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Quality of care in the context of universal health coverage: a scoping review

Bernice yanful.

1 Division of Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

Abirami Kirubarajan

2 Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

Dominika Bhatia

Sujata mishra, erica di ruggiero.

3 Centre for Global Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

Associated Data

This work analyzed secondary sources, which are cited and are publicly accessible or with academic institutional credentials. Authors can confirm that all other relevant data are included in the article and/or its additional files.

Introduction

Universal health coverage (UHC) is an emerging priority of health systems worldwide and central to Sustainable Development Goal 3 (target 3.8). Critical to the achievement of UHC, is quality of care. However, current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries. The primary objective of this scoping review was to summarize the existing conceptual and empirical literature on quality of care within the context of UHC and identify knowledge gaps.

We conducted a scoping review using the Arksey and O’Malley framework and further elaborated by Levac et al. and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines. We systematically searched MEDLINE, EMBASE, CINAHL-Plus, PAIS Index, ProQuest and PsycINFO for reviews published between 1 January 1995 and 27 September 2021. Reviews were eligible for inclusion if the article had a central focus on UHC and discussed quality of care. We did not apply any country-based restrictions. All screening, data extraction and analyses were completed by two reviewers.

Of the 4128 database results, we included 45 studies that met the eligibility criteria, spanning multiple geographic regions. We synthesized and analysed our findings according to Kruk et al.’s conceptual framework for high-quality systems, including foundations, processes of care and quality impacts. Discussions of governance in relation to quality of care were discussed in a high number of studies. Studies that explored the efficiency of health systems and services were also highly represented in the included reviews. In contrast, we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC, particularly country-specific measures and measures related to equity.

There is growing evidence on the relationship between quality of care and UHC, especially related to the governance and efficiency of healthcare services and systems. However, several knowledge gaps remain, particularly related to monitoring and evaluation, including of equity. Further research, evaluation and monitoring frameworks are required to strengthen the existing evidence base to improve UHC.

According to the World Health Organization, universal health coverage (UHC) is achieved when ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’ [ 1 ]. UHC has gained renewed attention from researchers and policymakers following its inclusion in the 2030 Agenda for Sustainable Development (SDGs). SDG target 3.8 calls for achieving ‘universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all’ [ 2 ].

While there is growing evidence linking UHC to different health, economic and social outcomes, recent estimates suggest that about 800 million people globally still do not have access to full financial coverage of essential health services, including but not limited to high-income countries [ 3 ]. The WHO’s well-established UHC cube identifies three dimensions of UHC: (1) population (who is covered); (2) services (services that are covered); (3) direct costs (the proportion of the costs that are covered) [ 4 ]. Absent from the cube is the explicit inclusion of quality of care. However, without attention to the quality of care provided, increasing service coverage alone is unlikely to produce better health outcomes. As such, quality of care is critical to the achievement of UHC. A high-quality health system has been defined as one ‘that optimises health care in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs’ [ 5 , p. e1200].

Current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries (LMICs) [ 6 ]. While the era of the Millennium Development Goals (MDGs) expanded access to essential health services in LMICs, poor quality of care remains a significant problem, and explains persistently high levels of maternal and child mortality [ 6 ]. In addition, poor quality of care is estimated to cause between 5.7 and 8.4 million deaths yearly in LMICs [ 7 ]. Low-quality services are also an issue in high-income countries (HICs), particularly for disadvantaged populations such as immigrant and Indigenous groups [ 6 , 8 ].

As such, efforts to achieve UHC focused solely on expanding access to care are insufficient. Achieving UHC will require a more deliberate focus on quality of care across its various dimensions including effectiveness, safety, people-centredness, timeliness, equity, integration of care and efficiency [ 6 ]. However, existing literature synthesizing evidence on the quality of care within the context of UHC is more limited.

The primary objective of this scoping review is to synthesize and analyse the existing conceptual and empirical literature on quality of care within the context of UHC. The secondary objective is to identify knowledge gaps on quality of care within the context of advancing UHC and highlight areas for further inquiry.

We conducted a scoping review using the five-stage scoping review framework proposed by Arksey and O’Malley [ 9 ] and further elaborated by Levac et al. with the following stages [ 10 ]: (1) formulating the research question; (2) searching for relevant studies; (3) selection of eligible studies; (4) data extraction and (5) analysing and describing the results. In addition, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines [ 11 ]. In accordance with the guidelines, our protocol is publicly available through Open Science Forum [ 12 ]. The scoping review methodology was selected due to its relevance to both identifying emerging and established content areas, and integration of diverse study methodologies [ 13 ]. As such, our methodology was well-aligned with the exploratory aims of our study.

To synthesize the existing knowledge on quality of care within the context of UHC, we focused on retrieving and analysing relevant reviews (as opposed to primary research studies). Bennett et al. [ 14 ] applied this overview of reviews approach in identifying health policy and system research priorities for the SDGs.

Information sources and search strategy

We developed the search strategy in consultation with a research librarian with expertise in public health and health systems. After finalizing our search in MEDLINE (Ovid) through an iterative process involving pilot tests, we completed a systematic search of MEDLINE (Ovid), EMBASE (Ovid), CINAHL-Plus (EBSCO), PAIS Index, ProQuest and PsycINFO (Ovid) for articles published from 1 January 1995 to 27 September 2021. The date cut-off of 1995 was selected to capture articles published during the period leading up to the adoption of the MDGs. We applied adapted search filters from the InterTASC Information Specialists’ Subgroup Search Filter Resource for each database [ 15 ].

Our searches combined terms related to the concepts of (1) UHC (e.g. universal health insurance, universal coverage) and (2) quality of care and its seven dimensions (e.g. equity, safety, people-centredness). Our search strategy is available in Appendix A. Figure  1 outlines the eligibility criteria we used to assess studies for inclusion in the review.

Eligibility and exclusion criteria

Data management

Results from database searches were managed through Covidence ( www.covidence.org ) for deduplication and screening.

Study selection

Two reviewers (BY&AK) independently assessed studies against the eligibility criteria in two phases: (1) titles and abstracts and (2) full-text articles. A pilot test of the title and abstract screening was completed for approximately the first 100 search results. The two reviewers discussed disagreements to revise eligibility criteria as required. Any disagreements were resolved via consensus and in consultation with senior co-authors.

Data extraction

BY & AK independently completed data extraction for the first 10 articles using a standardized form. Following the pilot, the full data extraction was completed by the two reviewers in parallel. We extracted data on key study characteristics and according to each domain and subcomponent identified in Kruk et al.’s [ 5 ] framework described in the following section. The process of data extraction was iterative, with the form subject to revisions. Geographic regions were classified either by WHO regions [ 16 ] or through self-identification by the articles, such as a global focus, LMICs, HICs, ‘developing’ or ‘developed’.

Data synthesis

We synthesized the results through both a descriptive summary and a qualitative, narrative synthesis. We anchored our narrative synthesis in Kruk et al.’s [ 5 ] conceptual framework for high-quality health systems. The framework draws from Donabedian’s well-known conceptual model of quality of care, which was first developed in the 1960s and identifies structures, processes and outcomes as three components of quality of care. Kruk et al. [ 5 ] offer a new evidence-based framework relevant to present-day health systems, recognizing the heterogeneity of health systems across HIC and LMIC contexts.

They define three key domains of a high-quality health system, which they argue should be at the core of implementing and advancing UHC: foundations, processes of care and quality impacts. Foundations refer to the context and resources required to lead a high-quality health system. Processes of care include competent care and systems, relating to evidence-based effective care and health systems’ ability to respond to patient needs. Quality impacts include both patient and provider-reported health outcomes and client confidence in the health system, as well as economic benefits such as a reduction of resource waste and financial risk protection. The Kruk et al. [ 5 ] framework does not explicitly address equity; however, the authors state that equity in the quality of healthcare is critical, which they define as ‘the absence of disparities in the quality of health services between individuals and groups with different levels of underlying social disadvantage [p. e1214].’ When compared with Donabedian’s model for evaluating the quality of care [ 17 ], Kruk et al. [ 5 ] offer a much more elaborated framework that explicitly names a range of subcomponents to guide quality measurement and improvement (e.g. governance, positive user experience, etc.).

As our scoping review examines the existing literature on quality of care within the context of UHC and identifies knowledge gaps, Kruk et al.’s [ 5 ] framework provided a useful analytic tool by which to organize and interpret our findings.

We organized the results from our narrative synthesis according to each component of the framework (foundations, processes of care and quality impacts), addressing equity as a cross-cutting theme across these components. Table ​ Table1 1 summarizes the components and subcomponents of the framework.

