Impact of digital premium payment in scaling health insurance coverage in sub-Saharan Africa: systematic review and meta-analysis protocol.

backgroundHealth insurance coverage in sub-Saharan Africa (SSA) remains low and digital premium payment systems have been suggested as a potential solution to increase enrolment and retention. This systematic review will collate and distill empirical evidence on the impact of digital premium payment in scaling health insurance coverage and retention and access to health service delivery in SSA.

methodsThis systematic review protocol has been prepared following robust methods, and it is reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will conduct searches through relevant databases, including PubMed, CINAHL, LILACS, HINARI, African Journals Online, Google Scholar, Scopus, Web of Science, Trip Pro and TOXNET from 2007 to 30 June 2026, without language restriction for studies that evaluated digital premium payment systems and reported health insurance enrolment or retention rates. The search terms and concepts include: 'national health insurance', 'health insurance coverage', 'insurance enrolment', 'digital premium', 'e-payment', 'online payment', 'electronic payment', 'mobile payment', 'telepayment' and 'cashless payment', together with their alternate terms and synonyms, singular and plural forms as well as British and American spelling. The names of the countries in SSA will be included as search terms. Grey literature including dissertation repositories, national health insurance databases and conference proceedings will be searched. Reference list of retrieved articles will be reviewed, and where necessary, experts working in the field of national health insurance will be contacted for knowledge about completed studies not captured by our searches. Two reviewers will independently screen studies, extract data (using pretested data extraction form developed from Microsoft Excel) and assess risk of bias in the included studies using the quality assessment tool for Risk Of Bias In Non-randomized Studies - of Exposures. Any disagreements will be resolved through discussion between the reviewers. Heterogeneity will be explored graphically for overlapping CIs and statistically using the [Formula: see text]-statistic. We will combine dichotomous outcomes using risk ratio and for continuous data mean difference employing random-effects meta-analysis and presenting weighted effect estimates with their 95% (CIs). Subgroup analysis will be performed to assess the impact of heterogeneity and sensitivity analyses to test the robustness of the pooled effect estimates. The overall level or certainty of evidence will be assessed using Grading of Recommendations, Assessment, Development, and Evaluation. ETHICS AND DISSEMINATION: This systematic review will collate empirical data on publicly available published and unpublished primary studies and no ethical approval is required. However, an eligible study with serious ethical issues will be excluded from the analysis and the reasons for exclusion documented. The review findings will be shared with key stakeholders and health authorities, agencies involved in digital premium health insurance and policymakers. The review results will be presented at scientific conferences and symposia, and a manuscript will be submitted for publication in a high impact factor journal. TRIAL REGISTRATION NUMBER: CRD42024576134.