Universal Health Insurance (UHI) in Côte d’Ivoire: Determinants of enrolment and impact on inequalities in access to care

Authors

  • N’DRI Kouamé Jean-Marc Péléforo Gon Coulibaly University, Korhogo, Ivory Coast
  • KOFFI Adjoua Binette Raïchata Laurène Alassane Ouattara University, Bouaké, Ivory Coast
  • IRIE Bi Gnanin Marius Willy Alassane Ouattara University, Bouaké, Ivory Coast
  • N’GOUANDI Chris Roland Ghislain Institute Universities d’Abidjan, Ivory Coast

Keywords:

Universal Health Coverage, healthcare access inequalities, multilevel logistic regression, concentration index, Propensity Score Matching, Ivory Coast

Abstract

This article analyses the determinants of enrolment in Universal Health Coverage (UHC) and its impact on inequalities in access to healthcare in Côte d’Ivoire, using data from the 2021 Harmonised Household Living Conditions Survey (EHCVM, n = 40,475 individuals). The study relies on a two-level multilevel logit model (individuals, regions), an Erreygers-corrected concentration index, and Propensity Score Matching (PSM). The results show that age, education, marital status, income and media access positively and significantly influence UHC enrolment, whereas gender, household size, area of residence and distance to a health facility show no robust effect. The concentration index (CI = -0.1348; Erreygers index = -0.1243) reveals that access to care is concentrated among the poorest individuals. Finally, the PSM estimation shows that UHC enrolment increases the probability of using a health service by about 9 percentage points (ATT = 0.0904; p < 0.01). These results suggest that UHC improves healthcare utilisation, but that its effect on reducing inequalities remains limited without a parallel improvement in the supply of care.

References

Adeniran, A., Wright, K. O., Aderibigbe, A., Akinyemi, O., Fagbemi, T., Ayodeji, O., Adepase, A., Zamba, E., Abdur-Razzaq, H., & Oniyire, F. (2024). Determinants of health insurance adoption among residents of Lagos, Nigeria: A cross-sectional survey. Open Health, 5(1), 20230043.

Adler, N. E., & Newman, K. (2002). Socioeconomic disparities in health: pathways and policies. Health Affairs, 21(2), 60–76.

Agyemang-Duah, W., Oduro, M. S., Peprah, P., Adei, D., & Nkansah, J. O. (2024). The role of gender in health insurance enrollment among geriatric caregivers: results from the 2022 informal caregiving, health, and healthcare survey in Ghana. BMC Public Health, 24(1), 1566.

Akerlof, G. A. (1970). The market for “lemons”: Quality uncertainty and the market mechanism. The Quarterly Journal of Economics, 84(3), 488–500.

Amu, H., Dickson, K. S., Adde, K. S., Kissah-Korsah, K., Darteh, E. K. M., & Kumi-Kyereme, A. (2022). Prevalence and factors associated with health insurance coverage in urban sub-Saharan Africa: Multilevel analyses of demographic and health survey data. PLoS One, 17(3), e0264162.

Amu, H., Seidu, A.-A., Agbaglo, E., Dowou, R. K., Ameyaw, E. K., Ahinkorah, B. O., & Kissah-Korsah, K. (2021). Mixed effects analysis of factors associated with health insurance coverage among women in sub-Saharan Africa. PLoS One, 16(3), e0248411.

Andersen, R. (1968). A behavioral model of families’ use of health services. University of Chicago, Center for Health Administration Studies.

Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavior, 36(1), 1–10.

Anindya, K., Lee, J. T., McPake, B., Wilopo, S. A., Millett, C., & Carvalho, N. (2020). Impact of Indonesia’s national health insurance scheme on inequality in access to maternal health services: A propensity score matched analysis. Journal of Global Health, 10(1), 10429.

ANSTAT. (2021). Profil de pauvreté de la Côte d’Ivoire 2021. Agence Nationale de la Statistique.

Arrow, K. J. (1963). Uncertainty and the welfare economics of medical care. The American Economic Review, 53(5), 941–973.