Summary of Kruk et al.’s conceptual framework on high-quality health systems

Description of included reviews

The database searches yielded 4128 results after deduplication. Following screening, 45 articles that met eligibility criteria were included in the review. The search results are shown in Appendix A and a summary of each article is presented in Table ​ Table2. 2 . Narrative reviews comprised 40.0% of the studies ( n  = 18), 35.6% were systematic reviews (n = 16), while 20.0% were scoping reviews ( n  = 9), and 4.4% were overviews of systematic reviews ( n  = 2). Of the 45 reviews, 28 covered multiple WHO regions (62.2%). This included reviews with a broad global focus, reviews focused on LMICs, ‘developing’ or ‘developed’ countries, as well as reviews with an explicit focus on more than one of six WHO regions. Regarding the dimensions of quality of care, equity was the most well represented, examined by 40 of the studies (88.9%). Integration of care and safety were the least represented across the studies, each examined by 11 of the reviews (24.4%). We did not formally appraise the quality of studies included in our review, which is not required for a scoping review given its overarching aim to map the scope and size of the available literature on a given topic.

Description of included studies

CHW, community health worker; NHIS, National Health Insurance Scheme; NHS, National Health Service; UHC, universal health coverage; LMICs, low- and middle-income countries; PHC, primary healthcare; WPR, Western Pacific Region; AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asian Region; LICs, low-income countries 

Narrative synthesis of results

Conceptualizing universal healthcare/coverage and quality of care.

The included studies highlighted varying definitions of UHC and quality of care. A common definition of UHC was that all people who require any essential healthcare services, including but not limited to promotion, prevention and treatment, are able to access services without financial stress [ 18 – 20 ]. One study further expanded this definition to include that UHC was the desired outcome of health system performance [ 18 ]. Some studies specified the definition was outlined in the Alma Ata declaration [ 21 , 22 ].

Definitions of quality of care also varied. One study distinguished between service quality (e.g. patient satisfaction, responsiveness) and technical quality (e.g. adherence to clinical guidelines) [ 23 ]. Another study defined high-quality healthcare as ‘providing the highest possible level of health with the available resources’ [ 24 , p. 142]. However, most studies did not provide a working definition of quality of care, and instead used proxy indicators such as infant mortality [ 25 ] to highlight quality-related outcomes.

Synthesis according to Kruk et al. Conceptual framework

Below, we synthesize findings from the studies according to the components of Kruk et al.’s [ 5 ] conceptual framework (foundations, processes of care and impacts). We highlight the most common themes that we identified in the literature for each domain and provide illustrative examples. Unless specified, findings were not specific to LMIC or HIC contexts.

Foundations

Governance: leaders, policies, processes and procedures providing direction and oversight of health system(s).

A common theme across the literature was health system governance at local, regional and national scales, and its relationship to quality of care within the context of UHC. Naher et al. [ 26 ] identified transparency, accountability, laws and regulations, and citizen engagement as critical components of governance. The articles discussed both poor and good governance, their underlying determinants and drivers, as well as interventions to improve governance and thus quality of care [ 22 – 54 ].

The literature suggests that poor governance is a common issue across health systems, and is both a cause and indicator of poor-quality care. Causes and forms of poor governance include weak supervision of, and inadequate incentives and remuneration for healthcare providers; lack of transparency and accountability in decision-making; and insufficient financial capacity; in addition to fragmented regulations and policies. Poor governance has also been found to result in low patient trust and confidence in the health system, wasted resources and poor patient outcomes [ 26 , 40 , 44 ]. In contrast, the reviewed literature described strong governance as critical to effective healthcare services [ 26 ] and the basis for achieving UHC [ 32 ].

Interventions to improve governance described by the reviewed literature include decentralization, social accountability mechanisms, such as social audits, and policy reforms to strengthen provider incentives and service integration [ 26 , 28 , 31 , 45 , 47 , 53 ]. However, the evidence regarding the effectiveness of these interventions on governance and quality of care was largely inconclusive. Regarding integration, White [ 45 ] noted the need to ensure adequate leadership and organizational capacity before integrating services, as a key determinant of success.

Quality of care measures

Six studies identified measures and/or measurement instruments to assess quality of care or its various dimensions within the context of UHC [ 19 , 22 , 27 , 30 , 42 , 51 ]. These measures differed based on their service areas of focus (e.g. family planning, primary care), the geographic contexts for which they are intended and whether they assessed foundations, processes of care or quality impacts. The reviewed literature identified a lack of standardized quality assessment tools as a significant barrier to the realization of UHC [ 22 , 42 ]. However, researchers also noted the need for country-specific indicators reflective of a country’s unique social, political and economic circumstances, and population needs and expectations [ 18 , 22 , 30 , 39 , 51 ]. Studies also emphasized the importance of integrating equity as an explicit component in the measurement and monitoring of UHC through for example, disaggregation of data by key socioeconomic and demographic variables including place of residence, occupation, religion, ethnicity and migration status [ 18 , 27 , 30 , 35 ]. Table ​ Table3 3 maps the measures identified in the studies according to the domains and subdomains of Kruk et al.’s framework.

Quality domains and subdomains assessed by measures reported in the studies

Skills and availability of health system workers

Several studies also identified critical health workforce shortages and inequities in the distribution of appropriately qualified staff between urban and rural areas as significant constraints to the provision of high-quality, equitable care within the context of UHC, particularly in LMIC contexts [ 21 , 23 , 25 , 29 , 31 , 38 , 40 , 43 , 44 , 46 – 50 , 53 ]. Strategies discussed to address these concerns included (i) improving recruitment and retention of health system staff for rural and remote areas [ 21 , 46 , 47 , 50 ]; (ii) recruiting and training community health workers, while increasing the skills of lay health workers [ 21 ]; (iii) training traditional medicine practitioners in conventional medicine and utilizing them as community health workers [ 49 ]; and (iv) increasing task shifting, through delegating tasks to less specialized health workers [ 21 , 31 ], for which supportive supervision and adequate training is required [ 21 ].

Processes of care

Access to competent care and systems, incentives to improve quality of care delivery.

Evidence from the reviewed studies suggests that poor provider competence across a range of health services remains an ongoing issue, particularly in LMICs, posing a considerable barrier to the provision of timely, safe and effective quality of care [ 22 , 23 , 29 , 31 , 33 , 39 , 40 , 46 , 47 , 49 ]. For example, in China, a study with standardized patients found that providers in village hospitals provided correct treatment for tuberculosis only 28% of the time [ 47 ].

Within health systems seeking to provide UHC, significant inequities remain in both LMICs and HICs regarding the quality of care received by different populations. Vulnerable populations, who are more likely to receive care from lower-level health facilities, such as health centres, are disproportionately impacted by incompetent care and systems, having already constrained access to care [ 26 ], fewer options regarding providers and being more likely to receive inappropriate referrals [ 40 ], all indicators of lower-quality care.

Four studies described organizational factors influencing provider competence, including performance appraisal, continuing education, incentives, and remuneration and payment mechanisms [ 27 , 31 , 40 , 46 ]. For example, Sanogo et al. [ 40 ] discussed how delays in provider reimbursement as observed in Ghana, can demotivate healthcare providers, which Agarwal et al. [ 27 ] noted may decrease providers’ willingness to exert maximum effort on assigned tasks, compromising the quality of care.

Regarding incentives to improve motivation and quality of care delivery, Yip et al. [ 47 ] suggested a pay-for-performance system in China, as physicians are traditionally incentivized for treatment-based care through fee-for-service. However, the systematic review from Wiysonge et al. [ 46 ] noted a lack of evidence to support whether financial incentives for healthcare providers would improve quality of care in low-income countries.

User experience: wait times and people centredness

Wait times, a core component of quality of care, were noted as ongoing concerns in HICs and LMICs [ 21 , 23 , 33 , 39 , 40 , 47 , 48 , 55 , 56 ]. In HICs such as Norway and the United Kingdom, long wait times have been found to increase the demand for duplicative voluntary private health insurance, which Kiil argues may threaten the overall quality of public-sector driven UHC and exacerbate inequities [ 56 ]. In LMICs, evidence has shown that service quality is often superior in the private sector compared with the public sector, defined in relation to shorter wait times, better hospitality and increased time spent with providers [ 23 ].

Several studies described the relationship between positive user experience and people-centred care, which focuses on the needs and preferences of populations served while engaging them in shaping health policies and services. In addition, people centredness has been linked to improved mental and physical health, and reduced health inequities among other outcomes [ 20 , 22 , 31 , 35 , 57 ].

One study presented a people-centred care partnership model intended to support the work of advanced practice nurses in sustaining UHC, identifying nine attributes of people centredness including mutual trust and shared decision-making [ 20 ].

Several studies also discussed strategies aimed at increasing patient/community voice and engagement and the people centredness of health systems. These strategies included citizenship endorsement groups in Mexico [ 34 ] and various public forums to foster accountability and transparency [ 26 ]. However, McMichael et al. [ 35 ] cautioned that approaches to increase the voice of patients and communities risk excluding the most vulnerable, as those facing the greatest barriers to participation in such initiatives are often the most disadvantaged in their access and use of health services.

Quality impacts

Quality of care outcomes.

