Factors influencing the adoption of Universal Health Coverage in Africa: Insights from a realist synthesis

Abstract

Background: Achieving Universal Health Coverage (UHC) is a critical goal for improving health equity and access in Africa. Knowledge gap exists on the underlying factors that drive UHC performance in the African context. Our study sought to explore the complex landscape of UHC adoption in Africa, examining the factors that influence its implementation and the strategies that could accelerate progress towards this vital goal.

Methods: This study employs a realist synthesis approach to explore the mechanisms driving the success or failure of UHC reforms across the continent. We conducted a systematic literature search on the Cochrane database of systematic reviews, PUBMED, EBSCO, Eldis, SCOPUS, CINHAL, TRIP, and Google Scholar. The inclusion criteria emphasized on UHC adoption, rollout, implementation, challenges, and opportunity in African countries. We included qualitative, quantitative, mixed methods studies, as well as grey literature. The realist synthesis was guided by Realist and Meta-Narrative Evidence Syntheses: Evolving Standards (RAMESES II).

Findings: Drawing on evidence from 167 studies spanning 18 African countries, the analysis identifies key factors influencing UHC outcomes, including political commitment (mechanism), community engagement (mechanism), and trust (context) in healthcare systems. The findings reveal that strong political commitment is essential for leveraging donor-imposed conditionality (context) and aligning reforms with local priorities. Community engagement emerges as a transformative mechanism, fostering trust, ownership, and collaboration, which are critical for sustaining UHC initiatives. Conversely, the absence of political will or community involvement leads to stagnation or failure of reforms. Tailored, context-specific approaches, such as Rwanda's Community-Based Health Insurance (CBHI) demonstrate the importance of adapting strategies to local socio-economic and political conditions.

Conclusion: The success of UHC in Africa hinges on community trust, responsive governance, and sustained political and community support. These findings provide actionable insights for policymakers and stakeholders working to advance UHC goals across diverse African contexts.