Drawing on literature and country case studies, our work examines how and when shocks and crises have enabled UHC reforms, and what lessons can be drawn from global experience to support future transitions to UHC.
Focus and core questions
For the purposes of understanding the role of crises in potentially enabling UHC reforms, the research team, supported by the Commission for Universal Health, focused on acute events at national and subnational levels, and examined the relationships between crisis situations and the likelihood of UHC reforms. It hypothesized that crisis events may create a window of opportunity for policy realignment and reforms. Encompassing conflict-related situations, public health emergencies, natural disasters, and economic and social crises, the analysis sought instances of substantial policy shifts targeting increased UHC.
Our key questions were:
- What is the relationship between UHC reforms and crises and shocks of various kinds? To what extent, and how, have shocks and crisis triggered or enabled UHC reforms?
- What contextual factors and strategies have enabled crises and shocks to be used to catalyse or enable UHC reforms? What lessons can we draw from global experience to support future UHC reforms?
The analytical framework considered the relationship between context, shocks and the impact that these have, using Kingdon’s ‘multiple streams’ approach to analysis of problem, policy and politics. Following Kingdon, the central hypothesis was that for reforms to be implemented successfully, perceptions of the urgency of the problem, the availability of policies to address that problem, and a supportive constellation of actors need to converge, creating windows of opportunity for change. This guided the analysis to focus on the following:
- Context and problem: To what extent and how have shocks and crisis triggered or enabled reforms towards UHC? What was the state of health coverage prior to the crisis or shock? What contextual factors enable crises and shocks to be used to catalyse or enable UHC reforms? What contextual factors make reform more challenging?
- Policy and institutional reforms: How have countries’ policies and strategies, in response to crises and shocks, transitioned towards UHC? What are the characteristics and trajectories of UHC policy and institutional reforms in countries experiencing shocks? How have crises influenced these trajectories, and what lessons do these generate?
- Stakeholders and politics: Which stakeholders supported or opposed policy reforms, and why? How were their positions influenced by crisis – i.e. how did it change their interests, power and ideological framings? How were these different stakeholders managed in order to ensure the eventual reforms were effective?
- Outcomes: To what extent, and how, have the reforms improved progress towards UHC? What lessons can be drawn to support future UHC reforms in other countries experiencing crises and shocks?
Literature review
We undertook a rapid scoping of grey and published literature on UHC reforms following crises and shocks, focusing on understanding factors that favour or block reforms, and drawing lessons on strategies for making effective use of potential windows of opportunity.
Search terms included:
- Crisis; OR shock; OR conflict; OR natural disaster; OR epidemic; OR pandemic; OR disease outbreak; health emergencies; humanitarian
- AND universal health coverage; OR health systems; OR health services; OR healthcare; OR health security; OR public health; OR health reforms; OR health financing; OR political economy
Databases included Google Scholar and PubMed. The team also searched the websites of organizations active in this area of work, including the World Health Organization (WHO), the World Bank and the Organisation for Economic Co-operation and Development (OECD), and identified relevant work in the reference lists of included studies. Members of the Commission for Universal Health were also approached to provide an overview of known literature.
Selection criteria for identified literature reflected the definitions and boundaries laid out above, and included empirical studies (multiple or single case studies) as well as conceptual literature if it focused on the issues of interest. No language or time restrictions were imposed, but only English-language search terms were used.
Data extraction: An initial descriptive analysis of the data was conducted by extracting data from documents, using a thematic content-analysis approach. An extraction matrix and a coding tree were developed for this purpose, mostly based on pre-identified themes but also with additions of emerging codes and themes as the extraction was under way (deductive/inductive approach).
Analysis: Findings are structured around the analytical framework developed (Figure 1), which emphasizes trying to assess (i) how crises and shocks of different types modify the political, ideological and technical options for reforms; and (ii) the interaction of political economy and technical strategies for advancing the reform agenda post-crisis.
Country case studies
In addition to the literature review, the authors developed country case studies, drawing on both published sources and on commissioners’ personal experiences and knowledge of countries where crises and shocks of various types have triggered UHC reforms. The countries selected for the case studies – Brazil, China, Cyprus, Rwanda, Thailand, Ukraine and Uruguay – spanned a number of regions and income levels.