A few of the reviewed articles reported on empirical studies that analyzed patient and population health outcomes in relation to quality of care in the context of UHC. Where reported, these outcomes were discussed in reference to (i) specific programmes intended to improve quality of care and advance UHC, (ii) the impacts of health insurance schemes or health system reforms, (iii) private versus public sector provision of healthcare and/or (iv) the effects of specific service delivery models.

• (i) Regarding programmes intended to improve the quality of care, a community health extension programme in Ethiopia was associated with increased perinatal survival and decreased prevalence of communicable diseases. Though resource constraints such as inadequate medical supplies and limited supervision of health extension workers were noted as challenges, a key success factor included strong community engagement [ 29 ].
• (ii) Another six studies examined health outcomes in relation to health insurance schemes or health system reforms [ 25 , 40 , 46 – 48 , 55 ]. Some improvements in health outcomes were noted. For example, in China, health system reforms aimed at achieving UHC have been associated with decreased maternal mortality rates [ 25 ]. However, the burden of noncommunicable diseases such as diabetes is rising amid significant gaps in their detection and treatment [ 47 ].
• (iii) Studies also compared patient outcomes in relation to private versus public sector healthcare provision [ 24 , 56 , 58 ]. How the private sector was conceptualized varied across the studies, both in terms of how it was categorized (e.g. for-profit versus not-for-profit), as well as its role in healthcare financing and delivery. Given this heterogeneity, whether the public or private sector leads to higher-quality care and consequently, better health outcomes, is unclear in the reviewed literature. However, the private sector, when financed through out-of-pocket payments, is more likely to exacerbate inequities in access to healthcare.
• (iv) Finally, two studies examined integrated models of care and their relationship to health outcomes [ 52 , 54 ]. According to these studies, different forms of service integration may positively impact health, for example, through slowed disease progression [ 54 ] and decreased preterm births [ 52 ].

Patient-reported satisfaction and trust in health system

Reports of poor perceived quality of care and low patient satisfaction as barriers to healthcare uptake and enrollment in health insurance schemes were common across the reviewed studies [ 26 , 28 , 36 , 40 , 44 , 47 , 55 , 56 ]. For instance, Alhassan et al. [ 28 ] found that perceived low quality of care, long wait times and poor treatment by healthcare providers reduced clients’ trust in Ghana’s National Health Insurance Scheme, reducing subsequent re-enrollment rates. In Ghana, perceived quality of care was found to exert a greater influence on men’s decisions regarding care uptake than on women’s decisions [ 36 , 44 ]. O’Connell et al. [ 36 ] suggested this gendered difference may be due to men’s care being more likely to be prioritized within household financial decisions, affording them the opportunity to be more discerning regarding the quality of care.

Several studies also discussed the effects of health system reforms and different service delivery models on patient satisfaction and trust in healthcare systems [ 23 , 28 , 29 , 31 , 38 , 43 , 47 , 54 , 57 ]. Yip et al. noted that despite reforms aimed at expanding access to care across China, many patients have chosen to forgo care at primary healthcare facilities altogether due to a lack of trust and dissatisfaction with quality of care [ 47 ]. Similarly, Ravaghi et al. identified contradictory results regarding the effects of hospital autonomy reforms on patient satisfaction. Two studies in Indonesia cited in Ravaghi’s review reported improvements, while others noted decreased or no change in patient satisfaction [ 38 ]. In contrast, four reviews found that integrated, people-centred health services may positively impact patient satisfaction [ 29 , 31 , 54 , 57 ].

Efficiency of healthcare services and systems

Twenty-seven studies addressed the efficiency of healthcare systems and services, which the review by Morgan et al., defined as ‘the extent to which resources are used effectively or are wasted’ [ 23 , p. 608]. These studies discussed inefficiencies in health systems [ 22 , 26 , 28 , 29 , 44 , 48 ], the possible effects of health reforms and other interventions on efficiency [ 21 , 25 , 31 , 37 , 38 , 41 , 44 – 47 , 50 , 53 – 55 , 58 , 59 ], efficiency as a criterion in health policymaking [ 32 ], and the measurement of efficiency [ 22 , 30 , 42 , 51 ], an example of which, as cited in Rezapour et al.’s study, was the percentage of prescriptions including antibiotics in health centres and health posts [ 51 ].

Additionally, some studies compared the efficiency of public and private sector healthcare provision, reporting mixed results [ 23 , 24 , 48 , 58 , 61 ]. For example, higher overhead costs and lower quality of care outcomes, including higher death rates, have been observed in private hospitals compared with public hospitals in the United States [ 24 ]. In contrast, research on the National Health Service in England has suggested that privatization and market-oriented reforms have improved the efficiency of hospital care through cost cutting without evidence of reduced quality [ 58 ].

In LMICs, the private sector has been linked to increased service costs related to overprescribing and use of unnecessary and expensive procedures [ 23 ]. However, Morgan et al. noted that studies assessing private sector performance in LMICs have often focused on unqualified or informal small private providers, such as small drug shops, operating amid weak public health systems and poor regulation, providing an incomplete picture of the role of the private sector in progress towards UHC [ 23 ]. Table ​ Table4 4 captures a high-level overview of the key highlights related to each domain and subdomain of Kruk et al.’s [ 5 ] framework discussed in the studies.

Overview of key findings mapped to the domains and subdomains of Kruk et al.’s framework

In the middle column, cells are shaded according to the representation of the (sub)domain in the reviewed literature. Green = high representation (30–45 studies), yellow = moderate representation (16–29 studies), red = low representation (0–15 studies)

Identified evidence gaps and priorities for future research

Substantial evidence gaps that were identified in the reviewed literature are grouped thematically below. Themes are ordered by how frequently they were discussed by the reviewed studies.

Gap 1: How to measure and monitor UHC, with particular attention to quality of care and equity

Several studies identified the need for additional research to inform the development, selection and use of monitoring and evaluation frameworks and measures to assess quality of care and equity in relation to UHC in various geographic contexts at multiple levels of the health system, including facility and institutional levels [ 22 , 30 , 31 , 34 , 39 , 42 ]. For example, Rodney et al. stressed that countries should select contextually relevant indicators, and pay particular attention to the measurement of equity within UHC, cautioning that measuring equity based solely on wealth quintiles may mask inequities related to other factors such as race or disability [ 39 ]. In addition, two studies discussed the lack of client-reported measurements and advocated for further research to integrate data from household surveys and user-experience surveys [ 22 , 30 ].

Gap 2: Comparative information on the efficiency and effectiveness of public and private health provision and appropriate mix of public and private healthcare

Researchers noted the need for more conclusive evidence comparing the efficiency and effectiveness of public and private health sector provision, and the role of the private sector in contributing to UHC [ 21 , 23 , 56 , 57 , 62 ]. For example, Morgan et al. highlighted the need for greater evidence on how system-level influences such as regulations, may be used to create a public–private healthcare mix that promotes high-quality care and supports the achievement of UHC [ 23 ].

Gap 3: Effects of financial and insurance schemes on quality-of-care delivery and patient outcomes

The reviewed literature identified a lack of evidence regarding the impacts of different financial and insurance schemes on quality-of-care delivery and patient outcomes, particularly for vulnerable groups including women-headed households, children with special needs and migrants [ 34 , 46 , 55 , 62 ]. For example, van Hees et al. noted a lack of evidence regarding the impacts of financial schemes, such as pooling of funds and cost sharing, on equity [ 55 ].

Gap 4: Effects of integrated service delivery models

Studies identified the need for more robust evidence related to the effects of integrated service delivery models on access to quality care, as well as patient and population health outcomes [ 22 , 37 , 52 , 54 ]. Lê et al. specifically highlighted the lack of evidence on equity outcomes related to service integration, suggesting the need for further research in this area [ 54 ].

Gap 5: Mechanisms and contexts that enable and hinder implementation of quality-related interventions

Finally, researchers called for additional evidence regarding the mechanisms and contextual factors such as societal stigma that influence the effectiveness of interventions related to quality of care in the context of UHC [ 34 , 37 , 55 ]. To this aim, van Hees et al. recommended realist evaluations to surface what works, for whom, and in what contextual circumstances [ 55 ]. For example, Palagyi et al. identified a need for further research on task shifting, particularly how the skills gained by health workers can be maintained, and its implications for team dynamics and the delivery of existing programmes [ 37 ].

This scoping review aimed to characterize the existing conceptual and empirical literature on quality of care within the context of UHC. As noted in our results, in the reviewed literature, quality of care was often ill defined or defined inconsistently. A lack of conceptual clarity compromises the development of a robust evidence base able to inform the design and implementation of effective quality-related policies and interventions.

The 45 articles we reviewed for our study reveal a heterogeneous body of literature when compared with Kruk et al.’s quality of care framework. While some framework components including governance and the efficiency of healthcare services and systems were highly represented in the included literature, others were less represented such as physical and technological resources and tools, and patient and population health outcomes.

