Assessing the integration of social protection into infectious disease policies: a multi-country analysis of TB, HIV, and malaria strategies in Sub-Saharan Africa.

Background: Tuberculosis (TB), HIV, and malaria continue to impose major economic hardship on households in Sub-Saharan Africa. While global frameworks such as the WHO End TB Strategy and Universal Health Coverage (UHC) emphasize social protection, evidence remains limited on how national policies translate these commitments into practice. Objectives: This study assessed how national TB, HIV, and malaria policies and strategic plans in Kenya, Malawi, Mozambique, Nigeria, and Zambia define and operationalize social-protection mechanisms to reduce household economic burden. It also examined alignment with global targets on catastrophic-cost elimination and financial-risk protection, and identified policy-practice and equity gaps. Methods: A structured policy and document review was conducted in five countries, covering strategic plans, operational guidelines, and financing frameworks published between 2015 and 2025. Documents were sourced from government portals and partner repositories, including the Global Fund, PEPFAR, WHO IRIS, and UNAIDS. Analysis used a five-domain matrix adapted from WHO Health Systems Building Blocks and the Global UHC Readiness Framework: (A) Social Support Types, (B) Financial Protection, (C) Implementation Details, (D) Targeting & Equity, and (E) Coordination & Accountability. Domains were scored from 0 to 3 (0 = absent, 3 = high readiness). Two reviewers independently coded data and resolved discrepancies by consensus. Domain averages were used to generate national readiness indices for cross-country comparison. Results: A total of 111 policy documents were reviewed. No country had institutionalized catastrophic-cost monitoring. Overall readiness ranged from 2.6 to 2.9, indicating moderate to high preparedness to integrate social protection within infectious-disease programs. Malawi (2.9) and Zambia (2.8) scored highest due to costed, multisectoral frameworks and insurance linkages. Kenya (2.7) demonstrated strong coordination and legal anchoring but lacked formal catastrophic-cost monitoring. Mozambique (2.6) and Nigeria (2.7) scored lower in financial protection due to donor dependence and limited accountability. Implementation and coordination were strongest domains (3.0), while financial protection was weakest (2.1). Conclusion: Though national policies increasingly acknowledge social protection in infectious-disease control, significant gaps persist in financial-risk monitoring, budgeting, and accountability. Institutionalizing catastrophic-cost surveillance, integrating costed interventions into financing strategies, and reinforcing multisectoral coordination are critical to protect households from the economic impacts of infectious diseases.