International Journal of Health Policy and Management

International Journal of Health Policy and Management

Barriers and Facilitators to International Universal Health Coverage Reforms: A Realist Review

Document Type : Review Article

Authors
Liz Farsaci 1
Padraic Fleming 1
Louise Caffrey 2
Sara Van Belle 3
Catherine O'Donoghue 1
Arianna Almirall-Sanchez 1
David Mockler 4
Steve Thomas 1
1 Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
2 School of Social Work and Social Policy, Trinity College Dublin, Dublin, Ireland
3 Institute of Tropical Medicine, Antwerp, Belgium
4 Assistant Librarian Reader Services, Trinity College Dublin, Dublin, Ireland
10.34172/ijhpm.8709
Abstract
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. 
Keywords
Universal Health Coverage
UHC
Health Reform
Access
Implementation
Financial Protection
  1. Fox AM, Reich MR. The politics of universal health coverage in low- and middle-income countries: a framework for evaluation and action. J Health Polit Policy Law. 2015;40(5):1023-1060. doi:1215/03616878-3161198
  2. Busse R, Schlette S. Focus on Prevention, Health and Aging, New Health Professions. Gütersloh: Verlag Bertelsmann Stiftung; 2007.
  3. World Health Organization (WHO). World Health Report: Primary Health Care–No More Than Ever. Geneva: WHO; 2008.
  4. World Health Organization (WHO). World Health Report: Health Systems Financing: The Path to Universal Coverage. Geneva: WHO; 2010.
  5. Elias PE, Cohn A. Health reform in Brazil: lessons to consider. Am J Public Health. 2003;93(1):44-48. doi:2105/ajph.93.1.44
  6. Fusheini A, Eyles J. Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision. BMC Health Serv Res. 2016;16(1):558. doi:1186/s12913-016-1797-4
  7. Gilson L, Orgill M, Shroff ZC. A Health Policy Analysis Reader: The Politics of Policy Change in Low-And Middle-Income Countries. Geneva: World Health Organization; 2018.
  8. Meng Q, Mills A, Wang L, Han Q. What can we learn from China's health system reform? BMJ. 2019;365:l2349. doi:1136/bmj.l2349
  9. Burke S, Barry S, Siersbaek R, Johnston B, Ní Fhallúin M, Thomas S. Sláintecare - a ten-year plan to achieve universal healthcare in Ireland. Health Policy. 2018;122(12):1278-1282. doi:1016/j.healthpol.2018.05.006
  10. Obama B. United States health care reform: progress to date and next steps. JAMA. 2016;316(5):525-532. doi:1001/jama.2016.9797
  11. Schäfer W, Kroneman M, Boerma W, et al. The Netherlands: Health System Review. Copenhagen: WHO Regional Office for Europe; 2010.
  12. Berman P, Azhar A, Osborn EJ. Towards universal health coverage: governance and organisational change in ministries of health. BMJ Glob Health. 2019;4(5):e001735. doi:1136/bmjgh-2019-001735
  13. Ranabhat CL, Acharya SP, Adhikari C, Kim CB. Universal health coverage evolution, ongoing trend, and future challenge: a conceptual and historical policy review. Front Public Health. 2023;11:1041459. doi:3389/fpubh.2023.1041459
  14. United Nations. Sustainable Development Goals. https://sustainabledevelopment.un.org/sdg3.
  15. Duddy C, Wong G. Grand rounds in methodology: when are realist reviews useful, and what does a 'good' realist review look like? BMJ Qual Saf. 2023;32(3):173-180. doi:1136/bmjqs-2022-015236
  16. Fleming P, Caffrey L, Belle SV, et al. How international health system austerity responses to the 2008 financial crisis impacted health system and workforce resilience - a realist review. Int J Health Policy Manag. 2023;12:7420. doi:34172/ijhpm.2022.7420
  17. Duddy C, Roberts N. Identifying evidence for five realist reviews in primary health care: a comparison of search methods. Res Synth Methods. 2022;13(2):190-203. doi:1002/jrsm.1523
  18. Friedemann Smith C, Lunn H, Wong G, Nicholson BD. Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care. BMJ Qual Saf. 2022;31(7):541-554. doi:1136/bmjqs-2021-014529
  19. Fleming P, Farsaci L, Mockler D, Thomas S. PROTOCOL: A Realist Review to Identify the Key Factors Internationally That Impact the Development of Systemic Health Reform and to Identify When and How to Preserve Reform Integrity and/or Embrace Reform Evolution. PROSPERO - International Prospective Register of Systematic Reviews (CRD42023394427). Retrieved from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023394427.
