The development of capable and adaptive governance arrangements is a hallmark of countries that have successfully achieved UHC. Countries such as Thailand prioritize accountability by implementing measures that separate the healthcare purchaser and provider functions, establish quality standards, develop a robust capacity for strategic goal-setting, and assess new technologies and pharmaceutical products for inclusion in benefit packages. To counteract interest group pressures, an oversight board with substantial civil society participation has been created.
In Thailand, reform advocates made strategic use of available evidence to generate locally relevant knowledge, drawing from both experience and the international literature, and were directly engaged in political processes or closely associated with them, demonstrating political acuity in the use of evidence. This approach ensured that evidence was swiftly available for decision-making while preventing decision-makers from becoming mired in excessive detail, which may be paralysing at times when rapid reforms are necessary.
Sequencing and pace of reforms
Sequencing approaches differ across countries. For instance, Thailand built coverage extension on earlier health system strengthening, while others prioritized boosting demand initially and later invested in the supply side.
Governments typically do not start with the goal of achieving UHC. Rather, UHC is reached through iterative reforms over time.
Whether to pursue gradual or rapid health system reforms is an inherently political, not technical, decision. Right-wing politicians often prefer gradual expansion based on voluntary insurance, seeking to neutralize more radical demands. By contrast, left-wing parties tend to view expansion as both an expression of political ideology and a means to secure popular support. Coalition governments, with their characteristic broader policy debates, can provide space for a wider range of actors, often favouring social insurance and gradual expansion.
Governments typically do not start with the goal of achieving UHC. Rather, UHC is reached through iterative reforms over time. Sometimes, a considerable period of time elapses between the initiation of reforms and the realization of UHC. Once achieved, however, UHC tends to be stable. A historical example of this longer trajectory is the UK, where mandatory health insurance for workers in 1911 expanded over decades, culminating in the National Health Service Act in 1946.
Similar patterns are observed in lower-income settings. In Thailand, the government initially moved into healthcare provision in 1975 to enhance care for the rural poor. In subsequent decades, coverage was extended to public sector workers and those in formal employment. After 2000, Thailand moved to UHC by offering a defined range of treatments, initially with limited user fees that were later eliminated.
Equity often becomes a focal point in later reform stages, particularly if the formal sector is covered first and reforms then slow down, excluding informal and poorer groups. Early interventions in the countries studied by McDonnell et al. covered vulnerable groups in about a third of cases, but later-phase strategies (89 per cent) consistently integrated the goal of reaching those left behind. The focus often shifted to expanding coverage to people in poverty, with specific attention to rural populations in several countries or targeting vulnerable groups such as children, pregnant women and people with disabilities.
Thailand’s post-crisis Universal Coverage Scheme (UCS) reform in 2001–02 was notable for rapid decision-making and implementation, capitalizing on a window of opportunity and preventing the consolidation of opposition. Subsequently, the pace of reform slowed, with gradual and incremental implementation characterized by flexibility. The context for reform in Nepal was different in the years following the 2006 Comprehensive Peace Agreement. Healthcare reforms in Nepal were iterative and took place over a more extended period, reflecting less opposition from organized groups and a less deliberate reform process.
‘Adaptive learning’ played a crucial role in the success of reforms in both Nepal and Thailand. This flexible approach enabled continuous improvements, responses to criticisms, and adaptation to emerging evidence. The evolution of China’s health reforms also highlights the importance of adaptive learning in avoiding early mistakes becoming entrenched and hardening opposition to reforms.
Consideration of path dependencies is essential. In Thailand, purchasing and provider payment reforms were strategically significant, with capitation (per-person fixed annual payments) chosen early on in an effort to overcome challenges associated with transitioning from fee-for-service payments. Early decisions on payment arrangements, private sector regulation and the development of risk pools can have lasting effects on the financial sustainability and equitable impact of UHC. Some countries, such as Ghana, have faced difficulties updating their initial healthcare benefits package, emphasizing the need for careful decision-making in these areas.
Stakeholders and political economy strategies used to manage reforms
UHC is inherently political, necessitating a thorough understanding of key actors and effective management strategies. Stakeholders in UHC reforms can be categorized based on their interest, position on the issue, and their power and influence. Key stakeholder groups include a ‘change team’, political leadership, bureaucratic actors, budget-related groups, beneficiaries, external actors and other interest groups.
