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One of the key targets of sustainable development goal 3.8 is UHC which requires that all persons irrespective of their social economic background should have access to quality health services when required without incurring financial hardship. To attain this goal, countries must mobilise sufficient resources, reduce OOP payments at the point of use, and improve equity and efficiency. Although most high-income countries have achieved or are very  close to this target, low- and middle-income countries (LMICs) especially those in SSA are experiencing challenges with its achievement. One of the observed challenges in SSA is that even where services are supposed to be “free” at point-of-use because they are covered by a health insurance scheme, OOP fees are sometimes being  made by clients. This represents a policy implementation gap. This study sought to synthesise the known evidence from  the published literature on the ‘what’ and ‘why’ of this policy implementation gap in SSA.  The results show that OOP still persist in most SSA countries even among those who are ensured, representing an implementation gap. Based on the findings, the authors suggest that it is important to explore a bottom up approach when it comes to health insurance implementation taking into account issues related to accountability and trust.
 
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