Increasing Health Insurance Coverage for Low-Income Populations in Côte d’Ivoire

In Côte d’Ivoire people living in extreme poverty have limited access to health services. While the government recently implemented the National Health insurance program (CMU), results have been unsatisfactory in terms of enrollment. R4D is working with the government to evaluate the implementation of the national health insurance program to identify root causes and propose recommendations to ultimately improve health outcomes.

The Challenge of Ensuring Quality Health Services for All

Since independence, Cote d’Ivoire has seen an average economic growth rate of 8% per year and is recognized by the IMF as one of the fastest growing economies not only in Africa, but in the world. Although Côte d’Ivoire has experienced strong economic growth since 2012, 46 percent of the population is living below the poverty line, and the country’s health metrics are among the lowest in West Africa. For example, Côte d’Ivoire has an exceptionally high maternal mortality rate despite being an economic powerhouse in West Africa (617 per 100,000 according to UNICEF in 2017).

To ensure high-quality health services for the most marginalized, the government of Côte d’Ivoire adopted a national social protection strategy (Stratégie Nationale de Protection (SNPS)) and a universal health coverage law (UHC) in 2014 which created the Caisse Nationale d’Assurance Maladie (CNAM) as a part of the program to achieve UHC. The national health insurance program officially began enrolling people in 2018, but as of 2022, the program had only enrolled 13 percent of the population. And of the people who had received health insurance cards, only 2 percent were extremely poor — despite that this was target population for the program.

Our Work in Cote d’Ivoire

R4D was recruited to lead an assessment of the implementation process of the program to identify any bottlenecks, analyze the effect of the program on the most vulnerable, and to propose recommendations to improve the program, harmonize the various health financing reforms and achieve buy-in from the population.

To identify challenges and bottlenecks, R4D developed a theory of change for the UHC model in Côte d’Ivoire, local consultants conducted 20+ key informant interviews, and R4D facilitated a series of experiential workshops with various government stakeholders.

In October 2022, the evaluation team produced a report and proposed short-term and strategic longer-term recommendations to improve the program and support its objective of reaching the most excluded populations.


As the CMU is an integral part of the current leadership, when national media outlets picked up the evaluation in the fall, there was a strong willingness from government officials to implement recommendations to improve the program.

H.E. Prime Minister Patrick Achi began engaging directly in the process and his involvement helped improve collaboration among government agencies and accelerate progress on solutions.

As a result of this process, the government of Côte d’Ivoire has agreed to implement several measures including:

  • Adopting a decree to operationalize the program’s mandatory membership while also making it easier to enroll in the UHC program, including for those without administrative documents.
  • Adopting the UHC number as the unique identifier for the health sector.
  • Reducing the waiting period for the program and adopting a regulatory framework to ensure the financial sustainability of the program.

The team finalized the evaluation report in April 2023 after an experience sharing workshop and a presentation to the Prime Minister, the Minister of Health, Public Hygiene and Universal Health Coverage, the Minister of Employment and Social Protection, and their advisors and cabinet.

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