We also noted in the reviewed literature a lack of clarity regarding how the studies distinguished between private sector involvement in financing and/or delivery of care. This lack of clarity limits our understanding of the implications of private sector engagement for the quality of care and the achievement of UHC in various geographical contexts. Research is required to provide greater clarity of the role and impacts of private sector involvement in financing and/or delivery of health services, to help inform countries’ decision-making regarding private sector engagement. In addition, further research is needed regarding the interactions between the public and private sector and their effects on the sustainability of UHC. For example, studies have noted a concern that the availability of concierge services can create downstream implications for people who cannot afford private insurance, such as an imbalance in resource distribution [ 57 ].

Overall, the identified evidence gaps pointed to the need to build a stronger evidence base about what works, for whom, and under what contextual circumstances, and with what effects on equity to improve quality of care in LMICs and HICs. This includes a need for further evidence on the effects of integrated service delivery models, as well as how regulation can be used to create a public–private healthcare mix promoting high-quality and equitable care. The literature further highlighted the urgent need for additional research to inform the creation of robust monitoring and evaluation frameworks prioritizing equity that could support improvements to quality of care. This includes further research to help support the inclusion and use of disaggregated data, such as by wealth, sex and ethnicity to monitor and inform efforts to increase equity in access, utilization and outcomes for vulnerable populations. Beyond the above-noted research priorities, we also recommend additional research comparing quality related outcomes before and after UHC implementation, and how they intersect with health equity.

Strengths of our scoping review include the use of a broad search methodology and validated search filters in consultation with an expert librarian, and the use of a conceptual framework to guide analysis of findings. Further, our search was not constrained based on country of origin. In our search of the literature, we did not find other published reviews of similar scope about quality of care within the context of UHC.

The primary limitation of our review is the small number of included studies that met our eligibility criteria. This highlights that quality-related research in UHC remains an emerging field. In addition, many of the included studies were narrative reviews, which may not have captured the full breadth of the literature. Another limitation of our review is that we included only English-language studies. Future reviews should attempt to search and synthesize evidence in additional languages to provide more global relevance. Further, the conceptual framework we applied to the analysis of findings does not consider various factors that render health systems more fragile such as pandemics, disasters and conflicts, which may compromise the quality of care and realization of UHC. As our study did not include search terms for specific vulnerable populations such as Indigenous or racialized groups, there is also need for future research related to LMICs and communities experiencing marginalization and discrimination within HICs.

In addition, there may be limited applicability of findings across studies to different geographic regions. Finally, due to the heterogeneity and qualitative nature of the included studies, meta-analysis and synthesis beyond thematic analysis were not feasible.

This review summarized the existence of available evidence on quality of care within the context of UHC, identifying strategies aimed at improving quality of care as well as diverse knowledge gaps. Further research, evaluation and monitoring frameworks including those that attend to equity are required to strengthen the existing evidence base.

Acknowledgements

Thank you to Vincci Lui from Gerstein Science Information Centre at the University of Toronto for her guidance and advice regarding the search strategy. We also would like to acknowledge Garry Aslanyan, Beverley Essue, Miguel Ángel González Block, Greg Marchildon and Jeremy Veillard, for their guidance.

Abbreviations

APPENDIX A: Appendix: Search Strategy

Database: ovid medline: epub ahead of print, in-process & other non-indexed citations, ovid medline® daily and ovid medline®, 1946: september 27, 2021.

Appendix B: Study Selection

Author contributions

All listed authors were involved in the study design. BY and AK performed title/abstract and full-text screening, data extraction, and data synthesis, as well as drafting the manuscript. All authors contributed to subsequent revisions. All authors read and approved the final manuscript.

This research was funded by the Canadian Institutes of Health Research (CIHR) (#407149) for the project titled ‘Towards Equitable Universal Health Coverage in a Globalized Era: A Research Agenda-Setting Workshop’.

Availability of data and materials

Declarations.

Not applicable.

The authors declare that they have no competing interests.

Sara Allin and Erica Di Ruggiero are co-senior authors.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Universal Healthcare in the United States of America: A Healthy Debate

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Article Contents

Introduction, limitations of the analysis, conclusions, acknowledgements.

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The political economy of universal health coverage: a systematic narrative review

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Syed Shahiq Rizvi, Rundell Douglas, Owain D Williams, Peter S Hill, The political economy of universal health coverage: a systematic narrative review, Health Policy and Planning , Volume 35, Issue 3, April 2020, Pages 364–372, https://doi.org/10.1093/heapol/czz171

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The uptake and implementation of universal health coverage (UHC) is primarily a political, rather than a technical, exercise, with contested ideas and diverse stakeholders capable of facilitation or resistance—even veto—of the policy uptake. This narrative systematic review, undertaken in 2018, sought to identify all peer-reviewed publications dealing with concepts relating to UHC through a political economy framing. Of the 627 papers originally identified, 55 papers were directly relevant, with an additional eight papers added manually on referral from colleagues. The thematic analysis adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions to organize the analysis. The results identified a literature strong in its exploration of the ideologies and ideas that underpin UHC, but with an apparent bias in authorship towards more rights-based, left-leaning perspectives. Despite this, political economy analyses of country case studies suggested a more diverse political framing for UHC, with the interests and institutions engaged in implementation drawing on pragmatic and market-based mechanisms to achieve outcomes. Case studies offered limited detail on the role played by specific interests, though the influence of global development trends was evident, as was the role of donor organizations. Most country case studies, however, framed the development of UHC within a narrative of national ownership, with steps in implementation often critical political milestones. The development of institutions for UHC implementation was predicated largely on available infrastructure, with elements of that infrastructure—federal systems, user fees, pre-existing insurance schemes—needing to be accommodated in the incremental progress towards UHC. The need for technical competence to deliver ideological promises was underlined. The review concludes that, despite the disparate sources for the analyses, there is an emerging shared narrative in the growing literature around the political economy of UHC that offers an increasing awareness of the political dimensions to UHC uptake and implementation.

Key Messages

Uptake and implementation of universal health coverage (UHC) is primarily a political, rather than technical, exercise.

The political economy of UHC arises from contested ideas and ideologies, diverse stakeholder interests and formal and informal institutions for its implementation.

A framework of analysis is needed to clarify concepts and identify obstacles and nodes of possibility for policy influence.

Universal health coverage… is intrinsically political and cannot be achieved without recognition of its dependence on, and consequences for, both governance and politics ( Greer and Méndez, 2015 ).

As Greer and Méndez (2015) suggest, even in contexts where universal health coverage (UHC) is being proposed for implementation, it will remain contested—policy advocates cannot presume on political consensus to support it. In this article, we use the current World Health Organization (WHO) definition of UHC:

Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition of UHC embodies three related objectives: •  Equity in access to health services - everyone who needs services should get them, not only those who can pay for them; •  The quality of health services should be good enough to improve the health of those receiving services; and •  People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm ( WHO, 2019 ).

UHC incurs cost—and the commitment to increase coverage, ensure financial protection and enhance the scope and quality of services and access to medicines will require increased fiscal space in health expenditure. Recent global economic downturns have resulted in some countries moving away from their commitments to UHC as economic austerity bites ( McKee et al. , 2013 ). ‘Leaving no-one behind’—the promise of the Sustainable Development Goals, where UHC ‘cuts across all of the health-related SDGs’ ( WHO, 2019 )—will necessarily result in redistribution of resources, and in some cases reprioritization. Clearly, both political and economic factors will be at play—and a political economy approach, examining this interface among power, resources and their deployment, is necessary to inform advocacy and implementation. For this review:

Political economy analysis is concerned with the interaction of political and economic processes within a society: the distribution of power and wealth between different groups and individuals, and the processes that create, sustain and transform these relationships over time ( Collinson, 2003 ).

Krieger draws attention to the importance of political economy to the study of the determinants of disease, a perspective readily translated to the policy uptake and analysis of UHC, a health systems framework that is intimately engaged in those relationships and in shaping a health systems response to both disease and its social determinants:

Analysis of causes of disease distribution requires attention to the political and economic structures, processes and power relationships that produce societal patterns of health, disease, and wellbeing via shaping the conditions in which people live and work ( Krieger, 2011 ).

This article analyses the peer-reviewed literature to examine this interface between political economy and UHC, and uses a framework for research and development analysis. The value of a political economy analysis to health systems research, as Krieger (2011) points out, is in the explicit linkage of health to its social and political determinants. Given the relatively recent introduction of political economy to health systems and policy analysis, this systematic review has identified a literature that is divided between the theoretical exploration and implementation of UHC. The resultant analysis offers a deeper understanding that reaches beyond the technical implementation of UHC to identify factors in its political and social context that enable or constrain it, allowing both researchers and policy-makers to explore for themselves these complex factors as they engage UHC in its local context.

