Health insurance is a form of risk pooling mechanism designed to protect households from catastrophic healthcare expenses while enhancing access to essential health services [1]. Contributory health insurance requires beneficiaries to pay premiums directly often through employers or self-contributions while non-contributory health insurance is fully funded by the government or donors, providing coverage without direct payments from beneficiaries[2]. The effectiveness of a health insurance mechanism is often measured by coverage levels and user satisfaction, as these factors reflect its ability to improve healthcare access, provide financial protection, and ensure service quality [3].

Global health insurance coverage remains highly uneven across regions. In Europe, most countries have achieved near-Universal Health Coverage (UHC) through social health insurance or tax-based systems, with service coverage indices averaging above 70% across the region [4–5]. In contrast, coverage in the Americas show significant disparities such that while over 90% of individuals in the United States are insured, rates remain considerably lower across Latin America and the Caribbean [6]. The World Health Organization (WHO) Western Pacific Region demonstrates moderate progress, with a UHC service index of approximately 75%, reflecting expanding access through national schemes such as those in Vietnam, Indonesia, and the Philippines [7–8]. Africa, however, continues to lag behind, with only about 17% of the population covered by any form of health insurance [4,9]. These regional disparities underscore persistent inequities in financial protection and access to essential health services globally.

In sub-Saharan Africa (SSA), health insurance coverage remains low and highly fragmented, with majority of the population still relying on out-of-pocket (OOP) payments, which expose them to catastrophic health expenditure (CHE) and limit healthcare access [10]. According to the WHO, CHE typically occurs when OOP health payments exceed 10% or 25% of household income or total expenditure [11]. In SSA, where over 40% of total health spending is financed through OOP payments, millions of families experience financial distress and impoverishment due to healthcare costs [4, 12]. Despite growing global efforts to expand financial protection and make progress towards UHC, the region faces several structural, economic, and policy-related barriers that hinder widespread health insurance adoption. OOP costs despite coverage discourage participation [13], while low public health spending leads to under-resourced insurance programs [14]. The dominance of informal employment in Africa makes it difficult to collect premiums or extend coverage beyond formal sector workers [15]. Additionally, limited public awareness, low trust in health systems, poor service quality, and widespread poverty hinder enrollment efforts [16–18]. Table 1 depicts health financing and other relevant socio-demographic indicators in countries in Africa.

Dissatisfaction of insured individuals with the health insurance schemes arises due to limited provider choices, poor service quality, delays in reimbursements, and gaps in benefit packages [19]. Willingness to pay (WTP) for the health insurance schemes has remained moderate and has been shown to be influenced by factors such as socio-demographic characteristics, income and economic considerations, information availability and sources, illness-related expenses, health service factors, social capital and solidarity [20]. Further, retention within the schemes is particularly influenced by perceived quality of care, provider responsiveness, and ease of claims processing [21].

While some countries have attempted to implement mandatory health insurance (e.g., Ghana’s National Health Insurance Scheme) and Kenya’s new Social Health Insurance Fund (SHIF), sustainability challenges persist due to low enrollment rates, inadequate premium collection, and inefficiencies within the health insurance agencies [22,23]. Understanding the factors that influence both coverage and satisfaction is essential for improving the design and implementation of health insurance mechanisms in the region. These factors are closely linked to Strategic Health Purchasing (SHP), which aims to enhance efficiency, quality, and equity by aligning financial resources with provider performance. SHP involves defining service entitlements, selectively contracting high-performing providers, and monitoring performance to achieve health system goals - access to quality services and financial risk protection [22, 24]. By identifying barriers to insurance uptake and retention, purchasing agencies can undertake evidence-based reforms in benefit package design, provider contracting and provider payment mechanisms.

To examine the key predictors of health insurance coverage and satisfaction with health insurance schemes and health care providers, this study employs a regression model analysis using household survey data from eight Sub-Saharan African countries (Ethiopia, South Sudan, Kenya, Uganda, Tanzania, Malawi, Zambia and Senegal) where Amref Health Africa works. This analytical approach allows for a systematic evaluation of socio-economic, demographic, and institutional factors that shape enrollment decisions and user experiences. Key variables examined included: socio-economic factors such as age, gender, education level, household size, number of dependents; and health insurance factors such as type of coverage and premiums, satisfaction with health insurance mechanisms and health provider factors (satisfaction with health services). The study aims to provide insights into existing gaps within the region, challenges, and opportunities to support policymakers and development partners in designing effective risk pooling mechanisms and enhance financial protection and equitable access to quality health care.