Each country has its own path to achieve UHC, which depends on existing structures, resources, political will and many other factors [41]; however, a tool designed in this study can be potentially used to track progress towards UHC irrespective of these differences.
As mentioned in the introduction, WHO and the World Bank had previously suggested tracer indicators that allow tracking progress towards UHC in any country. However, these indicators focus on achieving certain metrics of outputs and outcomes of the health system [5, 42, 43]. We aimed to complement this great work by developing a broader and more detailed framework that could provide additional insights into the process of such progress towards UHC, specifically by identifying potential factors that are impeding or advancing such progress. In comparison to other studies, the suggested tool is focused on the national health system as a whole and can incorporate ready available country specific data. Our framework incorporates tracer indicators suggested by the WHO, World Bank and the scientists and researchers, but contains additional dimensions, totally to eight: (1–2) social infrastructure and social sustainability; (3) financial and economic infrastructures; (4) population health status; (5) service delivery; (6) coverage; (7) stewardship/governance; and (8) global movements.
Social infrastructure and social sustainability (dimensions 1–2) seem to be influential factors in progress towards UHC: society literacy, community income, poverty, age group and population [201]. To reach social sustainability and providing social infrastructure, as well as providing sustainable development, political will and determination, technical skills and expertise and administrative cooperation are required. Political commitment can be a pivotal issue in progress to achieve UHC [79].
Economic conditions in a particular country (dimension 3) were identified as an important dimension of the tool and it is one of the main determinants of progress towards UHC. According to the studies conducted in Latin American countries, economic crises, high inflation and socio-economic inequalities can lead to a failure in progress towards UHC [61, 79]. To achieve UHC, some countries have adopted important policies and measures that led to integration of education and health policies in order to eliminate the barriers to achieving UHC [61, 79]. Social, economic, and political sustainability were already regarded as essential bases for health systems to achieve UHC [68]. The same studies have identified economic crisis and the inflation as the main causes of socio-economic problems [61, 79]. Countries can ease the work of achieving UHC by mitigating the consequences of the economic crisis [119], concentrating on achieving economic growth [61, 138, 161], and by increasing the GDP share of THE [121, 141].
A fundamental dimension that challenges any country in achieving UHC is financing [111, 138]. Financing includes three functions, such as revenue collection, pooling, and strategic purchasing [1]. Brazil [202], South Korea [203] and Thailand [4] have used strategic purchasing as a key policy instrument to achieve UHC goals of improved and equitable access and financial risk protection [40, 41]. Insurance agencies can alleviate unnecessary expenditures and out-of-pocket payments if they manage the strategic purchasing function well [204–207]. A fragmented pooling system may lead to disorders and is an obstacle in achieving UHC [121]. Previous studies have stated that the use of financial mechanisms such as pooling can reduce many of the financial problems of the health systems and thus are effective for progress towards UHC [4, 10, 208, 209].
According to Savadoff (2012), all countries that have achieved UHC have done so with significant involvement of the government in health care financing, regulation, and sometimes direct provision of health care services [4]. The most tangible and clear aspect of assessing the country’s progress towards UHC is the population’s current health status (dimension 4). Understanding the population’s health status of the country, epidemiologic and demographic transitions, correct assessment of the population’s health needs, can help resources prioritization and allocation according to the needs, as well as provision of necessary quality health services [56, 67, 158, 210, 211].
Service delivery (dimension 5) is another dimension of the suggested tool with four axes: basic benefit package, geographical access, quality of care and human resources for health. In regards to the benefit package axes, developing an affordable, sustainable, and equitable basic package of health care services that can serve various population needs is a challenge [212]. Studies have shown that people are more interested in the basic benefit package that covers inpatient and outpatient services with heavy costs [212–214]. By covering the basic healthcare needs and resulting into increased people’s satisfaction from healthcare system, it could be possible to narrow the health gap in the country [215].
Access to health care services is another axes of service delivery dimension to progress towards UHC that has been long neglected by many countries [15, 56, 216, 217], with only a few implementing appropriate interventions aimed to improve services provisions. This gap in access to health care services can be narrowed by removing the geographical barriers [57], assuring proper geographical distribution of the services [41], and by providing the necessary drugs [218].
Also, the efficiency of the health system is considered as an important fundamental function to providing health services and transitioning to UHC. In countries Brazil, Russia, India, China, South Africa and Laos that together account for approximately 40% of the world’s population, political and economic constraints, lack of trained and experienced human resources, large and powerful unofficial sectors, inefficient political leadership and government in planning, implementation, and management, and lack of sufficient resources related to the efficiency of the health system, are among the key underlying challenges in transition towards UHC [41, 120].
