A qualitative study of stakeholders' perceptions towards the implementation of the National Health Insurance Scheme in Zambia: equity and financial sustainability in question.

Low- and middle-income countries are expanding health insurance to enhance financial protection. However, there is scarcity of evidence on the stakeholder perceptions towards health insurance. This study explores stakeholders' perceptions towards the implementation of the National Health Insurance Scheme (NHIS) in Zambia. This qualitative study is based on 21 in-depth interviews with key stakeholders involved in the NHIS implementation in Zambia. We used qualitative content analysis to describe and interpret the manifest and latent meaning of transcribed interviews. The analysis yielded three overarching themes: (i) politics can make or break the scheme; (ii) equity in question: winners and losers; and (iii) pointing at the need for financial sustainability of the NHIS. The themes are supported by 6 subthemes and 18 data categories. Participants perceived the scheme as having contributed to improved quality of care and offering a generous health benefit package. However, implementation is perceived to be hindered by political interference, limited use of empirical evidence, weak institutional coordination, and exclusion of key stakeholders from decision-making processes, low enrolment, operational inefficiencies, inequities and a benefit package misaligned with available resources. The Zambia NHIS is perceived as a promising initiative for expanding access to health and enhancing financial protection. However, it faces numerous challenges ranging from limited enrolment among the poor, vulnerable and informal sector populations to concerns about financial sustainability. Addressing these issues is essential to realize the scheme's potential benefits.