Fox and Reich (2015) , in their framework for evaluation and action, offer four variables that act to enable or obstruct the uptake and implementation of UHC: ‘interests’, ‘institutions’, ‘ideas’ and ‘ideology’. For the purposes of this analysis, we have combined ‘ideology’ and ‘ideas’, and changed the order of the variables. ‘Ideas and ideology' are logically linked to the ‘interests’ that embody them, and are shaped by them—and subsequently the ‘institutions’ that operationalize their policy directions:

‘Ideology’ is the higher-level political framing against which ideas are explored and establishes the political rationale and justification for the adoption and implementation of UHC. ‘Ideas’ become important because they embody the narratives, the metaphors that shape how UHC is perceived, and how it is discussed and popularly represented.

‘Interests’ expands the sense of stakeholders to include all individuals and groups who have a substantive interest in UHC—government ministries, political parties, private companies, professional organizations and unions, civil society organizations, donors and most importantly population groups, the direct beneficiaries of UHC.

‘Institutions’ necessarily include the formal political structures linked to UHC policy and its implementation, with particular attention to veto points—those conjunctures in the process that are entirely dependent on the support of specific individuals or agencies. They also extend to the informal institutions—cultural norms and expectations, precedent and existing structures—that shape (and may contest) that implementation ( Fox and Reich, 2015 ).

We have used these variables as headings in our analysis, seeking to explore within them their influence on the processes of UHC implementation.

This study uses a systematic narrative review process as articulated in the RAMESES guidelines ( Wong et al. , 2013 ). These are designed to combine both systematic comprehensiveness with the capacity to incorporate knowledge from a diverse range of disciplinary sources, making the sense of available evidence, and integrating it into an explanatory narrative. Following an exploratory search in Google, Google Scholar and Abstract reviews, the terms integral to UHC and political economy were exploded to identify alternative terminologies and are documented in Table 1 . From these exploded keywords, combinations were set out in six search strategies ( Table 2 ) across 14 health, economics and social and political science databases. The search period was limited by the development of the concept of UHC, commencing from 2005, when Universal Coverage was cited in a World Health Assembly resolution ( WHA, 2005 ), to February 2018.

Key terms and alternative terminology

Keyword combinations for searches

A total of 1159 papers were identified in the search, with 627 papers remaining following the removal of duplicates. Inclusion criteria included English language publications, referring to UHC or one of the three related objectives in its definition ( WHO, 2019 ), and explicitly linked to a political economy perspective ( Collinson, 2003 ). Papers were excluded where they did not use a political economy framework, or where the details of their analysis were narrower than the three stated objectives. Following the screening of title and abstract, 127 papers were identified as likely to be relevant and two researchers (R.D. and P.S.H.) independently examining full text confirmed 55 publications for analysis, with the difference of opinion on five papers, which were discussed and subsequently included. An additional eight papers were added manually, identified as relevant by the researchers and their networks ( Figure 1 ). The analysis of the papers was undertaken manually, using the adapted Fox and Reich’s (2015) framework: the first tranche of thematic analysis examined ideologies and ideas. This explored accounts of the policy uptake and implementation of UHC but also examined the theoretical premises of political economy analyses applied to UHC. The second tranche of analysis identified the interests—the stakeholders in UHC analyses and, where possible, linked these to the framings already explored in the first tranche. The final tranche was into the institutions—the formal and informal agencies and processes that enable or obstruct the implementation of UHC. Following this analysis, a further exploration of those papers detailing political economy analysis of UHC initiatives in specific countries was undertaken, to be published independently.

Search and selection diagram for analysis

The search strategy used for this analysis focuses on the interface between political economy and UHC, identifying papers that have been filtered through peer review prior to publication. As a consequence of this specific focus on the intersection between political economy and UHC, the result is not a comprehensive representation of the literature on UHC, or of any single country’s progress to UHC, but only explores analyses of UHC where a political economy framing has been specifically used. The inclusion criteria, which required an explicit political economy perspective, meant that, in most cases, only one or two analyses of each country were available. To apply a political analysis to any individual country, a richer, more complex understanding would be achieved from the engagement of local expertise and the integration of a broader literature into the framework offered in this study.

The values of UHC—universality, service quality and access and financial protection and equity—are themselves politically framed, and there is a resultant bias towards social democratic perspectives both in the cases represented and in the analyses of them. Despite this, there is a wide range of political positions expressed in the implementation and analysis of UHC initiatives: it is not exclusively a ‘left’ agenda, and in many countries, UHC has been introduced and supported by a broad spectrum of political parties and philosophical and political positions.

The findings of the analysis of the selected literature have been organized using the four variables identified by Fox and Reich (2015) .

Ideology and ideas

Ideologies as defined by Fox and Reich (2015) are world views that may be drawn upon to justify or underpin change. They can be seen as the overarching logic or ‘cognitive background’ that guides an institution’s policy preferences ( Campbell, 1998 ). Within this study, ideologies advocated within social democracy, liberalism and conservatism are formed on the basis of values that are deemed important by the proponents of each respective world view—or in cases such as ‘neo-liberalism’, used by ideological opponents to characterize a perceived position. Values, such as solidarity, equality and autonomy, rest upon certain assumptions about human rights and behaviour, and Frenk and Gómez-Dantés (2015) point out that these assumptions are expressed either explicitly or implicitly through the distribution, delivery and financing of healthcare resources. This then gives us a framework to dissect the implied motivations and emotions that fuel specific positions and actions taken by actors and institutions, in influencing a state’s progress towards UHC. Similar values-based frameworks have also been proposed by Shiffman (2009) , Rushton and Williams (2012) and van Olmen et al. (2012) , among others.

The economic structures that these ideologies, values and assumptions act upon may be either private market oriented or public intervention oriented, or in most modern pluralistic health sectors, a combination of the two, necessary to appease all parties and to achieve comprehensive UHC ( McPake and Hanson, 2016 ). Levels of market regulation will vary even among countries that ascribe to the same political ideology. Identifying ideological elements and values at play at the beginning of the policy-making process is important for two reasons as described by McInnes and Lee (2012) . The first is to avoid proceeding with a mix of contradictory policies that will ultimately need to be reconciled; the second is to provide insight into opportunities for effective framing and priority setting during debate and negotiation processes.

Reeves et al. (2015) and McKee et al. (2013) suggest that governments led by left-leaning parties were more likely to implement UHC and tended to better utilize progressive sources to ultimately invest more money on healthcare than right-leaning parties. Raphael and Bryant (2006) overtly advocate social democratic policy models as a preferred platform for UHC, but it is clear that UHC implementation is formed by diverse political and historical narratives and other contextual factors. The literature offers examples of both success and failure from similar contextual backgrounds, as well as examples of achieving similar results from vastly different contextual backgrounds. The persistent imprint of colonialism continues to impact on Bangladesh through its highly centralized public administration, ultimately constraining the responsiveness of services to societal healthcare needs, though civil society initiatives have compensated for this, producing significant progress ( Osman and Bennett, 2018 ). Ichoku et al. (2013) , drawing light to the differences between the ideas of social solidarity embedded within traditional Sub-Saharan African institutions and the pseudo-capitalistic ideology that persisted after colonial domination, argue that historically injected values that once made sense might now conflict and restrict progress. Values can be instilled from a variety of sources: countries where the residual impacts of colonialism seem remote may now face economic policy practices similar to those experienced under colonialism as a result of the forced adoption of neoliberal values attached to conditional aid contacts, written by global developmental partners ( Ravindran, 2014 ).

Given the apparent bias of analysts in this space, and the selective narratives of policies used by countries to achieve UHC, the literature points to social democratic ideologies as most conducive to progress towards UHC—in particular those that utilize the values of equity, solidarity and welfare as a means of increasing worker productivity ( McKee et al. , 2013 ; Reeves et al. , 2015 ). In practice, there is a massive overlap between institutional ideologies, and at times, institutions may act in direct opposition to the ideology they lay claim to. Ghana’s social welfare cash transfer programme—Livelihood Empowerment against Poverty (LEAP)—was initiated by its free market-oriented ‘right of centre’ New Patriotic Party ( Abdulai, 2019 ). The contested political support—or resistance—around the US Affordable Health Care Act reflects current diversity and polarized extremes in political ideology ( Osman and Bennett, 2018 ), but political actors from all ends of the ideological spectrum can, and do, come together and find common ground in the pursuit of UHC.

Within the literature, ideologies, although presented as the background paradigms that underlie policies, also may be applied in a reductionist—and unhelpful—labelling of actors and institutions. Political ideologies usually comprise both a social set of values and an economic set of values. Social values embrace a range of values based on equity to those based on individualism. Economic values cover a continuum from private sector and free market oriented to public sector oriented—and complex combinations of both ( Figure 2 ). The evidence is that governments and their oppositions simultaneously utilize mechanisms from all ends of both social and economic spectrums and also draw from vastly different values, when dealing with different policies. It then follows that the ‘left-wing’ and ‘right-wing’ labels often used to describe governments are not only imprecise but also polarizing when seeking to explore the most politically appropriate interventions for the specific context ( Davidson, 2014 ).

