A framework policy analysis of national health insurance policymaking in sub-Saharan Africa

National health insurance (NHI) is a financing mechanism established by a national government with the goal of covering all or almost all of its citizens. A number of low- and middle-income countries have established NHIs as part of a strategy to progress towards universal health coverage. The establishment of an NHI presents a potentially significant shift in national health sector governance, but little is available in the literature regarding how policymaking authority and health governance is shared between NHIs and ministries of health (MOHs). To answer this question, we conducted a descriptive, qualitative comparative analysis of policies, including legislation, guidelines and webpages, from four sub-Saharan African countries that have established or are in the process of establishing an NHI scheme as of 2019 (Ghana, Kenya, Zambia and South Africa). We developed a novel conceptual framework comprising 16 NHI policy domains and conducted a deductive review of relevant policies. We then extracted and indexed policy elements according to this framework to facilitate comparative analysis. We found substantial variation across countries in the types of policies developed and the decision-making authority around those policies. MOHs in all four countries retained at least some decision-making power over the NHIs through regulations and appointment of board members. However, NHIs were often delegated policymaking authority in key areas including financing mechanisms, provider payments, member payments, benefit schemes, accreditation and relationships with private health insurance schemes. The results of this analysis illustrate many aspects of health regulatory power and oversight that will need to be defined as part of establishing NHIs. The approaches from these four countries and the conceptual framework presented in this manuscript may be helpful for other countries in evaluating differing approaches to shared health governance between NHIs and MOHs.