Kerman University of Medical Sciences International Journal of Health Policy and Management 2322-5939 14 1 2025 12 01 Barriers and Facilitators to International Universal Health Coverage Reforms: A Realist Review 1 14 4726 10.34172/ijhpm.8709 EN Liz Farsaci Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland 0000-0003-3175-0253 Padraic Fleming Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland 0000-0003-1284-4860 Louise Caffrey School of Social Work and Social Policy, Trinity College Dublin, Dublin, Ireland 0000-0003-1608-5830 Sara Van Belle Institute of Tropical Medicine, Antwerp, Belgium 0000-0003-2074-0359 Catherine O'Donoghue Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland 0000-0002-6608-1902 Arianna Almirall-Sanchez Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland 0000-0003-1191-2614 David Mockler Assistant Librarian Reader Services, Trinity College Dublin, Dublin, Ireland 0000-0001-6171-8751 Steve Thomas Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland 0000-0001-9306-0114 Journal Article 2024 07 17 Background The journey towards universal health coverage (UHC) began decades ago but has recently moved to centre stage in global health discourses with its inclusion in the Sustainable Development Goals (SDGs). As part of this renewed interest, 193 countries have committed to introducing UHC by 2030. However, its implementation often necessitates far-reaching health system reforms. This, coupled with the struggles countries face in relation to health financing, as well as distinct political, social and cultural contexts, means there are significant challenges to UHC implementation. This article contributes new knowledge to these discourses by identifying key contexts and mechanisms that facilitate the successful implementation of UHC reforms, as well as barriers that can impede progress. Methods This realist review identifies key contexts and mechanisms that can facilitate the successful implementation of UHC reforms. EMBASE, MEDLINE and Web of Science were searched (1995-2022), resulting in 957 articles with the protocol published through Prospero (PROSPERO 2023: CRD42023394427). Further theory-driven searches resulted in an additional 988 studies. Descriptive, inductive, deductive, and retroductive realist analysis aided the development of Context-Mechanism-Outcome Configurations (CMOCs), along with stakeholder engagement to confirm or refute results. Causal pathways, and the interplay between contexts and mechanisms that triggered outcomes, were revealed. Results How each country goes about implementing UHC reforms depends on its context. Cohesion across all systems, as well as the functions of financing, governance and service delivery, facilitates these reforms. Implementation can also be facilitated through political commitment, communication between stakeholders in the public health system and the development of a strong primary care sector. Conversely, fragmentation across these functions pose significant barriers to UHC reforms. Conclusion Examining international experiences of UHC reforms supports learning around the mechanisms that support or hinder implementation processes. These learnings can empower policy-makers and health system leaders by providing roadmaps for reform implementation.

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