A well-equipped change team, adept in both political and technical aspects, plays a crucial role in identifying windows of opportunity, particularly following crises, and mobilizing the necessary resources for reform. Witter underscores the significance of a dedicated reform group in Thailand within the Ministry of Public Health and the Health Systems Research Institute. The shape of the post-crisis UHC reform resulted from a convergence of political commitment, civil society mobilization and technical expertise. The change team seized the moment of political opportunity of 2000–01, aligning with the Thai Rak Thai party’s openness to radical social reforms. They conducted a comprehensive assessment of the financial and practical feasibility of UHC, gaining support from future prime minister Thaksin Shinawatra. The establishment of a ‘war room’ committee further facilitated coordination, monitoring and problem-solving during policy implementation.
Thailand’s UHC change team successfully mobilized crucial resources across bureaucratic, political and social spheres, employing effective strategies to drive the reform forward. Harris (2015) characterizes this as an instance of ‘developmental capture’, where networks of reformist bureaucrats within the state aim to advance inclusive state social and developmental policies for the broader population. Described as ‘the triangle that moves the mountain’, the strategy involves the simultaneous and synergistic mobilization of civil society and public support, political backing and the use of evidence and technical expertise. The case of Cyprus also underscores the pivotal role of popular pressure for reform following the economic crisis of the late 2000s.
UHC champions may have limited influence over the political settlement, but they can still influence UHC through the policy domain. Their understanding can help them to design strategies that align policies, funding and governance arrangements with the strengths and weaknesses in the current political settlement.
Political leaders at national and sub-national levels with vision and commitment are key for UHC reforms, but so too are mobilized interest groups and social movements. Government officials, political parties, the medical profession, organized labour, insurance and pharmaceutical companies, industrialists, the media and the general public are all key stakeholder groups. As regards organized opposition, a coalition involving clinicians, pharmaceutical companies and insurance systems, who perceive they benefit from the status quo, often resists publicly financed UHC. Conversely, trade unions, nurses and community health workers typically support enhanced public financing.
Reflecting on the UHC policies of Turkey and Thailand, Reich et al. (2016) emphasize the importance of both strong executive leadership and broad public support. Social movements played a pivotal role in Brazil and Thailand by placing UHC on the political agenda. Successes in these cases built on past experiences and institutions, offering opportunities to develop programmatic capacity. However, the authors underscore that relying solely on past experiences and new opportunities is insufficient; effective management of pressures from interest groups is crucial. In Turkey, reformers developed a comprehensive roadmap, identifying and strategically managing opposition from various groups, including civil servants, trade unions, social security and health workers. Public support was enhanced through measures such as abolishing the practice of detaining patients in hospital for non-payment of healthcare bills, reorganizing facilities for better patient care, expanding emergency services, establishing a new health workers’ union and introducing pay-for-performance incentives to improve quality of care.
The crucial role of evidence and information is highlighted in case studies of the UHC reforms in Thailand, Nepal and Indonesia.
Coalition building and enhancing policy legitimacy through approaches such as the Millennium Development Goals (MDGs) and rights-based methods (in Nepal) or traditional social values (in Thailand) are also highlighted. Uruguay’s successful UHC reforms relied on a diverse coalition, including non-medical workers, medical organizations, private providers and service users. Involving multiple stakeholders in policy design and implementation ensured the continuity of reforms beyond political cycles.
Mobilizing support, especially from civil society, and addressing opposition by meeting some of their demands were identified as significant strategies in both Thailand and Nepal. However, strategies to manage the opposition seemed more pronounced in Thailand, possibly anticipating resistance from the beneficiaries of existing schemes, from the Ministry of Public Health in view of its changing role, as well as from private providers.
Mobilizing support, especially from civil society, and addressing opposition by meeting some of their demands were identified as significant strategies in both Thailand and Nepal.
Case studies of UHC reforms from lower-income settings are more likely to highlight the influence of global development trends and role of donor organizations, albeit framed within a narrative of national ownership. Development partners played a vital role in providing technical and financial support, including evidence-gathering, and supporting policy adoption and adaptation. In Nepal, external actors had a more significant role, given the country’s weaker economic situation and greater aid dependency, necessitating consensus-building among donors. Thailand engaged with international actors differently; the change team leveraged international learning early on, and drew on external approval of the country’s work on UHC to embed reforms, notwithstanding initial concerns about affordability by institutions such as the World Bank.
International targets, notably the MDGs, provided normative impetus for UHC in various case studies, such as Nepal, where lagging behind on MDG 5 (targeting reduced maternal mortality, together with universal access to reproductive health) led to a focus on maternal healthcare. McDonnell et al. (2019) found a similar effect concerning the 1978 Alma-Ata Declaration, indicating that countries launching early healthcare strategies after Alma-Ata were more likely to align with its recommendations.
