Many low‐income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle‐age and middle‐income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale‐up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low‐income country differs substantially from high‐income settings. Replication studies for other countries are warranted.

Ghana and South Africa proactively implemented lockdowns very early in the pandemic. We analyze a three‐wave panel of households in Accra and Greater Johannesburg to study the mental and economic well‐being of the urban poor between the COVID‐19 lockdown and the “new normal” one year later. We find that even if economic well‐being has mostly recovered, life satisfaction has only improved slightly and feelings of depression are again at lockdown levels one year into the pandemic. While economic factors are strongly correlated with mental health and explain the differences in mental health between South Africa and Ghana, increasing worries about the future and limited knowledge about the pandemic (both countries) as well as deteriorating physical health (South Africa) and trust in government (Ghana) explain why mental health has not recovered. Therefore, we need broad and country‐specific policies, beyond financial support, to accelerate the post‐pandemic recovery of the urban poor.

Introduction: School feeding programs (SFPs) can contribute to address undernutrition in low- and middle-income country settings while can simultaneously improve education outcomes and deliver social and economic benefits. However, evidence on their comprehensive value for money (VfM) remains limited. This study models the multi-sectoral impacts of SFPs across education, health, social protection, and the local agricultural economy in five sub-Saharan African countries, providing benefit-cost ratio (BCR) and VfM estimates to inform policy decisions. Methods: The analysis used secondary data from national reports, program budgets, and national household surveys. SFP impacts on education were assessed through changes in years of schooling and linked to lifetime income gains. Health impacts were quantified as averted anemia cases, converted into disability-adjusted life years (DALYs) and monetized using gross domestic product (GDP) per capita. Social protection benefits were measured as the in-kind value of school meals relative to household food expenditures, while local economic impacts were assessed through monetary transfers to smallholder farmers (SHFs) from local food procurement. BCRs were calculated considering education and health impacts, with additional VfM and expanded BCR estimates considering broader benefits and transfers. Results: Across countries, SFPs were associated with a cumulative gain of 0.6 to 2.3 years of schooling per beneficiary. Moreover, reductions in anemia cases are expected to avert between 4 to 51 DALYs per 1,000 beneficiaries. The BCR for education and health ranged between 3 and 31. Meals provided covered up to 28% of annual household food expenditures for low-income families. Local food procurement generated economic transfers between USD 7 and USD 15 per beneficiary per year to SHFs. Conclusion: SFPs demonstrate high VfM, offering significant educational, health, and economic benefits. Policymakers in sub-Saharan Africa should prioritize the expansion and scaling of SFPs to enhance educational attainment, improve health, and foster economic resilience, contributing to sustainable development.