'Highlight' Health financing for universal health coverage in the era of shocks, monitoring risks and opportunities in Sub-Saharan Africa "The proposed research draws on the World Health Organization framework for monitoring progress towards UHC. The framework identifies three areas for monitoring: financing arrangements; intermediate outcomes of efficiency and equity; and UHC goals of service coverage and affordable health expenditures. Our research applies this framework to assess health financing at the national and subnational levels in five Sub-Saharan African countries with varied degrees of fiscal decentralisation and income levels: Tanzania, Malawi, Zambia, Senegal and Sierra Leone. Our research describes the evolution of health financing arrangements before and after COVID-19, and progress in relation to efficiency and equity of health financing and UHC goals. This research draws on routine household surveys, government and donor expenditure
information systems, and global data from the World Health Organzaition and the Organisation for Economic Cooperation
and Development"
 COVID-19 This research aims to assess whether and how COVID-19 has affected progress in health financing for universal health coverage (UHC), in terms of health financing arrangements, efficiency, equity and UHC goals in five African countries: Tanzania, Malawi, Zambia, Senegal and Sierra Leone. This research has six main objectives. This research has six main objectives. First, we will examine whether there is evidence of changes in health funding levels and sources since COVID-19 and if there is evidence of a displacement of funds away from reproductive, maternal, newborn and child health (RMNCH) towards infectious diseases. We will explore the health financing arrangements in each country by describing the trends in levels of health funding by source, the share of funding that is pooled (through government and health insurance), and the allocation of funding to RMNCH relative to infectious diseases, to explore funding displacement. Second, we will explore trends in the alignment and harmonisation of aid for health, RMNCH and infectious diseases with country systems and determine eventual changes since COVID-19. Alignment is assessed as the proportion of aid channelled through government systems and the share of aid that is pooled. Harmonisation is measured in terms of fragmentation (the number of donors in a given country relative to the total aid for health/RMNCH) using the Herfindahl-Hirschman Index (HHI). Third, we will describe the levels and trends in subnational health funding by source of funding. Forth, we will assess trends in technical efficiency at the subnational level in relation two financing inputs: government and donor health expenditure and three UHC outputs: (1) service coverage; (2) financial risk protection; (3) an unweighted UHC index which combines (1+2). We will use two-stage Data Envelopment Analysis (DEA) to determine the efficiency score for each subnational unit using an output orientated approach. We will identify drivers of inefficiency using a Tobit model regressing efficiency scores against household income per capita, health facility and health worker density, and share of household expenditures in total health expenditure. Fifth, we will examine trends in equity of the allocation of government and donor health funding across subnational units in relation to economic and health need. We will also assess trends in equity of out-of-pocket payments and health insurance contributions. The equity analysis will use the Kakwani Index (KI) with economic need measured in relation to income and health need in relation to under five and neonatal mortality. Sixth, we will explore the relationship between efficiency and the UHC service coverage and financial protection goals using pairwise correlation analysis to test the associations in the UHC financing framework. We will thus test the UHC framework and determine whether efficiency and equity are good markers of progress towards UHC. The research will use the Countdown2030 partnership to widely disseminate findings, analytical toolkits for analysing health financing for UHC in the context of shocks; and to build capacity through training within Sub-Saharan Africa. We will develop skills among early career researchers in our team, through training and pairing with senior researchers.