Background: To advance Universal Health Coverage (UHC), many countries have introduced Health Insurance Subsidy Programs (HISPs) to extend financial protection to poor and vulnerable populations by covering their insurance premiums. This study examined the institutional design of HISPs in Africa and their contribution to UHC goals, including equity, financial protection, and service coverage.
Methods: We undertook a literature search on Google, Google Scholar, PubMed, Web of Science, Scopus and EconLit to identify published and grey literature on African countries with HISPs. HISPs were defined as government-driven health insurance programs that extend health insurance coverage to vulnerable groups by fully or partially subsidizing their insurance premiums. Screening and selection of relevant articles were done using Covidence. A total of 98 articles were reviewed, detailing the institutional design features of 25 HISPs in 18 African countries. Institutional design features of the HISPs were analysed using a framework adopted from Vilcu and Mathauer (2016).
Findings: Our review identified 25 Health Insurance Subsidy Programs (HISPs) across 18 African countries. Institutional design features that promoted financial risk protection of vulnerable groups included full premium subsidisation, government financing, and the provision of comprehensive benefits packages. However, several design elements undermined effectiveness - most notably, the use of indirect targeting methods prone to high inclusion and exclusion errors, fragmented risk pools, and voluntary membership structures that reduced enrolment among healthy individuals. Implementation of partial subsidies, as observed in Burkina Faso’s Assurance Maladie à Base Communautaire (AMBC), increased the risk of adverse selection, while restrictive definitions of indigence, as in Ghana, limited program reach.
Conclusion: HISPs are a common mechanism for extending financial protection and health service access to vulnerable populations in Africa. However, their impact on UHC goals depends heavily on how they are designed and implemented. Achieving equity and financial protection will require aligning targeting mechanisms with local contexts, mandating enrolment where feasible, and ensuring predictable public financing.
Keywords: Financial protection; Health insurance subsidy programs; Institutional design features; Universal Health Coverage; Vulnerable groups.