In Thailand, changes in decision-making processes to overcome challenges was highlighted by researchers as a key strategy on the part of reformers. Establishing bodies such as the National Health Security Board and the National Health Assembly not only garnered support for reforms, but also influenced the scope of future reforms. Dialogue in Thailand involved seeking common goals, reflecting opposition demands, and emphasizing compromise, negotiation and strategic participation. Flexibility and a ‘win-win’ narrative were crucial, while maintaining focus on reform goals prevented drift.
The literature suggests that dissatisfaction and political pressure for radical change persist until countries achieve universality in their health coverage. Post-universality, health becomes a significant government component but with more confined debates. Rather than ideological questions, discussions focus on iterative reforms and operational aspects of the health system.
UHC and wider outcomes
The outcomes of UHC reforms are critical indicators of success, and are described in a number of studies. There is a problem relating to the counterfactual. As UHC tends to be a whole-of-system reform, there is no control to assess what would have happened in its absence. Nonetheless, key points emerging from the literature include the following:
- Literature and case studies all illustrate the potential for UHC reforms to significantly increase health coverage, improve the quality of care and financial protection, as well as reducing health and wider inequalities and improving health outcomes, such as life expectancy.
- Countries examined for this report have typically injected around 1 per cent of GDP of additional public financing into their health systems to improve the supply side and improve access during their UHC reforms.
All the countries examined in the case studies conducted as part of the research for this report demonstrated the improved service coverage achieved by UHC reforms, alongside measures that boost the capacity of the system to sustain services, such as increasing public staffing and infrastructure (as, for instance, in Cyprus) and strengthening information systems (as in Ukraine).
Thailand’s UHC reforms, in the first decade of UCS implementation, resulted in improved access to essential health services for citizens, especially for the poor, along with a decrease in catastrophic expenditures and household impoverishment for health service users, and increased satisfaction of both UCS beneficiaries and healthcare providers. And over the period 2000–19, the country’s health expenditure per capita grew significantly, from $62 to $296, accompanied by substantial increases in government spending on health (which rose as a percentage of total health expenditure from 55 to 72 per cent). Meanwhile, OOP payments dropped from 43 per cent of total health spending to less than 9 per cent, providing better financial protection for service users.
China’s UHC reforms demonstrate the extensive benefits of well-designed reforms, including notable increases in coverage. Medical insurance coverage surged from 50 per cent in 2006 to 96 per cent in 2015 for urban residents, and from 48 per cent to 98 per cent for rural residents. OOP health costs plummeted from 61 per cent of total health expenditure in 2003 to 29 per cent in 2018, while government health spending rose from 1.3 per cent of GDP in 2003 to 2.5 per cent in 2013.
Uruguay also experienced substantial increases in coverage, leading to a reduction in OOP spending from 22 per cent in 2005, when the country embarked on its UHC reform programme, to 15 per cent in 2022.
Greater government expenditure on health has been an important element in expanding UHC, although increases have in many cases been modest. Overall health spending in Uruguay rose from 8.5 per cent of GDP in 2005 to 9.5 per cent in 2018, with public spending on health increasing to 6 per cent of GDP. In Rwanda, a significant expansion in health coverage saw health expenditure, as a share of GDP, grow from 1.6 per cent in 2005 to 2.9 per cent in 2020.
However, UHC is not necessarily about spending more. Rather, it is about spending the same money better: pooling payments potentially enables more cost-effective purchasing and allocation. While few studies directly compare health system costs before and after UHC reforms, cross-sectional analyses consistently support the idea that systems with higher public financing and effective coverage yield better outcomes for similar expenditures, reflecting greater efficiency.
This feeds through into health gains. Over the period 1995–2008, a 10 per cent increase in government health spending across 153 countries was associated with average reductions of 7.9 deaths per 1,000 for children aged under five years, and adult mortality by 1.3 deaths per 1,000. There can also be gains in relation to equity: in Thailand, for example, the introduction of a universal coverage scheme resulted in equalization of infant mortality rates across poorer and richer provinces between 2001 and 2005. An OECD study also highlights positive correlations between population health coverage and life expectancy, with a clear negative relationship between OOP payments and life expectancy, under-five mortality and maternal mortality.
UHC can play a protective role against shocks, with evidence that countries that have made greater progress towards UHC experienced significantly smaller declines in childhood immunization coverage in 2020 during the COVID-19 pandemic. UHC also contributes to system resilience amid extreme shocks. The case of Ukraine, following Russia’s 2022 invasion, is notable in this respect.
