Expanding Social Health Insurance Coverage for the Informal Sector in Zambia: Lessons and Insights from LMICs

Progress toward Universal Health Coverage (UHC) remains a priority for low- and middle-income countries (LMICs). For countries that have adopted Social Health Insurance (SHI) as a strategy, expanding coverage among informal sector households presents an important pathway to this goal. This scoping review examines strategies and interventions employed in LMICs to improve the enrollment and retention of informal sector households in SHI schemes. The review highlights common barriers, including irregular incomes, limited awareness, administrative challenges, and trust deficits. Potential strategies include designing flexible contribution mechanisms, simplified registration processes, targeted awareness campaigns, leveraging existing community structures, and designing comprehensive benefit packages that balance coverage goals with fiscal sustainability. Our findings emphasize the importance of context-specific and innovative approaches that could include tiered premiums, mobile payment platforms, and partnerships with microfinance institutions to address financial and logistical barriers. However, there is also evidence to suggest that net revenue gains from contributory mechanisms are typically modest, with enrollment expansion often requiring substantial public subsidies and incurring additional administrative costs. For Zambia, integrating some of these lessons into the National Health Insurance Scheme (NHIS) offers a pathway to enhancing coverage among the informal sector and advancing equitable access to healthcare, while acknowledging the fiscal constraints.