Research gaps on universal health coverage in the South African context and other low and middle-income countries; putting things into perspective: a scoping review.

objectivesThis scoping review aimed to synthesize existing literature on the implementation of Universal Health Coverage (UHC) and or National Health Insurance (NHI) in Low and middle-income countries (LMICs) to identify knowledge gaps and potential research priorities.

designFollowing Arksey and O’Malley’s framework, which was updated by Levac and colleagues, and adaptations from the Joanna Briggs Institute (JBI) methodology, we conducted a comprehensive literature search across PubMed and African Journal Online databases as well as Google and Google Scholar search engines. Studies were included if they addressed aspects of UHC/NHI implementation in LMICs. ELIGIBILITY: We included any study designs that investigated implementation aspects of UHC/NHI implementation in LMICs, with no limitation to publication year. We excluded studies that did not focus on UHC/NHI in LMICs. DATA EXTRACTION: Data extraction was done using a pre-designed data extraction form on key study characteristics, country/region, thematic areas, key findings, and evidence gaps. The analysis of evidence gaps was structured around six key domains: health system governance, financing mechanisms, service delivery, equity and access, public-private integration, and implementation research.

resultsWe included 121 studies that were published between 1999 and 2025. Most studies were conducted in Africa (62.8%), with South Africa accounting for the majority. Cross-sectional and qualitative studies dominated the methodological landscape. Thematic analysis of evidence gaps revealed persistent gaps across six domains, particularly in financing mechanisms (n = 41), health system governance (n = 37), and implementation strategies (n = 20). Research questions were most concentrated around designing sustainable funding models, improving stakeholder engagement, and integrating services across public-private systems. Vulnerable groups such as migrants, LGBTIQ+ populations, and rural dwellers were also underrepresented in benefit package design.

conclusionsFindings highlight critical research needs to guide equitable, context-specific, and sustainable NHI implementation in South Africa and other LMICs. Addressing these gaps, perhaps from a coordinated research agenda, requires stakeholder engagement, improved public-private collaboration, and implementation research that reflects the lived realities of the health system users and providers.