Universal Health Coverage in Africa: an analysis of what works, for whom, why and in what context

The United Nations Agenda for Sustainable Development requires that by 2030 no one is left behind from participating in and benefiting from global and national development. This requirement includes universal health coverage (UHC), defined as access to quality health care for all who need it without financial hardship. Progress toward UHC is commonly assessed along three core dimensions: expanding priority services, extending coverage to more people, and reducing out‑of‑pocket payments by shifting toward prepayment and pooled financing. These dimensions, articulated by the WHO and widely adopted in global monitoring frameworks, shape how countries evaluate their UHC trajectories. Although existing evidence has documented performance across these dimensions, there remains limited understanding of the causal pathways behind UHC progress. This dissertation examines UHC approaches in Africa, focusing on understanding how and why different approaches to UHC succeed or struggle, and identifies actionable strategies for developing equitable and sustainable healthcare systems, using Kenya as the case study. To achieve this aim, the study employed a theory driven sequential qualitative mixed‑method design. The realist approach, a theory-driven approach was chosen as it that emphasizes the need to clearly explain how and why an intervention works. Realist synthesis, guided by the Context–Mechanism– Outcome (CMO) framework, was used to develop candidate theories explaining how, why, and under what conditions UHC reforms in African contexts succeed or fail. Realist interviews were conducted in Kenya with stakeholders from government to non-governmental organizations (NGOs) to validate and refine these theories. Finally, a health systems strengthening lens and qualitative inquiry was used to explore Kenya’s UHC reforms, identifying key enablers, challenges, and strategic recommendations. The study identified a range of UHC approaches implemented across the continent including community‑based health insurance (CBHI), social health insurance (SHI), and PHC‑oriented models which, despite their promise, face persistent challenges such as financial constraints, workforce shortages, and governance gaps. Political commitment and community engagement emerged as critical mechanisms that drive UHC success in Africa. Where these mechanisms were absent or weak, UHC progress was significantly hindered. Interviews with stakeholders in Kenya revealed additional mechanisms specific to Kenya’s context, including intersectoral collaboration and strengthened governance and accountability structures. These findings highlight the importance of a more nuanced approach that considers the continents and individual countries unique challenges. Addressing persistent financial barriers, workforce shortages, and supply chain inefficiencies remains essential for delivering equitable, high‑quality care in Africa. Achieving UHC by 2030 remains a difficult challenge for Africa, but not impossible. This dissertation reveals the complexity of UHC implementation in Africa, highlighting the dynamic interplay between political commitment, community engagement, intersectoral collaboration, governance, accountability, and the broader need for strengthened health systems. The application of realist frameworks enables these multifaceted factors to be theorised in relation to one another and to the national contexts in which UHC reforms unfold. By examining UHC approaches across Africa and focusing on Kenya as a case study, the findings offer valuable insights into the mechanisms that drive UHC successes, the challenges that persist, and the strategies required to move towards UHC.