Protocol: How Has Sustainable Development Goals Declaration Inuenced Health Financing Reform Processes for Universal Health Coverage at the Country Level? A Systematic Review of Literature

Achieving universal health coverage (UHC) is necessitating reforms in the way countries nance health systems. However, health nancing reforms (HFR) are inherently political and SDGs declaration is a political one. Therefore, the terrain where efforts for reforming health nancing occurs is likely being inuenced by the SDGs declaration. However, how the SDGs have inuenced health nancing reform processes at the national level, the outcomes of these processes and how stakeholders especially ministries of health are using SDGs to inuence reforms towards UHC have not been explored. This review is proposed to provide information and lessons on how SDGs have inuence health nancing reforms for UHC at national level and identify methodological and empirical gaps in studies exploring the relationship between SDGs and health nancing reforms for UHC.


Abstract Background
Achieving universal health coverage (UHC) is necessitating reforms in the way countries nance health systems. However, health nancing reforms (HFR) are inherently political and SDGs declaration is a political one. Therefore, the terrain where efforts for reforming health nancing occurs is likely being in uenced by the SDGs declaration. However, how the SDGs have in uenced health nancing reform processes at the national level, the outcomes of these processes and how stakeholders especially ministries of health are using SDGs to in uence reforms towards UHC have not been explored. This review is proposed to provide information and lessons on how SDGs have in uence health nancing reforms for UHC at national level and identify methodological and empirical gaps in studies exploring the relationship between SDGs and health nancing reforms for UHC.

Methods
We propose a systematic review of literature and shall adhere to preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. We shall search 5 databases (Ovid Medline, PubMed, EBSCO, Scopus and Web of Science) and grey literature. Boolean operators "OR" and "AND" will be used to combine the concepts of sustainable development goals and health nancing. The literature to be reviewed will be those on health nancing reforms (population), one of the factors in uencing the reform is SDGs declaration (exposure/intervention), and there is change in a health nancing function (outcome). Identi cation and selection of studies shall be done in duplicate using a prede ned tool, the overall process shall be depicted in a PRISMA ow chart. Quality assessment will be conducted using Joanna Biggs Institute checklist. Data shall be managed in NVIVo, where a thematic synthesis of data will be conducted. The results will be presented narratively.

Discussion
We shall share our nding with relevant stakeholders through workshop and publications. The SDGs declaration is relatively new, how it is in uencing health nancing reforms towards UHC at national level needs to be documented and shared for cross-country learning by stakeholders involved in this area. In addition, the review is anticipated to provide information on the methodological and/or empirical gaps in studies exploring the linkage between SDGs declaration and health systems reforms.