  20. Lewis-Beck M, Bryman AE, Liao TF. The SAGE Encyclopedia of Social Science Research Methods. SAGE Publications; 2004. doi:4135/9781412950589
  21. Jagosh J. Retroductive theorizing in Pawson and Tilley's applied scientific realism. J Crit Realism. 2020;19(2):121-130. doi:1080/14767430.2020.1723301
  22. Atun R, de Andrade LO, Almeida G, et al. Health-system reform and universal health coverage in Latin America. Lancet. 2015;385(9974):1230-1247. doi:1016/s0140-6736(14)61646-9
  23. Atim C, Bhushan I, Blecher M, et al. Health financing reforms for universal health coverage in five emerging economies. J Glob Health. 2021;11:16005. doi:7189/jogh.11.16005
  24. Ferrera M. The rise and fall of democratic universalism: health care reform in Italy, 1978-1994. J Health Polit Policy Law. 1995;20(2):275-302. doi:1215/03616878-20-2-275
  25. Mahmood Q, Muntaner C. Politics, class actors, and health sector reform in Brazil and Venezuela. Glob Health Promot. 2013;20(1):59-67. doi:1177/1757975913476902
  26. Eckhardt M, Carlfjord S, Faresjö T, Crespo-Burgos A, Forsberg BC, Falk M. Universal health coverage in marginalized populations: a qualitative evaluation of a health reform implementation in rural Ecuador. Inquiry. 2019;56:46958019880699. doi:1177/0046958019880699
  27. Wishnia J, Goudge J. Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa. BMJ Glob Health. 2020;5(10):e003524. doi:1136/bmjgh-2020-003524
  28. Petmesidou M, Guillén AM. ‘Southern-style’ National Health Services? Recent reforms and trends in Spain and Greece. Soc Policy Adm. 2008;42(2):106-124. doi:1111/j.1467-9515.2008.00598.x
  29. Tang S, Brixi H, Bekedam H. Advancing universal coverage of healthcare in China: translating political will into policy and practice. Int J Health Plann Manage. 2014;29(2):160-174. doi:1002/hpm.2207
  30. Rosa RM, Alberto IC. Universal health care for Colombians 10 years after Law 100: challenges and opportunities. Health Policy. 2004;68(2):129-142. doi:1016/j.healthpol.2003.10.004
  31. Burke SA, Normand C, Barry S, Thomas S. From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis. Health Policy. 2016;120(3):235-240. doi:1016/j.healthpol.2015.12.001
  32. Derkyi-Kwarteng AN, Agyepong IA, Enyimayew N, Gilson L. A narrative synthesis review of out-of-pocket payments for health services under insurance regimes: a policy implementation gap hindering universal health coverage in sub-Saharan Africa. Int J Health Policy Manag. 2021;10(7):443-461. doi:34172/ijhpm.2021.38
  33. Mbau R, Kabia E, Honda A, Hanson K, Barasa E. Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. Int J Equity Health. 2020;19(1):19. doi:1186/s12939-019-1116-x
  34. Khankeh HR, Bagheri Lankarani K, Zarei N, Joulaei H. Three decades of healthcare system reform in Iran from the perspective of universal health coverage: a macro-qualitative study. Iran J Med Sci. 2021;46(3):198-206. doi:30476/ijms.2020.84023.1342
  35. Rao KD, Petrosyan V, Araujo EC, McIntyre D. Progress towards universal health coverage in BRICS: translating economic growth into better health. Bull World Health Organ. 2014;92(6):429-435. doi:2471/blt.13.127951
  36. Cabiedes L, Guillén A. Adopting and adapting managed competition: health care reform in Southern Europe. Soc Sci Med. 2001;52(8):1205-1217. doi:1016/s0277-9536(00)00240-9
