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

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. We conducted a systematic review of published studies that assessed equity in health insurance schemes implemented under the UHC agenda in Africa. Seven databases, Web of Science, Medline, CINAHL, Scopus, Cochrane Library, EMBASE and World Bank eLibrary, were searched; we operationalized the PROGRESS-Plus (place of residence; race/ethnicity/culture/language; occupation; gender/sex religion; education; socioeconomic status; social capital) equity framework to assess equity areas. 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 self-employed or working in the informal sector, men, those with lower educational attainment, and the poor were less likely to be covered by health insurance schemes. Broadly, the insurance schemes, especially, community-based health insurance (CBI) schemes improved utilization by disadvantaged groups, however, the same groups were less likely to benefit from health services. Evidence on equity of PFHIS is mixed, however, CBI schemes seem to offer more equitable coverage and utilization of essential health services in Africa.