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Social health insurance is increasingly being considered as a mechanism for providing financial protection and moving towards Universal Health Coverage (UHC). In recent years there has been a political will and interest to explore the implementation of National Health Insurance Schemes (NHIS) in most African countries.  In this peer reviewed study, the authors investigate whether social health insurance schemes are effectively and efficiently covering all groups in selected African countries that have implemented the schemes. The objective is to provide evidence of how these schemes have been implemented and whether the fundamental goals are met. The study draws lessons from the literature about how policy tools can be used to reduce financial barriers whilst ensuring a broad geographic coverage in Africa. The results show that each of the selected countries relies on a plurality of health insurance schemes with each targeting different groups. Additionally, many of the NHI programs start by covering the formal sector first, with the hope of covering other groups in the informal sector at a later stage. Health insurance coverage for poor groups is very low, with targeting mechanisms to cover the poor in the form of exemptions and waivers achieving no desirable results. The marginalization of the poor in the NHIS would negatively affect progress towards UHC in these countries.
 
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