  37. De Vos P, De Ceukelaire W, Van der Stuyft P. Colombia and Cuba, contrasting models in Latin America's health sector reform. Trop Med Int Health. 2006;11(10):1604-1612. doi:1111/j.1365-3156.2006.01702.x
  38. Spigel L, Pesec M, Villegas Del Carpio O, et al. Implementing sustainable primary healthcare reforms: strategies from Costa Rica. BMJ Glob Health. 2020;5(8):e002674. doi:1136/bmjgh-2020-002674
  39. Pesec M, Ratcliffe HL, Karlage A, Hirschhorn LR, Gawande A, Bitton A. Primary health care that works: the Costa Rican experience. Health Aff (Millwood). 2017;36(3):531-538. doi:1377/hlthaff.2016.1319
  40. Yip W, Fu H, Chen AT, et al. 10 years of health-care reform in China: progress and gaps in universal health coverage. Lancet. 2019;394(10204):1192-1204. doi:1016/s0140-6736(19)32136-1
  41. Schut F, van de Ven W. Health care reform in the Netherlands: the fairest of all? J Health Serv Res Policy. 2011;16(1):3-4. doi:1258/jhsrp.2010.010158
  42. Mhazo AT, Maponga CC. The political economy of health financing reforms in Zimbabwe: a scoping review. Int J Equity Health. 2022;21(1):42. doi:1186/s12939-022-01646-z
  43. Schulmann K, Bruen C, Parker S, Siersbaek R, Conghail LM, Burke S. The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018-2023. BMC Health Serv Res. 2024;24(1):578. doi:1186/s12913-024-11048-2
  44. Becerril-Montekio V, Meneses-Navarro S, Pelcastre-Villafuerte BE, Serván-Mori E. Segmentation and fragmentation of health systems and the quest for universal health coverage: conceptual clarifications from the Mexican case. J Public Health Policy. 2024;45(1):164-174. doi:1057/s41271-024-00470-9
  45. World Health Organization (WHO). WHO Health System Performance Assessment. Geneva: WHO; 2022.
  46. Kutzin J. A descriptive framework for country-level analysis of health care financing arrangements. Health Policy. 2001;56(3):171-204. doi:1016/s0168-8510(00)00149-4
  47. Atun R, Aydın S, Chakraborty S, et al. Universal health coverage in Turkey: enhancement of equity. Lancet. 2013;382(9886):65-99. doi:1016/s0140-6736(13)61051-x
  48. Wren MA, Connolly S. A European late starter: lessons from the history of reform in Irish health care. Health Econ Policy Law. 2019;14(3):355-373. doi:1017/s1744133117000275
  49. Normand C. The Health Care System in Ireland: Controlling Growth in Expenditure and Making the Best Use of Resources. In: Callan T, ed. Budget Perspectives 2012. Dublin 2: ESRI; 2012.
  50. Chuma J, Okungu V. Viewing the Kenyan health system through an equity lens: implications for universal coverage. Int J Equity Health. 2011;10:22. doi:1186/1475-9276-10-22
  51. Domapielle MK. Adopting localised health financing models for universal health coverage in low- and middle-income countries: lessons from the National Health lnsurance Scheme in Ghana. Heliyon. 2021;7(6):e07220. doi:1016/j.heliyon.2021.e07220
  52. Uzwiak BA, Curran S. Gendering the burden of care: health reform and the paradox of community participation in Western Belize. Med Anthropol Q. 2016;30(1):100-121. doi:1111/maq.12195
  53. Bertram K, Koonin J. Simplifying the universal health coverage narrative can help to achieve political action. BMJ. 2024;387:q2441. doi:1136/bmj.q2441
