**9. Discussion, conclusions, and recommendations**

Inequities in health insurance coverage and access to health care between people with different incomes and wealth are pervasive in several LMICs. Based on Rawls' theory of social justice, there is unfairness in health insurance coverage of which the less privilege people in society, especially in LMICs, have always been disadvantaged. The paper explored the types of health insurance schemes and the choices LMICs policymakers can make to ensure equitable health care for all. It elucidated on successful factors of key health insurance schemes and health policies that can ensure universal health coverage for all without anyone left out. The question often posed by LMICs policymakers is which type of health insurance scheme to implement and what should be the strategic factors to adopt for success.

To answer the question which insurance model to choose, it is important to conclude that there is no blueprint for successful implementation of a health insurance scheme that will cover the poor. However, the review of the existing types of health insurance schemes shows that publicly taxed-financed health insurance schemes tend to cover and benefit the poor. Publicly financed single-payer national health insurance schemes, as in Ghana, Thailand, United Kingdom, and Canada, facilitate the achievement of universal health coverage than private health insurance schemes. However, they all have their ups and downs. Proponents of PHIs argue that they ensure freedom of choice of health insurance, efficiency, and quality of care. But in most cases, PHIs are limited to the privilege, are profit-oriented, and do not ensure equity in health insurance coverage [11].

Where there is multiplicity of private health insurance schemes of all forms, as in the case of the United States, the poor tend to suffer in terms of coverage because of high premiums [10]. It is argued that PHI breeds competition and enhances technological advancement in health care and therefore promotes the quality of care delivery [11]. But what is the point of quality of care where large majority of the population have no health insurance and find it difficult to access health care? PHI might not be a good option for LMICs striving to achieve UHC. At best, private health insurance can be encouraged as a supplementary insurance to cover for highly sophisticated health care services, while the government subsidizes for the poor to ensure equity of access. Where PHI is the health financing policy, the government should adopt measures to cover the poor through subsidies or premium exemptions.

Though it would be naïve to recommend a particular health insurance model for any country as the best model for replication, the "Bismarkian" model has stood the test of time of time and, therefore, worth replication in LMICs but with caution. The caveat might be the large informal sector in LMICs and high unemployment rates, which might be difficult to mandate insurance contribution through social security. Even though CBHI is a community initiative based on social solidarity, the evidence suggests that they do not have the capacity to mobilize large pools or revenue and risk, and they may not be able to ensure universal health coverage [15]. Consequently, CBHIs might not be recommendable option for LMIC who are about to start universal health insurance scheme. In LMICs with high prevalence of CBHIs, it is imperative that governments legislate to merge them to form a single-payer national health insurance scheme.

Progressive tax-based health insurance schemes, in the case of Ghana and Thailand, present best practices that LMICs can adapt while marking the red flags to avoid on their pathways to universal health insurance coverages. It is crucial for LMICs to understand that there is no perfect health insurance scheme or straight jacket strategies for success. It all depends on the terrain and the dynamics of the political economy.

Both advanced and developing countries are continuously experimenting models for equitable and sustainable health financing for quality UHC. There is no straight jacket or blueprint method to achieve Universal Health Coverage. Nonetheless, to implement a viable and sustainable health financing systems for universal health coverage, the best health financing and organizational options should be derived from a broad spectrum of choices, including, but not limited to, private financing options, tax-based financing, social health insurance, single-payer system, and mixed models' health financing systems. The choice of health financing systems should be driven by prevailing social, economic, and political economy factors. Progressive taxedbased single-payer systems with strong mechanisms put in place to check that abuse and corruption would be a better option to cover the poor and to achieve UHC. It is imperative to implement policies that are preponderantly country context-specific and culturally acceptable to get the people's buy-in. We recommend LMICs to adopt and adapt the best practice models of health insurance schemes to suit their prevailing economic, social, political, and cultural situations. COVID-19 had a huge devastating impact on the economies of LMICs. Implicitly, it behooves on LMICS to invest in research, health systems strengthening, financing, and human resource for health to establish strong health sectors against such unanticipated epidemics and pandemics. More in-depth and further research is needed to look at the impact of COVID-19 on health systems financing of LMICs [28].
