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

OBJECTIVES: This 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. DESIGN: Following 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. RESULTS: We 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. CONCLUSIONS: Findings 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.