Schematic diagram of political ideas

A more pragmatic approach would be to assess the nuance in what Fox and Reich (2015) term the ‘ideas’ truly represented and held by stakeholders, institutions and their proposed policies. Chemouni (2018) was able to illustrate this with the case of Rwanda and its community-based health insurance (CBHI). A superficial analysis might conclude that the Tutsi-dominant Rwandan regime had no interest in expanding social protection benefits to the majority-Hutu rural population, but with the implementation and commitment to CBHI, the government was able to achieve 86% population coverage. Further analysis shows that the prevailing values of a self-reliant nation, long-term regime legitimization and the role of the state in coordinating socio-economic progress allowed the Rwandan Patriotic Front to progress these reforms in apparently counterintuitive ways. The political construction of the ‘good Rwandan’—self-reliant, rejecting dependence—was critical to expanding the ‘mutuelles’ and resisting external donor pressure to increase co-payments ( Chemouni, 2018 ).

A key starting point for all interventions is being receptive to the tensions and congruencies between the implicit and explicit values held by stakeholders and institutions ( Borgonovi and Compagni, 2013 ; Lavers and Hickey, 2016 ). The links between ideologies and ideas are not necessarily linear: ideologies may be maintained in political rhetoric, but the operational ideas and values held by the parties might not be congruent with traditional understandings of the ideologies that these institutions lay claim to. While conflicts between claimed or implied ideologies might be difficult to reconcile, productive alliances can still be built around the operational ideas and goals. This capacity to find shared functional territory is absolutely vital, as political commitment from a wide variety of ministries, levels of government and industries is needed to progress towards UHC. Okech and Lelegwe (2016) , seeking to identify the key factors limiting Kenya’s progress towards UHC, cite the complete absence of collaboration as a result of self-serving interests, and the resulting lack of communication between interests in policy, research and practice. Korea and Taiwan’s multi-stakeholder approach to UHC policy planning and implementation presents contrasting perspectives: neither the strengths nor weaknesses of their UHC policies could be adequately explained by the apparently superficial political positions held by actors in the health governance space ( Kwon and Chen, 2008 ). Other factors were clearly at play.

Fox and Reich’s (2015) usage of ‘interests’ suggests an expanded definition of stakeholders—recognizing the importance not only of agencies but also of individuals and coalitions sharing ideologies or ideas, or invested in the institutions that would implement UHC. Analysis of these interests can make it clear as to which actors will impede or expedite progress through the policy cycle. It can also give a sense of how progress is perceived by interest groups, which can help during the agenda-setting process. Further analysis of the underlying values and assumptions of the institutions and interest groups involved, based on their previous actions and stated mandates, can identify points of tension and opportunity that might not be immediately apparent. This can also suggest which new institutions or multi-sectoral alliances need to be established, and how they might interact with the existing ecosystem. The positioning of analysts influences how interests are represented. Political economic analyses of the patterns of behaviour and political and economic histories of the institutions and interest groups may be explicitly represented through the political and theoretical prisms of the authors ( Ichoku et al. , 2013 ; Kelsall and Heng, 2016 ; Lavers and Hickey, 2016 ; Fouda and Paolucci, 2017 ) and may not reflect how stakeholders would represent themselves. In contrast, ‘technical’ analyses framed as exemplars of successful UHC implementation, may offer less overt political framing ( Bayarsaikhan et al. , 2015 ; Okech and Lelegwe, 2016 ; Frenk and Gómez-Dantés, 2015 ; Reich et al. , 2016 ; Lan, 2017 ). Despite this, the construction of a technical analysis as independent, ‘objective’ assessment brings its own inherent values framework, which may still be implicit in the text ( Carrin et al. , 2007 ; Carrin et al. , 2008 ; Minh et al. , 2014 ).

The case studies examined in this review are not consistent in the degree of granularity with which they identify stakeholders in their exploration of the political economy of UHC. The lessons from the African SHIELD project are quite explicit in their identification of domestic—and where relevant, international—institutions and their positions and support, though individuals and their influence are not specified ( Gilson et al. , 2012 ). Other studies may refer to selected individuals by name or title ( Krajewski-Siuda et al. , 2008 ; Basaza et al. , 2013 ; Chemouni, 2018 ), but specific identification of stakeholders is more frequent at the level of agencies—or networks and coalitions of interests.

Analysis of the reports of country case studies suggests that for high- or upper-middle-income countries, the coalitions of importance for UHC have been domestic, with political and popular alliances critical. Krajewski-Siuda et al. ’s (2008) analysis of the Polish National Health Fund credits its creation—despite substantial opposition—to key political alliances with union support, and an ambivalent media, and its demise to the collapse of that coalition. Despite that uncertain beginning, the initiative has served as a platform for subsequent developments in UHC. The review confirms that the political routes to UHC are diverse. Costa-Rica’s ‘Caja Costarricense de Seguro Social’ has been tracked across 7 decades towards UHC ( Vargas and Muiser, 2013 ), with critical shifts—and reversals—of coalitions of support and opposition over that period enabling UHC implementation. In this case, UHC implementation was driven by political support at the highest level and popular demand, despite the ‘the absence of real consensus among the policy elite’. Chee (2008) , examining the contested healthcare sector in Malaysia, documents the transition from a statist to more pluralist system, with incremental alliances between the state and private services counterbalanced by the response of civil society organizations. Lan (2017) identifies a path-dependent, incremental implementation of UHC in Taiwan, with progress constrained by a cultural–ideological framing shared by both political elites and the population, until fiscal crisis drove a resolution.

Lower-middle- or low-income country studies are more likely to make reference to international influences, though the extent to which this is explicit varies and makes tracking the influence of international agencies more difficult, with the extent of that influence often underplayed ( Lavers and Hickey, 2016 ). In their analysis of Uganda's national health insurance scheme, Basaza et al. (2013) directly acknowledge the policy advice of the Social Health Protection Network P4H (Providing for Health) through facilitating study visits of countries offering models UHC progress, and list bilateral and multilateral donor agencies as influential stakeholders, together with domestic actors. Reference to a ‘Joint Learning Network for UHC’ review of Mongolia’s Social Health Insurance suggests some significant level of engagement by WHO and the World Bank, but the key political drivers described are clearly domestic ( Bayarsaikhan et al. , 2015 ).

The interplay between domestic and international actors is complex. Abdulai (2019) revisits Ghana’s LEAP implementation and questions the extent to which donor conditionalities played in its implementation. Pisani et al. ’s tracking of UHC in Indonesia attributes the dominant impetus to domestic political imperatives but makes reference to the contribution of academics and civil society and the financial underpinnings of US, Australian and German bilateral assistance, ‘though no interviewees reported that the views of foreign development agencies significantly influenced the shape or outcome of domestic discussions’. In their presentation of Kenya’s social health insurance proposal, the authors—with multiple representatives from the Kenyan Ministry of Health (MoH) and the National Hospital Insurance Fund, technical advisors from both WHO and the International Labor Organization and UK and German bilateral development agencies—make only glancing reference to international support, though domestic stakeholder positions are carefully documented ( Carrin et al. , 2007 ). Chemouni’s (2018) account of Rwanda’s path to UHC documents the contribution of multiple multilateral, bilateral and global public–private partnerships over the past 2 decades, providing technical assistance in the analysis and development of proposals. He points to the unexpected success of a health systems strengthening bid submitted by the MoH and a coalition of then GTZ 1 and the United Nations Development Program and the Rwandan First Lady’s Protection and Care of Families against AIDS to the Global Fund to fight acquired immune deficiency syndrome, tuberculosis and malaria. The collapse of this alliance, in the face of MoH opposition, is one instance of Rwanda’s assertion of its own policy direction against external influences, even in coalition with significant internal interests. The review indicates that local ownership necessarily reframes the financial and technical contributions from international agencies to progress on UHC and that ownership is critical to the success of its implementation.

Institutions

The institutions that drive UHC—the formal political structures linked to UHC policy and its implementation—are key to translating the systematic review into a narrative that permits the identification of nodes of possible influence in the policy trajectory of UHC. They also influence the informal expectations and precedents that might shape UHC uptake but are shaped by the existing infrastructure from which they are developed. It is this local context that shapes the diversity of options in the institutions that build UHC, as evidenced in the political economy analyses from different country case studies. They are also vulnerable to political and economic changes in both global and domestic contexts. The inclusion of the achievement of UHC as one of the United Nations' Sustainable Development Goals targets (SDG3.8) provides a global commitment for translation into national institutions, though economic austerity has seen countries withdrawing from those same commitments, unpicking legislation and regulation relevant to UHC ( McKee et al. , 2013 ; Osman and Bennett, 2018 ). Politicization of the UHC agenda can expedite its progressive implementation into local institutions ( Borgonovi and Compagni, 2013 ), as in overt politicization as in the Ghanaian experience ( Fusheini, 2016 ), but then render it vulnerable to political reversal, as was also the case in Poland ( Krajewski-Siuda et al. , 2008 ).