Babitsch, B., Gohl, D., & Von Lengerke, T. (2012). Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. GMS Psycho-Social-Medicine, 9, Doc11.

Banque mondiale. (2022). Indicateurs du développement dans le monde : espérance de vie à la naissance.

Barman, P., Karmakar, R., Roy, A., & Dakua, M. (2025). Mass media exposure moderates the association of education and wealth with enrollment in health insurance among older adults aged 60 years and older in India. Journal of Aging & Social Policy, 37(3), 451–475.

Bennett, S., Ozawa, S., & Rao, K. D. (2010). Which path to universal health coverage? Perspectives on the World Health Report 2010. PLoS Medicine, 7(11), e1001001.

Beveridge, W. (1942). Social insurance and allied services. HMSO.

Blanchet, N. J., Fink, G., & Osei-Akoto, I. (2012). The effect of Ghana’s National Health Insurance Scheme on health care utilisation. Ghana Medical Journal, 46(2), 76.

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it’s time to consider the causes of the causes. Public Health Reports, 129(1_suppl2), 19–31.

Carré, B., Jusot, F., & Wittwer, J. (2026). Do prices matter for healthcare accessibility? Evidence from a means-tested complementary health insurance in France. Health Economics, 35(4), 609–637.

Caisse Nationale d’Assurance Maladie (CNAM). (2025). Rapport sur l’enrôlement à la Couverture Maladie Universelle.

Cutler, D. M., & Lleras-Muney, A. (2010). Understanding differences in health behaviors by education. Journal of Health Economics, 29(1), 1–28.

Dowou, R. K., Atanuriba, G. A., Adzigbli, L. A., Balame, S. K., Tahidu, I., Aggrey-Korsah, J., & Aboagye, R. G. (2024). Determinants of health insurance coverage among women in Mauritania: a multilevel analysis. BMC Public Health, 24(1), 229.

Einav, L., & Finkelstein, A. (2018). Moral hazard in health insurance: What we know and how we know it. Journal of the European Economic Association, 16(4), 957–982.

Einav, L., Finkelstein, A., & Levin, J. (2010). Beyond testing: Empirical models of insurance markets. Annual Review of Economics, 2(1), 311–336.

Ekman, B. (2007a). Catastrophic health payments and health insurance: some counterintuitive evidence from one low-income country. Health Policy, 83(2–3), 304–313.

Erreygers, G. (2009). Correcting the concentration index. Journal of Health Economics, 28(2), 504–515.

Finkelstein, A., Taubman, S., Wright, B., Bernstein, M., Gruber, J., Newhouse, J. P., Allen, H., Baicker, K., & Oregon Health Study Group. (2012). The Oregon health insurance experiment: evidence from the first year. The Quarterly Journal of Economics, 127(3), 1057–1106.

Frimpong, A. O. (2023). Contribution of the Ghana national health insurance scheme to inequality in healthcare utilisation. Journal of Health Management, 25(1), 97–106.

Giedion, U., Alfonso, E. A., & Díaz, Y. (2013). The impact of universal coverage schemes in the developing world: a review of the existing evidence. World Bank.

Grossman, M. (1972). On the concept of health capital and the demand for health. Journal of Political Economy, 80(2), 223–255.

Handebo, S., Demie, T. G., Woldeamanuel, B. T., Biratu, T. D., & Gessese, G. T. (2023). Enrollment of reproductive age women in community-based health insurance: An evidence from 2019 Mini Ethiopian Demographic and Health Survey. Frontiers in Public Health, 11, 1067773.

Kakwani, N., Wagstaff, A., & Van Doorslaer, E. (1997). Socioeconomic inequalities in health: measurement, computation, and statistical inference. Journal of Econometrics, 77(1), 87–103.

King, G., Gakidou, E., Imai, K., Lakin, J., Moore, R. T., Nall, C., Ravishankar, N., Vargas, M., Téllez-Rojo, M. M., & Ávila, J. E. H. (2009). Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme (Seguro Popular). The Lancet, 373(9673), 1447–1454.

Leyland, A. H., & Groenewegen, P. P. (2020). Health in context. In Multilevel Modelling for Public Health and Health Services Research (pp. 13–27). Springer.

