FRIEDRICH-EBERT-STIFTUNG – A majority working in the shadows Figure 3.1 Sources of finance for medical treatment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Zambia Kenya Ethiopia 49.1% 20.8% 13.0% 2.6% 1.2% 33.9% 38.2% 1.0% 26.0% 12.2% 31.0% 42.7% 11.7% 13.1% 3.4% Côte d’Ivoire Senegal 6.8% 0.4% 2.0% 1.1% 57.1% 27.1% 41.5% 47.9% No cost was charged Assistance(government, employer, co-workers) Sale of assets or taking loan(all forms) Other means Savings 8.6% 7.6% Note: No data available for Benin. Table 3.1 Out-of-pocket payments as share of total health spending(2018; per cent) Out-of-pocket payments(OOP) as ­percentage of total health spending Benin 45.0 Kenya 24.0 Senegal 52.4 Source: WHO, Global health expenditure data base. https://apps.who.int/nha/database/ViewData/Indicators/en Zambia 11.8 Côte d‘Ivoire 39.4 Ethiopia 35.0 Figure 3.2 Sources of finance for medical treatment by health insurance membership(two countries) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 33.5% 34.2% 17.3% No health insurance 22.7% 32.8% 32.8% Health insurance 44.7% 39.8% 9.7% No health insurance 39.2% 35.4% 18.8% Health insurance Kenya Ethiopia . No cost Savings Sale of assets or loans The high level of free services in Zambia reflects the free primary health care policy introduced a few years ago at the district level. Our finding that about 50 per cent of patients still pay for medical services points to medical treatment at secondary or tertiary level that is not provided free of charge or to capacity constraints and funding shortages at primary level which limit the use of free medical care. Despite these limitations, free primary health policy is a key reason why fewer patients in Zambia have to sell property or take out loans than in other countries. The positive impact of health insurance on burdensome forms of financing health treatment can be shown if mem­bership is compared with non-membership. In Ethiopia and Kenya, the two countries in our survey group with significant health insurance coverage(35.8 per cent and 25.6 per cent, see Chapter 4) the availability of free health services doubles 20