 This paper examined the policy implementation gap in sub-Saharan African countries regarding universal health coverage, UHC. The authors found that despite having health insurance schemes, patients often had to make out-of-pocket payments due to the lack of resources and conflicting policy objectives. These payments were often explained as coping strategies, such as structural violence and the corruption complex governed by practical norms. The authors suggest that a more bottom-up approach to health financing reform and UHC policy is needed, taking into account the realities faced by patients and healthcare providers. This article was authored by Abigail Nyarko, Kajou Durkii-Korting, Irene Akiwa-Ajipong, Nanna Anyumeo, and others.