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

Farsaci, Liz; Fleming, Padraic; Caffrey, Louise; Van Belle, Sara; O'Donoghue, Catherine; Almirall-Sanchez, Arianna; Mockler, David; Thomas, Steve

doi:10.34172/ijhpm.8709

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

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