Farsaci Liz, Fleming Padraic, Caffrey Louise, Belle Sara Van, O'Donoghue Catherine, Almirall-Sanchez Arianna, Mockler David, Thomas Steve
Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
School of Social Work and Social Policy, Trinity College Dublin, Dublin, Ireland.
Int J Health Policy Manag. 2025;14:8709. doi: 10.34172/ijhpm.8709. Epub 2025 May 19.
The journey towards universal health coverage (UHC) began decades ago but has recently moved to centre stage in global health discourses with its inclusion in the Sustainable Development Goals (SDGs). As part of this renewed interest, 193 countries have committed to introducing UHC by 2030. However, its implementation often necessitates far-reaching health system reforms. This, coupled with the struggles countries face in relation to health financing, as well as distinct political, social and cultural contexts, means there are significant challenges to UHC implementation. This article contributes new knowledge to these discourses by identifying key contexts and mechanisms that facilitate the successful implementation of UHC reforms, as well as barriers that can impede progress.
This realist review identifies key contexts and mechanisms that can facilitate the successful implementation of UHC reforms. EMBASE, MEDLINE and Web of Science were searched (1995-2022), resulting in 957 articles with the protocol published through Prospero (PROSPERO 2023: CRD42023394427). Further theory-driven searches resulted in an additional 988 studies. Descriptive, inductive, deductive, and retroductive realist analysis aided the development of Context-Mechanism-Outcome Configurations (CMOCs), along with stakeholder engagement to confirm or refute results. Causal pathways, and the interplay between contexts and mechanisms that triggered outcomes, were revealed.
How each country goes about implementing UHC reforms depends on its context. Cohesion across all systems, as well as the functions of financing, governance and service delivery, facilitates these reforms. Implementation can also be facilitated through political commitment, communication between stakeholders in the public health system and the development of a strong primary care sector. Conversely, fragmentation across these functions pose significant barriers to UHC reforms.
Examining international experiences of UHC reforms supports learning around the mechanisms that support or hinder implementation processes. These learnings can empower policy-makers and health system leaders by providing roadmaps for reform implementation.
实现全民健康覆盖（UHC）的征程始于数十年前，但随着其被纳入可持续发展目标（SDGs），最近已成为全球卫生讨论的核心议题。作为这一重新兴起的关注的一部分，193个国家已承诺到2030年引入全民健康覆盖。然而，其实施往往需要进行意义深远的卫生系统改革。这一点，再加上各国在卫生筹资方面面临的困难，以及不同的政治、社会和文化背景，意味着全民健康覆盖的实施面临重大挑战。本文通过确定促进全民健康覆盖改革成功实施的关键背景和机制以及可能阻碍进展的障碍，为这些讨论贡献了新知识。
本现实主义综述确定了可促进全民健康覆盖改革成功实施的关键背景和机制。检索了EMBASE、MEDLINE和科学引文索引（1995 - 2022年），结果得到957篇文章，其方案通过国际系统评价前瞻性注册库（PROSPERO 2023：CRD42023394427）发表。进一步的理论驱动检索又得到988项研究。描述性、归纳性、演绎性和逆向现实主义分析有助于形成背景 - 机制 - 结果构型（CMOCs），并通过利益相关者参与来证实或反驳结果。揭示了因果途径以及触发结果的背景与机制之间的相互作用。
每个国家实施全民健康覆盖改革的方式取决于其背景。所有系统之间的凝聚力以及筹资、治理和服务提供的功能，有利于这些改革。政治承诺、公共卫生系统利益相关者之间的沟通以及强大的初级保健部门的发展也可促进实施。相反，这些功能的分散对全民健康覆盖改革构成重大障碍。
审视全民健康覆盖改革的国际经验有助于了解支持或阻碍实施过程的机制。这些经验可为政策制定者和卫生系统领导者提供改革实施路线图，从而增强他们的能力。