Nigeria’s National Health Insurance System points to the dynamic nature of institutional roles and the complex interplay between federal and state responsibilities in a federal system. Onoka et al. ’s (2015) account unpacks these challenges, with inadequate clarification of the role of the states in the policy design stage, and consequent independent development by individual states of their own health insurance structure. With inclusion in the programme made voluntary, the inconsistencies between states significantly compromised effective coverage and uniform implementation. There were also tensions between private providers and state accountability, compounded by this divergence between state programmes, and a loosely managed incorporation of private providers into the scheme ( Onoka et al. , 2013 ). McPake and Hanson (2016) point to the common role of the private sector in pluralistic health systems to provide higher-level services to those who can afford them. Their potential for contracted provision of publically accessible services within UHC depends on effective government financial stewardship and the capacity for effective regulation.

The political dynamic in Cambodia has proved positive in the incremental progress in the development of institutions towards UHC, despite ambivalent assessments of the political economy of health, with Kelsall and Heng (2016) describing it as ‘an elite bargain in which both appropriating rents and delivering health outcomes are important’. Procurement of medications and a largely unregulated private sector continue to offer challenges in terms of the institutions necessary for the implementation of UHC, but the history of health sector reform and, in particular, the Health Coverage Plan that extended health infrastructure throughout Cambodia have laid down a solid basis of technical competence and ensured almost universal access to health service delivery.

The Health Equity Funds (HEFs) were initially introduced to overcome the obstacles of user fees for the poor but have been increasingly standardized in terms of their processes and aligned with health sector administration. The MoH has increased the domestic proportion of funding for the HEFs, enabling an expansion in their availability. The reimbursement of fees for the poor enhances the salaries of health professionals in an apparent virtuous cycle that guarantees sustainability, with both patients and providers benefitting in this scenario ( Kelsall and Heng, 2016 ). Kelsall and Heng (2016) identify two contrasting dynamics—health seeking and rent seeking—working together within the MoH, with health seen both as a desirable outcome in its own right, but also ‘increasingly seen as a good ‘gift’ for constituents in order to buy legitimacy at the ballot box’ ( Jones, 2013 ). The scale up of the HEF from its civil society roots has also enabled local cheques and balances against leakage to be institutionalized, a valuable mechanism as it is incorporated into the broader coverage of UHC. Ironically, the frank political settlement analyses offered by both Jones (2013) and Kelsall and Heng (2016) suggest that an explicit awareness of the political economy allows for a more pragmatic and realistic framing to build the institutions of UHC.

McKee et al. (2013) draw attention to the window of opportunity that presents politically for the implementation of UHC—the British National Health System providing the iconic example. Clarke and Le Masson (2017) point to the transformative possibilities in rebuilding institutions in response to national calamity, but the positive political window can also see UHC aligned with other larger political concepts, and the institutions of UHC their embodiment. For Mexico, the window was political: a shift from single-party domination to a democratized state that enabled a greater diversity of voices to be heard in the Mexican parliament and social policies that targeted a broader proportion of the population ( Gómez-Dantés et al. , 2015 ). These political shifts in power reflect broader progress in civil and political rights and provide a platform from which to establish a sense of urgency and demand for policies framed towards reducing inequalities ( Frenk et al. , 2006 ). The right to health care was framed as a mechanism for achieving social equality in Mexico, made concrete through implementing the General Health Law in 2003, and introducing the state-sponsored health insurance system Segura Popular, that achieved universal coverage by 2012 ( The Lancet, 2012 ). Recognizing the opportune moments that invite intervention can be especially effective for getting UHC-oriented policies onto the broader political agenda ( Grépin and Dionne, 2013 ).

But the strategic response to the window of opportunity is often predicated on the solid foundation of building institutions for the implementation of UHC. Having framed UHC in terms of rights, technical capacity to operationalize that claim is imperative. One of the greatest strengths of the Mexican reform effort was the technical capacity of the MoH, with the Minister of Health launching a small pilot programme to establish the proof of concept and garner support from the President. Pilots and other evidence gathering mechanisms provided data that alleviated speculative worries held by international actors and key national actors, such as the Minister of Finance ( Gómez-Dantés et al. , 2015 ). Positive results from the pilot provided the basis of discussions with the Minister of Finance for expansion to begin. The technical expertise and research capacity provided by these institutions not only directed the content of the proposed policies but also fuelled the political drive and framing process ( Frenk et al. , 2006 ).

The implementation of UHC is heavily dependent on institutional evolution ( Savedoff et al. , 2012 ; Reich et al. , 2016 ), and there is extensive available experience across both health and health financing systems ( Carrin et al. , 2008 ; Musango et al. , 2012 ; Meheus and McIntyre, 2017 ). The insights of political economy complement this with a deep understanding of the social, economic and political economy of the context within which UHC institutions operate. Path dependency is evident in the need to deal with the legacy of existing user-fees legislation and infrastructure, as in the Cambodian example ( Kelsall et al. , 2016 ), or in the transition into universal health insurance for Tanzania ( Pederson and Jacob, 2018 ). The role of the private sector is implicit in many health systems, with private provision (both for-profit and not-for-profit) filling state service gaps either formally through contracting or other regulated relationships, or the provision of insurance ( Chee, 2008 ). Attitudes in low- and middle-income countries (LMICs) towards engagement of the private sector in the institutions that implement UHC are divergent, ranging from the negative (prohibition or constraint) to the positive (encouragement, subsidizing and purchasing of services) ( Montagu and Goodman, 2016 ), and some concern expressed around UHC lies in perceptions of the ‘privatization’ of health and the redirection of resources away from public health priorities ( Schmidt et al. , 2015 ).

There has been an exponential growth in interest in political economy in health over the past 5 years: a simple search using ‘political economy’ as the search term in PubMed reveals 191 records in 2014, rising consistently to 831 in 2019. The Prince Mahidol Awards Conference (2019) in Bangkok had as its theme ‘The Political Economy of NCDs: A Whole of Society Approach’; in anticipation of the High Level Meeting on UHC, the monograph ‘Health: A Political Choice. Delivering Universal Health Coverage 2030’ has been recently released in collaboration with the WHO ( Kirton and Kickbusch, 2019 ) and the political economy of health is the focus of a recent special issue of the journal Health Systems and Reform ( Sparkes et al. , 2019 ; Campos and Reich, 2019 ). Sparkes et al. (2019) , seeking to develop a political economy analysis for health financing reform, conducted two systematic reviews, one on the technical aspects of health financing reforms, which provided ‘very little information about the political economy of the process’, and the second on political economy and health policy ‘similarly did not lead us to an existing framework or model that would suit our purposes’. Despite extensive mobilization towards UHC across a range of countries ( Monteira de Andrade et al. , 2015 ; Reeves et al. , 2015 ; Alami, 2017 ), the political economy prism has been applied only to a limited number of country experiences.

The experience encountered by Sparkes et al. (2019) is not dissimilar to our own, with an apparent divide between those papers that elaborate the ideologies and ideas around the political economy of UHC, and the more technically oriented papers dealing with the interests and institutions involved in its implementation, despite their interdependence in practice. This may arise because of the professional backgrounds of the analysts, with the political or technical perspectives preferenced, depending on discipline. Recognizing the imperative for the technical to engage the political—and vice versa—and faced with the failure of the literature to yield an appropriate framing, Sparkes et al. (2019) have adopted the framework developed by Campos and Reich (2019) based on the major categories of stakeholders in health policy in LMICs: interest group politics, bureaucratic politics, budget politics, leadership politics, beneficiary politics and donor politics. The classification is heuristic and allows a useful exploration of political dynamics in the case studies explored but is grounded in a theorized categorization of stakeholder orientation, rather than emerging directly from research. The juxtaposition of the technical and political that Sparkes et al. (2019) highlight is the critical interface of this dialogue and lies at the heart of the implicit recognition of the importance of political commitment to the achievement of UHC referred to in SDG3.8—but the apparent uncertainty about how to ensure this.

Despite the challenges outlined in the discussion, there is some evidence of an emergent narrative evident in this nascent literature around the intersection between political economy and UHC. The central variables identified by Fox and Reich (2015) —ideologies and ideas, interests and institutions—have been useful both for clarifying the areas of focus for any analysis and highlighting their porosity and interdependence. The systematic review of literature points to an increasing awareness of the significance of the political economy of health ( Greer and Méndez, 2015 ) and its direct application to the global uptake of UHC, and a growing body of critical case studies of UHC and national health systems from a political economy perspective.

But the current interest in—but limited research application of—political economy analysis for UHC, and the sharp divide between technical and political analyses, points to the need for further multidisciplinary research that will cast light on the obstacles to UHC uptake and implementation. This narrative systematic review has demonstrated a growing health systems and policy literature that explicitly claims a political economy perspective but provides only glimpses of how this perspective is being applied to specific country contexts. The thematic analysis of the case studies identified in this study points to the interfaces between the variables as point of possible influence in the UHC policy process: an awareness of where ideology and ideas can influence interests, where interests and their ideas can be aligned to optimize the development of institutions, where changes in ideas or interests shape new contexts for UHC implementation and where contextual change or external factors open windows of opportunity for new policy.