  54. Thomas S, Fleming P. Handbook of Health System Resilience. Cheltenham: Edward Elgar Publishing; 2024.
  55. Wilsford D. Path dependency, or why history makes it difficult but not impossible to reform health care systems in a big way. J Public Policy. 1994;14(3):251-283. doi:1017/s0143814x00007285
  56. Duran A, Kutzin J, Menabde N. Universal coverage challenges require health system approaches; the case of India. Health Policy. 2014;114(2-3):269-277. doi:1016/j.healthpol.2013.11.009
  57. Brennan E, Abimbola S. The impact of decentralisation on health systems in fragile and post-conflict countries: a narrative synthesis of six case studies in the Indo-Pacific. Confl Health. 2023;17(1):31. doi:1186/s13031-023-00528-7
  58. Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy Plan. 2019;34(8):605-617. doi:1093/heapol/czz055
  59. Regmi K, Naidoo J, Pilkington PA, Greer A. Decentralization and district health services in Nepal: understanding the views of service users and service providers. J Public Health (Oxf). 2010;32(3):406-417. doi:1093/pubmed/fdp116
  60. Tynkkynen L. Big bang in the middle of a storm: lessons from implementing health system reform in Finland. Eur J Public Health. 2024;34(Suppl 3):ckae144.203. doi:1093/eurpub/ckae144.203
  61. Thomas S, Gilson L. Actor management in the development of health financing reform: health insurance in South Africa, 1994-1999. Health Policy Plan. 2004;19(5):279-291. doi:1093/heapol/czh033
  62. Luyten E, Tubeuf S. Equity in healthcare financing: a review of evidence. Health Policy. 2025;152:105218. doi:1016/j.healthpol.2024.105218
  63. McIntyre D, Meheus F. Fiscal Space for Domestic Funding of Health and Other Social Services. United Kingdom: Chatham House; 2014.
  64. Averill C, Marriott A. Universal Health Coverage: Why Health Insurance Schemes Are Leaving the Poor Behind. Oxfam International; 2013:176.
  65. Thomson S, Cylus J, Al Tayara L, et al. Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries. Lancet Reg Health Eur. 2024;37:100826. doi:1016/j.lanepe.2023.100826
  66. McGuire TG, Schillo S, van Kleef RC. Very high and low residual spenders in private health insurance markets: Germany, The Netherlands and the US marketplaces. Eur J Health Econ. 2021;22(1):35-50. doi:1007/s10198-020-01227-3
  67. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362(9378):111-117. doi:1016/s0140-6736(03)13861-5
  68. Witter S, Anderson I, Annear P, et al. What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies. Health Res Policy Syst. 2019;17(1):9. doi:1186/s12961-018-0410-1
  69. Agyepong IA, Adjei S. Public social policy development and implementation: a case study of the Ghana National Health Insurance Scheme. Health Policy Plan. 2008;23(2):150-160. doi:1093/heapol/czn002
  70. Lakin JM. The Possibilities and Limitations of Insurgent Technocratic Reform: Mexico's Popular Health Insurance Program, 2001-2006 [dissertation]. Harvard University; 2008.
  71. Lin CW. The policymaking process for the social security system in Taiwan: the national health insurance and national pension program. Dev Econ. 2002;40(3):327-358. doi:1111/j.1746-1049.2002.tb00918.x
  72. Wong J. Healthy Democracies: Welfare Politics in Taiwan and South Korea. Ithaca: Cornell University Press; 2004.
  73. Birn AE, Nervi L. What matters in health (care) universes: delusions, dilutions, and ways towards universal health justice. Global Health. 2019;15(Suppl 1):0. doi:1186/s12992-019-0521-7
  74. Farsaci L, Fleming P, Almirall-Sanchez A, O'Donoghue C, Thomas S. Understanding the legacies of shocks on health system performance: exploring Ireland's management of recent crises and its implications for policy. Health Policy. 2024;143:105063. doi:1016/j.healthpol.2024.105063
  75. Parker S, Siersbaek R, Mac Conghail L, Burke S. Public health responses to homelessness during COVID-19 in Ireland: implications for health reform. Int J Homelessness. 2023;3(3):36-52. doi:5206/ijoh.2023.3.14967
  76. Gurung G, Tuladhar S. Fostering good governance at peripheral public health facilities: an experience from Nepal. Rural Remote Health. 2013;13(2):2042.
  77. Zanga R. Regulation and participation of the private sector in the pursuit of universal health coverage: challenges and strategies for health systems. J Family Med Prim Care. 2024;13(5):2123-2129. doi:4103/jfmpc.jfmpc_1697_23
International Journal of Health Policy and Management
Volume 14, Issue 1
2025
Pages 1-14

XML
PDF 1.84 M
Supplementary File
(IJHPM does not take responsibility for any information provided in the supplementary files.)
Farsaci-Supple-File-1-IJHPM.pdf
Farsaci-Supple-File-2-IJHPM.pdf

  • Received Date 17 July 2024
  • Revised Date 20 February 2025
  • Accepted Date 05 April 2025
  • First Published Date 06 April 2025
  • Published Date 01 December 2025