Marmot, M. (2013). Fair society, healthy lives. In Public Health (2nd ed., pp. 460–470). Oxford University Press.

Marmot, M., & Wilkinson, R. (2005). Social determinants of health. Oxford University Press.

McGuire, T. (2000). Physician agency. In Handbook of Health Economics (Vol. 1, pp. 461–536). Elsevier.

Misnaniarti, Nugraheni, W. P., Laksono, A. D., Kusnali, A., Ardani, I., Latifah, L., Mubasyiroh, R., Yunitawati, D., & Warouw, T. S. (2025). National health insurance membership in Indonesia: Do socio-economic elements matter? PLoS One, 20(8), e0329781.

Muremyi, R., Migisha, L. B., Munezero, M. L. P., Mumararungu, S., Niyigena, E., Mpabuka, G. W., Batamuliza, J., & Ruranga, C. (2025). Barriers to health insurance uptake in Rwanda: a nationwide cross-sectional survey. The Pan African Medical Journal, 51, 8.

Njoumemi, Z., Fadimatou, A., Ntavoua, S. H., Mongbet, O., & Manouore, R. (2023). Health insurance coverage and its socioeconomic and demographic determinants in Cameroon. International Journal of Health Economics and Policy, 8(2), 44–56.

Nshakira-Rukundo, E., Mussa, E. C., Nshakira, N., Gerber, N., & von Braun, J. (2021). Impact of community-based health insurance on utilisation of preventive health services in rural Uganda: a propensity score matching approach. International Journal of Health Economics and Management, 21(2), 203–227.

Olatunji, E. A., Maredia, S., Freeman, N., Nguyen, A., & Washburn, D. J. (2021). Media exposure and the social determinants of health insurance coverage in Ethiopia 2011–2016. MedRxiv.

Or, Z., Cases, C., Lisac, M., Vrangbaek, K., Winblad, U., & Bevan, G. (2010). Are health problems systemic? Politics of access and choice under Beveridge and Bismarck systems. Health Economics, Policy and Law, 5(3), 269–293.

Organisation Mondiale de la Santé (OMS). (2023). Rapport mondial sur la couverture sanitaire universelle.

Organisation Mondiale de la Santé (OMS). (2024). Évaluation de la matrice des progrès en matière de financement de la santé : Côte d’Ivoire 2023.

Pauly, M. V. (1968). The economics of moral hazard: Comment. The American Economic Review, 58(3), 531–537.

Peters, D. H., Garg, A., Bloom, G., Walker, D. G., Brieger, W. R., & Hafizur Rahman, M. (2008). Poverty and access to health care in developing countries. Annals of the New York Academy of Sciences, 1136(1), 161–171.

Rapport Annuel sur la Situation Sanitaire (RASS). (2024). Rapport annuel sur la situation sanitaire 2024. Ministère de la Santé, de l’Hygiène Publique et de la Couverture Maladie Universelle.

Rosenbaum, P. R., & Rubin, D. B. (1983). The central role of the propensity score in observational studies for causal effects. Biometrika, 70(1), 41–55.

Sekyi, S., Nhamo, S., & Mudimu, E. (2024). Heterogeneous effects of national health insurance scheme on healthcare utilisation: evidence from Ghana. International Journal of Social Economics, 51(8), 1057–1075.

Sen, A. (1999). Development as freedom. Oxford University Press.

Shufani, N. (2023). Does the type of healthcare financing systems matter for efficiency? Journal of Health Management, 25(1), 87–96.

Sidibe, Y., & Audibert, M. (2022). Accès aux services de santé au Mali : l’assurance maladie serait-elle discriminante ? Revue Réflexions Économiques, 1(2), 28–39.

Singh, N., John, P., Shukla, S. K., Bajpai, R., Sengupta, R., Sadanandan, R., & Singh, N. (2025). Health insurance coverage among men and women in six countries within the Southeast Asia Region (2015–2022): a multilevel analysis of Demographic and Health Surveys. The Lancet Regional Health – Southeast Asia, 39.

Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health. WHO Document Production Services.

Spence, M. (1973). Job market signaling. The Quarterly Journal of Economics, 87(3), 355–374.

Stiglitz, J. E. (1987). The causes and consequences of the dependence of quality on price. Journal of Economic Literature, 25(1), 1–48.

Thuong, N. T. T. (2020). Impact of health insurance on healthcare utilisation patterns in Vietnam: a survey-based analysis with propensity score matching method. BMJ Open, 10(10), e040062.

Tsega, Y., Alemu, H. T., Geberu, D. M., Hagos, A., Jejaw, M., Abera, K. M., Tiruneh, M. G., Demissie, K. A., Asmare, L., & Endawkie, A. (2024). Rural–urban disparity in community-based health insurance enrollment in Ethiopia: a multivariate decomposition analysis. Frontiers in Public Health, 12, 1361793.

Tuolong, J. G., Alatinga, K. A., & Yendaw, E. (2024). Supply-side factors influencing national health insurance uptake, access and use of primary health care: Evidence from the Upper West Region, Ghana. SSM-Health Systems, 3, 100036.

Van Der Zee, J., & Kroneman, M. W. (2007). Bismarck or Beveridge: a beauty contest between dinosaurs. BMC Health Services Research, 7(1), 94.

Wagstaff, A., & Lindelow, M. (2008). Can insurance increase financial risk? The curious case of health insurance in China. Journal of Health Economics, 27(4), 990–1005.

Wagstaff, A., Paci, P., & Van Doorslaer, E. (1991). On the measurement of inequalities in health. Social Science & Medicine, 33(5), 545–557.

Wagstaff, A., & Van Doorslaer, E. (2000). Equity in health care finance and delivery. In Handbook of Health Economics (Vol. 1, pp. 1803–1862). Elsevier.

Wodessa, G., Gelchu, M., Fikrie, A., & Tuke, G. (2025). Determinants of the decision to enroll in community-based health insurance among households in the West Guji zone, Oromia state, southern Ethiopia, 2022. Frontiers in Health Services, 5, 1559578.

Zegeye, B., Idriss-Wheeler, D., Ahinkorah, B. O., Ameyaw, E. K., Seidu, A.-A., Adjei, N. K., & Yaya, S. (2023). Association between women’s household decision-making autonomy and health insurance enrollment in sub-Saharan Africa. BMC Public Health, 23(1), 610.

Zhang, L., Chen, R., & Fang, Y. (2023). Effects of urban and rural resident basic medical insurance on healthcare utilization inequality in China. International Journal of Public Health, 68, 1605521.

Ziegler, S., Srivastava, S., Parmar, D., Basu, S., Jain, N., & De Allegri, M. (2024). A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India. BMC Health Services Research, 24(1), 141.

Published

2026-11-07

How to Cite

N’DRI, K. J.-M., KOFFI, A. B. R. L., IRIE, B. G. M. W., & N’GOUANDI, C. R. G. (2026). Universal Health Insurance (UHI) in Côte d’Ivoire: Determinants of enrolment and impact on inequalities in access to care. International Journal of Economic Perspectives, 20(11), 1138–1160. Retrieved from https://ijeponline.org/index.php/journal/article/view/1414

Issue

Vol. 20 No. 11 (2026)

Section

Peer Review Articles
Copyright & Licensing

Copyright (c) 2026 N’DRI Kouamé Jean-Marc, KOFFI Adjoua Binette Raïchata Laurène, IRIE Bi Gnanin Marius Willy, N’GOUANDI Chris Roland Ghislain

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Allows users to: distribute and copy the article; create extracts, abstracts, and other revised versions, adaptations or derivative works of or from an article (such as a translation); include in a collective work (such as an anthology); and text or data mine the article. These uses are permitted even for commercial purposes, provided the user: gives appropriate credit to the author(s) (with a link to the formal publication through the relevant URL ID); includes a link to the license; indicates if changes were made; and does not represent the author(s) as endorsing the adaptation of the article or modify the article in such a way as to damage the authors' honor or reputation. CC BY