Equity in healthcare financing and access to care among vulnerable populations in Africa: a systematic review

Achieving equitable access to healthcare remains a major challenge across African health systems, largely influenced by inequitable financing mechanisms. While Universal Health Coverage (UHC) emphasizes financial risk protection and equitable service access, evidence on how different financing models affect vulnerable populations in Africa remains fragmented. This study systematically reviews the relationship between healthcare financing strategies and equity in access to care among vulnerable populations in Africa. A systematic review was conducted in accordance with PRISMA guidelines and registered with PROSPERO (CRD420251137174). Literature searches were performed in PubMed, Embase, Scopus, African Journals Online, and Google Scholar for studies published between January 2015 and August 2025. Eligible studies examined healthcare financing mechanisms and their impact on access to care among vulnerable populations in African countries. Study quality was assessed using the Newcastle–Ottawa Scale, CASP, and MMAT, while certainty of evidence was evaluated using GRADE and GRADE-CERQual. A narrative synthesis was undertaken. Eighteen studies were included. Insurance-based mechanisms, including national, social, and community-based health insurance, were consistently associated with increased healthcare utilization. However, persistent inequities were observed, particularly among low-income and rural populations. Financial barriers such as informal payments and out-of-pocket costs remained significant despite insurance coverage. Structural constraints, including geographic inaccessibility and health system limitations, further limited equitable access. Evidence certainty ranged from low to moderate for quantitative outcomes and high confidence for qualitative findings. While healthcare financing reforms in Africa have improved service utilization, they have not fully achieved equity in access. Addressing persistent disparities requires integrated financing strategies alongside structural health system strengthening to advance equitable UHC for vulnerable populations. Not applicable.