal deaths worldwide. Most of these deaths are preventable. Yet a key barrier to care is cost: high out-of-pocket expenditures prevent households from seeking care and can push them into poverty. Financial protection is thus a prerequisite for any meaningful improvement in health outcomes. In response, countries have committed to Universal Health Coverage (UHC) as a central pillar of the 2030 Sustainable Development Goals, pledging access to quality essential services without financial hardship. In practice, SSA countries have pursued a wide diversity of financing strategies to advance this agenda. This dissertation uses Senegal as an entry point to study two of these strategies. Papers 1 and 2 evaluate the impact of a community-based health insurance program and a free health care policy for children under five, two pillars of Senegal’s UHC strategy. Paper 3 then turns to Kenya to examine the promise and limits of personalized digital counseling tools for postpartum family planning.

Paper 1. Community-Based Health Insurance and Health: Evidence from Senegal

Community-based health insurance (CBHI) schemes have been widely promoted as a mechanism for extending financial protection to informal sector workers excluded from formal insurance. This paper provides the first nationwide, quasi-experimental evaluation of CBHI in Senegal, one of the few countries in SSA to have scaled community-based insurance to national coverage. Exploiting the staggered rollout of 676 mutual health organizations from 1990 to 2019 and applying difference-in-differences methods, I trace effects along the causal chain from coverage to financial protection, utilization, and health outcomes. CBHI increased maternal insurance coverage by 6.7 percentage points and reduced the probability of high out-of-pocket expenditures by 22.6 percentage points. I find no significant effects on healthcare utilization, pregnancy loss, or neonatal mortality. While voluntary CBHI can reduce financial barriers, low enrollment, weak provider contracting, and limited supply-side responsiveness constrain its effectiveness.

Paper 2. Free Health Care for Children and Child Health: Evidence from Senegal

This paper evaluates Senegal’s national free health care policy for children, introduced in 2013 to eliminate user fees for children under five in public health facilities. Using a difference-in-differences design, I find that out-of-pocket expenditures declined by 2,023 FCFA (roughly $3.30) per visit, the probability of costs exceeding the international daily poverty line fell by 26.4 percentage points, and the likelihood of receiving take-home medication rose by 26.5 percentage points. The monthly probability of child death fell by roughly 31 percent for children living within 5 kilometers of a public facility. Reductions were largest among children from poorer households, rural areas, and mothers with no primary education. Persistent gaps between statutory eligibility and reported coverage point to caregiver awareness and geographic access as the central constraints on the effective reach of the policy.

Paper 3. Can Remote Personalized Digital Counseling Improve Postpartum Contraceptive Use?

Digital health tools have emerged as a promising low-cost strategy for extending health services where provider capacity is strained. This paper evaluates a personalized SMS-based counseling intervention for postpartum family planning, delivered through Kenya’s government-endorsed PROMPTS platform in a randomized controlled trial of 4,751 pregnant women across 20 counties. The intervention improved knowledge of the lactational amenorrhea method by 36 percent and increased intention to continue family planning by 4 percent, but produced no significant effect on modern contraceptive use at three or six months postpartum. These precise null results rule out uptake increases larger than 4.3 percentage points. Limited engagement with the counseling tool and persistent demand-side frictions were the key mechanisms. The findings speak to both the promise and the limits of light-touch digital interventions at scale.