Equity of national publicly funded health insurance schemes under the universal health coverage agenda: a systematic review of studies conducted in Africa

Abstract

Background:The implementation of publicly funded health insurance schemes (PFHIS) is the major strategy to drive progress and achievement of universal health coverage (UHC) by 2030. We appraised evidence on the equity of insurance schemes across Africa.Methods: We conducted a systematic review of published studies that assessed equity in health insurance schemes implemented under the UHC agenda in Africa. Six databases, Web of Science, Medline, CINAHL, Scopus, Cochrane Library, EMBASE and World Bank eLibrary, were searched; we operationalised the PROGRESS-Plus equity framework to assess equity areas.Result: Forty-five studies met the inclusion criteria and were included in the study, in which 90% assessed equity by socioeconomic status. Evidence showed that rural residents, those selfemployed or working in the informal sector, men, those with lower educational attainment, and the poor were less likely covered by health insurance schemes. Broadly, the insurance schemes, especially, community-based health insurance (CBI) schemes improved utilisation by disadvantaged groups, however, the same groups were less likely to benefit from health services.Conclusion: Evidence on equity of PFHIS is mixed, however, CBI schemes seem to offer more equitable coverage and utilisation of essential health services in Africa

Assessing inequalities in publicly funded health insurance scheme coverage and out-of-pocket expenditure for hospitalization: findings from a household survey in Kerala

“…Results from a 2021 study by Singh and colleagues in India showed that states with higher penetration of PFHIS among richer quintiles have failed to cover disadvantaged populations [ 53 ]. Similar results have been seen in studies in LMICs: PFHIS enrolment often misses disadvantaged populations and is instead covering wealthier quintiles [ 54 , 55 ]. Studies cite lack of awareness and political will as major reasons for low coverage of eligible populations [ 56 , 57 ].…”