Background Determinants of health in a population are related to numerous factors beyond health services. However, means to provide access to and the actual shape of health services are important for planetary health. Ability to benefit from these services is essential in order to foster sustainable development. Universal health coverage (UHC), which is embedded within the United Nations Sustainable Development Goals, is defined by the World Health Organization as all individuals and communities having access to any health services they need, of sufficient quality to be effective, without suffering financial hardship. Effective strategies for financing healthcare are critical in achieving this goal yet remain a challenge in Sub-Saharan Africa (SSA). In this respect, the aim of this review is to determine the extent of research in the published literature that examine health financing approaches and strategies for UHC in SSA.

Methods A systematic literature review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. On 19 July 2019, MEDLINE, EMBASE, Web of Science, Global Health Database, the Cochrane Library, Scopus and JSTOR were searched for literature published from 2005. Studies that described health financing approaches and strategies for UHC in SSA were eligible for inclusion. For selected papers, reference lists were searched through the snowballing procedure for further studies. The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 14 August 2019 (registration number CRD42019142895).

Results Of the records screened, 39 papers were selected for inclusion and analysis. The results indicate that a majority of health care revenue in SSA is from direct out-of-pocket payments. Another common health financing mechanism throughout the region was donor funding, which was reported by most of the studies. Overall, many countries are starting to develop national health insurance schemes, while others have structures in place despite low population coverage of these schemes. On average, the quality score of all studies combined was 80.4%, indicating a high appraisal score across the selected studies.

Discussion Appropriate health financing strategies underpin sustainable health services and the attainment of UHC is inherently linked to planetary health. It is evident from the systematic review that existing health financing strategies in SSA are inadequate and innovative solutions are needed. Thus, establishing evidence-based, multi-sectoral strategies and sustainable solutions tailored to country contexts remains imperative.