Weather shocks affect smallholder farmers and pastoralists in Sub-Saharan Africa unequally. Agricultural insurance has emerged as a safety net option to protect farmers’ welfare. However, in comparison to other regions, fewer African farmers and pastoralists have adopted agricultural insurance. This review synthesises broad recent literature on why insurance take-up has remained low and highlights six key themes, including: (1) product quality, (2) product design, (3) affordability, (4) information and education, (5) behavioural and sociocultural factors, and (6) the role of government in enabling markets. We shed light on how insurance uptake can be encouraged.