Social Health Insurance Schemes in Sub-Saharan Africa: Examining Implementation, Uptake and Sustainability

Background: Like many low- and middle-income countries [LMICs], direct payments for healthcare by individuals account for a large share of health system financing in Ethiopia. These payments prevent individuals from seeking healthcare services when required and increase the risk of financial catastrophe for households. As a means to improving health system financing and achieve the goals of Universal Health Coverage [UHC], many LMICs including Sub-Saharan African [SSA] countries have introduced Social health insurance [SHI] as a key financing mechanism. Ethiopia is seeking to introduce SHI schemes to reduce the financial barriers to healthcare services and to achieve UHC; it is essential to understand the factors and conditions that contribute to favourable SHI implementation within SSA. This study, therefore, has examined the factors which influence implementation, uptake and more precisely sustainability of SHI schemes within the context of SSA. Methods: A desk-based narrative review of the literature was performed to examine the social, economic, political, organisational & management, scheme, and health system factors which influence implementation, uptake, and sustainability of SHI schemes. Applying a conceptual framework, a developed model of the Ecological Model framework, this study focused on analysing three countries in SSA which have implemented SHI. Results: Factors which have influenced implementation, uptake and sustainability of SHI schemes were found to be a range of interconnected factors. Socioeconomic factors such as age, education, employment, and inadequate finances were associated with enrolment in SHI schemes. Political factors which influenced implementation included strong political commitment and government ownership. Organisational and management factors such as having adequate government physical and technical resources were found to be beneficial for SHI implementation. Scheme factors like high premium payments, lack of awareness and complicated registration process were found to influence drop-out of scheme. Health system factors such as inadequate finances, unavailability of medications and healthcare providers negative attitude were found to influence service quality which significantly impacted renewal decisions among individuals. Conclusion: There is a range of interconnected factors at the social, economic, political, organisational & management, scheme and health system level which influenced the implementation, uptake, and sustainability of SHI schemes in SSA countries. To design effective SHI scheme, the contextual characteristics, together with the multitude of interconnected factors, need be cautiously examined for improved implementation and sustainability of SHI