The sixth dimension of the designed tool focuses on population coverage, financial coverage, and service coverage. According to this dimension, adequate financial risk protection of the citizens that become ill is a major step in achieving UHC [92, 98, 113]. For this purpose, the fair financial contribution [117] and contributions in the form of prepayment mechanisms [110, 118] can be helpful. The insurance coverage of the country’ population is highly important in achieving UHC. Some studies have previously identified adequate insurance coverage as a primary condition necessary to guarantee achieving UHC [78, 94, 100, 219]. The insurance coverage has direct and indirect effects on other dimensions of UHC (e.g. quality of health care provision, catastrophic risk protection). Adequate health insurance system can prevent the catastrophic and impoverishing effects of the out-of-pocket payments and thus protect people from the financial burden of a disease [94, 220]. Different countries use different types of health insurance such as national health insurance [101, 221] and social health insurance [155] that covers and protects the population against financial risks [69, 110, 116].
In Southeast Asian countries, reductions of out-of-pocket payments, increasing accumulation of funding for health, tax-based health care sector financing, ensuring equitable distribution of human resources, and focusing on reduction of unnecessary health expenditure were identified as key mechanisms and tools in achieving UHC [63].
Increasing in the share of health spending that is pooled rather than paid out-of-pocket by households, prepayment options, and prepaid health care services have been shown to greatly influential on progress towards UHC [4, 90, 94, 100, 209, 222, 223]. In wealthy nations, such as Germany and the United Kingdom, almost 90% of health care sector financing is done through finance pooling. In middle-income countries such as South Korea and Malaysia that have achieved UHC and in countries like Brazil and Mexico that are about to achieve UHC, more than 65% of health funding is also raised through finance pooling [4]. Studies conducted in different countries have demonstrated that out-of-pocket payments and inaccessible or inadequate health services are the main barriers to achieving UHC [83, 84, 87, 90, 92, 94, 100, 152, 224, 225]. Our findings from the systematic literature review indicate that the social and economic sustainability are also main determinants of the progress towards UHC and affect the path and time of achieving UHC [13, 68, 148].
The dimensions of Stewardship & Governance (dimension 7) introduced in the tool have been raised with regard to the country's power of execution and political commitment both inside and outside the country. For this reason, the role of politics in effective movement towards UHC is a pivotal issue. Political support and legitimacy to create public plans and polices that expand access to health care services, improve equity, and pool financial risks are key factors in progress towards UHC [4]. Strong health care services delivery system based on comprehensive primary health care system facilitates easy access to quality health care services for all citizens. The economic power of a country plays a major role in its political commitment to realizing UHC [68, 226]. In 2014, major actors in Iran’s health care system sought to achieve UHC by investing political capital and economic resources in implementing the Health Transformation Plan as a highly effective and sustainable policy decision. Political sustainability was identified as the essential element of achieving UHC [68]. Achieving UHC requires a powerful and multilateral support at the very top of the country’s political system. The political and national commitment to support the healthcare system is a major influencing factor in implementing programs of UHC [51, 124, 141, 155].
Global movements (dimension 8) can be reflected by using two major axes: country’s international goals and international commitments in moving towards UHC by earmarking financial resources.
Learning from experience of countries that managed to successfully achieve UHC, other countries can deal with similar challenges. However, all strategies, policies, and programs in order to achieve UHC need to be tailored according to country’s circumstances and needs. Identifying the key determinants of UHC and carefully planning in accordance with them will strengthen the country's implementation activities, while helping avoiding the resource waste.
Our findings showed that in order to achieve UHC as a major development in public health, all influential factors should be taken into consideration, including economic growth, percentage of national income devoted to health, demographic characteristics, technologies, politics, health financing system, and health spending. Although the factors mentioned above can foster the progress to UHC, the absence of these factors can also negatively impact progress towards UHC.
Strengths and limitations
We believe that this proposed standalone tool can be further refined and adjusted following a bigger international study using experience and expertise of other countries. One of the limitations of our tool is that it cannot be used as a standalone measure in a static manner to measure progress towards UHC. The recommend using the developed tool in a dynamic manner to be able to show the trends and progress towards UHC. A need to tailor the content of the tool and its possible necessary adaptation and revision can also affect comparability across countries. Nonetheless, we believe that this limitation is also the tool’s advantage, as it provides usability, flexibility to be adapted by any country to account for its context, needs and existing structures.