There is a need to build the theoretical and practical frameworks that would enable competent and consistent analysis, the necessary funding to expand that research and the policy preparedness to engage its findings and implications. A deeper exploration and theorizing of political economy is needed to complement the contribution of rapid reviews, and technical assessment in providing policy evidence towards UHC, outlining approaches that would enhance the rigour, accessibility and applicability of such evidence ( Langlois et al. , 2019 ), but rather than target specific evidence for policy-making, there is a need for a collaborative body of research that would provide an exploration of the political economy of UHC that would deeply inform its policy adoption and implementation—both in specific countries and across the broader international context. It would begin with the clarification of ideologies and ideas—beginning with reflective exercise for the analysts themselves, clarifying their own values and concepts—and map out the ideologies and ideas identified across stakeholder interests. It would trace the political influence of those ideologies and ideas through the stakeholder interests into the formal and informal institutions that enable UHC, identifying veto points and the nodes of possibility that catalyze UHC progress. From this base, the technical exploration of options for UHC becomes realistic, with the uncertainty around the political context of those largely clarified, alliances negotiated and challenges identified.

R.D. undertook the systematic review search as part of a WHO internship. S.S.R.’s primary analysis of the findings was funded through a University of Queensland Summer Research Scholarship. P.S.H.’s conceptualization and analysis were partially funded by a consultancy with the Social Health Protection Network P4H (Providing for Health).

The opinions expressed are those of the authors alone and do not reflect WHO or Social Health Protection Network P4H positions.

Ethical approval. None required.

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Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Every citizen of every country in the world should be provided with free and high-quality medical services. Health care is a fundamental need for every human, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal health care is the provision of healthcare services by a government to all its citizens (insurancespecialists.com). This means each citizen can access medical services of standard quality. In the United States, about 25% of its citizens are provided with healthcare funded by the government. These citizens mainly comprise the elderly, the armed forces personnel, and the poor (insurancespecialists.com).

Introduction

Thesis statement.

• Universal Healthcare Pros
• Universal Healthcare Cons

Works Cited

In Russia, Canada, and some South American and European countries, the governments provide universal healthcare programs to all citizens. In the United States, the segments of society which do not receive health care services provided by the government usually pay for their health care coverage. This has emerged as a challenge, especially for middle-class citizens. Therefore, the universal health care provision in the United States is debatable: some support it, and some oppose it. This assignment is a discussion of the topic. It starts with a thesis statement, then discusses the advantages of universal health care provision, its disadvantages, and a conclusion, which restates the thesis and the argument behind it.

The government of the United States of America should provide universal health care services to its citizens because health care is a basic necessity to every citizen, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal Healthcare Provision Pros

The provision of universal health care services would ensure that doctors and all medical practitioners focus their attention only on treating the patients, unlike in the current system, where doctors and medical practitioners sped a lot of time pursuing issues of health care insurance for their patients, which is sometimes associated with malpractice and violation of medical ethics especially in cases where the patient is unable to adequately pay for his or her health care bills (balancedpolitics.org).

The provision of universal health care services would also make health care service provision in the United States more efficient and effective. In the current system in which each citizen pays for his or her health care, there is a lot of inefficiency, brought about by the bureaucratic nature of the public health care sector (balancedpolitics.org).

Universal health care would also promote preventive health care, which is crucial in reducing deaths as well as illness deterioration. The current health care system in the United States is prohibitive of preventive health care, which makes many citizens to wait until their illness reach critical conditions due to the high costs of going for general medical check-ups. The cost of treating patients with advanced illnesses is not only expensive to the patients and the government but also leads to deaths which are preventable (balancedpolitics.org).

The provision of universal health care services would be a worthy undertaking, especially due to the increased number of uninsured citizens, which currently stands at about 45 million (balancedpolitics.org).

The provision of universal health care services would therefore promote access to health care services to as many citizens as possible, which would reduce suffering and deaths of citizens who cannot cater for their health insurance. As I mentioned in the thesis, health care is a basic necessity to all citizens and therefore providing health care services to all would reduce inequality in the service access.

Universal health care would also come at a time when health care has become seemingly unaffordable for many middle income level citizens and business men in the United States. This has created a nation of inequality, which is unfair because every citizen pays tax, which should be used by the government to provide affordable basic services like health care. It should be mentioned here that the primary role of any government is to protect its citizens, among other things, from illness and disease (Shi and Singh 188).

Lastly not the least, the provision of universal health care in the United States would work for the benefit of the country and especially the doctors because it would create a centralized information centre, with database of all cases of illnesses, diseases and their occurrence and frequency. This would make it easier to diagnose patients, especially to identify any new strain of a disease, which would further help in coming up with adequate medication for such new illness or disease (balancedpolitics.org).

Universal Healthcare Provision Cons

One argument against the provision of universal health care in the United States is that such a policy would require enormous spending in terms of taxes to cater for the services in a universal manner. Since health care does not generate extra revenue, it would mean that the government would either be forced to cut budgetary allocations for other crucial sectors of general public concern like defense and education, or increase the taxes levied on the citizens, thus becoming an extra burden to the same citizens (balancedpolitics.org).

Another argument against the provision of universal health care services is that health care provision is a complex undertaking, involving varying interests, likes and preferences.

The argument that providing universal health care would do away with the bureaucratic inefficiency does not seem to be realistic because centralizing the health care sector would actually increase the bureaucracy, leading to further inefficiencies, especially due to the enormous number of clientele to be served. Furthermore, it would lead to lose of business for the insurance providers as well as the private health care practitioners, majority of whom serve the middle income citizens (balancedpolitics.org).

Arguably, the debate for the provision of universal health care can be seen as addressing a problem which is either not present, or negligible. This is because there are adequate options for each citizen to access health care services. Apart from the government hospitals, the private hospitals funded by non-governmental organizations provide health care to those citizens who are not under any medical cover (balancedpolitics.org).

Universal health care provision would lead to corruption and rent seeking behavior among policy makers. Since the services would be for all, and may sometimes be limited, corruption may set in making the medical practitioners even more corrupt than they are because of increased demand of the services. This may further lead to deterioration of the very health care sector the policy would be aiming at boosting through such a policy.

The provision of universal health care would limit the freedom of the US citizens to choose which health care program is best for them. It is important to underscore that the United States, being a capitalist economy is composed of people of varying financial abilities.

The provision of universal health care would therefore lower the patients’ flexibility in terms of how, when and where to access health care services and why. This is because such a policy would throw many private practitioners out of business, thus forcing virtually all citizens to fit in the governments’ health care program, which may not be good for everyone (Niles 293).

Lastly not the least, the provision of universal health care would be unfair to those citizens who live healthy lifestyles so as to avoid lifestyle diseases like obesity and lung cancer, which are very common in America. Many of the people suffering from obesity suffer due to their negligence or ignorance of health care advice provided by the government and other health care providers. Such a policy would therefore seem to unfairly punish those citizens who practice good health lifestyles, at the expense of the ignorant (Niles 293).

After discussing the pros and cons of universal health care provision in the United States, I restate my thesis that “The government of United States of America should provide universal health care to its citizens because health care is a basic necessity to every citizen, regardless of age, sex, race, religion, and socio economic status”, and argue that even though there are arguments against the provision of universal health care, such arguments, though valid, are not based on the guiding principle of that health care is a basic necessity to all citizens of the United States.

The arguments are also based on capitalistic way of thinking, which is not sensitive to the plight of many citizens who are not able to pay for their insurance health care cover.

The idea of providing universal health care to Americans would therefore save many deaths and unnecessary suffering by many citizens. Equally important to mention is the fact that such a policy may be described as a win win policy both for the rich and the poor or middle class citizens because it would not in any way negatively affect the rich, because as long as they have money, they would still be able to customize their health care through the employment family or personal doctors as the poor and the middle class go for the universal health care services.

Balanced politics. “Should the Government Provide Free Universal Health Care for All Americans?” Balanced politics: universal health . Web. Balanced politics.org. 8 august https://www.balancedpolitics.org/universal_health_care.htm

Insurance specialists. “Growing Support for Universal Health Care”. Insurance information portal. Web. Insurance specialists.com 8 august 2011. https://insurancespecialists.com/

Niles, Nancy. Basics of the U.S. Health Care System . Sudbury, MA: Jones & Bartlett Learning, 2010:293. Print.

Shi, Leiyu and Singh, Douglas. Delivering Health Care in America: A Systems Approach . Sudbury, MA: Jones & Bartlett Learning, 2004:188. Print.

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IvyPanda. (2018, October 11). Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/

"Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." IvyPanda , 11 Oct. 2018, ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

IvyPanda . (2018) 'Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons'. 11 October.

IvyPanda . 2018. "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

1. IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

Bibliography

IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.