Background
Global declarations shape public policy priorities and guide development nance ows (1)(2)(3). The declarations usually energize governmental processes and provide reference point that guides national policies toward priority development issues. Therefore, global and regional declarations can be powerful tools for shaping policy and programme response on issues that are of public concern (4). In September 2015 in New York, the United Nations (UN) member states leaders, meeting under the theme, "Transforming our world: the 2030 Agenda for Sustainable Development", adopted 17 sustainable development goals (SDGs) as the post millennium development goals (MDGs) development blue print (5). Health is explicitly addressed in paragraph 26 of the SDGs declaration (6): To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind... Achieving universal health coverage (UHC) is one of the overarching targets of the 2030 agenda for sustainable development. Universal health coverage is based on the precept that all people should have access to health services they need and do not suffer nancial hardship while accessing the services (7). This implies, an effective, e cient and equitable health nancing system is a critical and essential component that contributes to achievement of UHC target under the SDGs declaration (8)(9)(10)(11). Health nancing in uences progress on the three UHC goals of equity in the use of health services, quality of care and nancial protection through effects on UHC intermediary objectives of transparency and accountability, e ciency and equity in resource distribution (8,12). Therefore, health nancing is central to efforts to improve health and health systems, because it is only when resources are adequately, e ciently and equitably mobilized, pooled and spent that all people can enjoy sustained progress towards UHC (13,14).
For many countries achievement of UHC require reforms in health nancing system so that people have nancial protection while accessing quality health care (15). Therefore, a number of countries in the African region have been attempting to reform the way health is nanced to ensure sustainable progress towards UHC (15)(16)(17)(18)(19). However, these attempts, largely spearheaded by Ministries of Health have been slow and interruptive as re ected in the slow and/or forward and backward movements in the reform processes (16,(20)(21)(22). The process of introducing comprehensive National Health Insurance Schemes (NHIS), has been ongoing in the last 2 to 3 decades in Uganda, Kenya, Zambia and South Africa (16,(20)(21)(22)(23)(24). In South Africa, Uganda, Kenya and Zambia Health Insurance Bills were (or have been) drafted, however they have not reached parliament or where the parliament approved the Bills, they never became Acts due to failure by the Executive arm of governments to ascent to the Bills or the process took very long (22,25,26).
The terrain where various efforts for strengthening or reforming health nancing systems occur may be different with the SDGs declaration. This is because health nancing reform is a political process, and SDGs is a political declaration, with UHC one of its targets. Effective, e cient and equitable health nancing systems are critical for achievement of UHC (27,28). Therefore, given the overarching importance of UHC as an SDG target, it is likely that the declaration has in uenced health nancing reforms and if so, the effects should be noticeable in changes to organization and management of subfunctions of revenue collection, pooling, purchasing, and policies on bene ts and rationing. However, there are no systematic studies documenting how the declaration has in uenced health nancing towards UHC. Particular country experiences of how SDGs declaration has in uenced health nancing reforms for UHC can provide valuable lessons to stakeholders attempting to do the same in their countries. Given that the SDGs declaration is a relatively recent event, this review shall also provide insights on the methodological and empirical gaps in studies that explores its in uence on health system nancing reforms for UHC. In addition, this study will contribute broadly to the call by the World Health Organization (WHO) in 2013 of the need for evidence based research to inform initiatives that advance UHC (29).

Study design, review questions and de nitions
We propose a systematic review of literature and will report on how SDGs declaration has in uenced health nancing reforms for UHC. Systemic review has a lower risk of bias in information synthesis compared to other review approaches (30). This protocol has been registered on the PROSPERO database (ref: CRD42020194090). PROSPERO was searched to ensure a similar systematic review study protocol has not been registered.
For this review, health nancing reforms for UHC is conceptualized to refer to changes in policy objectives, strategies, or in arrangement and management of health nancing system sub-functions of revenue collection, pooling, purchasing, and bene ts design and rationing towards e cient and equitable system (31). These reforms should have linkage or can be attributed to global discussion on sustainable development Agenda or SDGs declaration.
In line with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guideline (32), we have de ned the review questions; we shall also identify, select and appraise the documents, abstract and synthesize data, and interpret the results. The review questions are: -a) How has SDGs declaration in uenced the processes of health nancing reform for UHC at national level? b) What dimensions of health nancing system have been in uenced by SDGs declaration? and c) How have Ministries of Health and other stakeholders used SDGs declaration so far to in uence health nancing reforms for UHC?
Criteria for considering studies for this review All study designs will be considered for the review to account for the complex nature of health nancing reforms. Speci cally, we will include randomized and non-randomized studies, evaluation studies, policy analyses, stakeholder analyses, and peer-reviewed case studies and commentaries. Proposals and studies published in abstracts only will be excluded.
The inclusion criteria will be based on population, intervention (exposure) and outcomes (PEO) elements (33). That is, the document to be included for review: (i) is on health systems reforms, or other government reforms where health nancing is a part of the reform process, or is speci cally on health nancing reforms, and is published from 2012 onwards i.e. studies conducted after the 2012 Rio de Janeiro United Nations Conference on Sustainable Development, where the process of developing SDGs was initiated. They will form the study population; (ii) describes how sustainable development goals declaration has in uenced reforms in health systems nancing for UHC as the intervention; and (iii) reports on changes to at least one of the following health nancing dimensions of management or organization i.e. revenue collection, pooling, purchasing and policy on bene ts design and rationing as the outcomes.
Search methods for identi cation of studies Databases search: A comprehensive electronic search will be conducted using indexed and free text words in the following databases: Ovid Medline, PubMed, EBSCO, Scopus, Web of Science. Previous experience has demonstrated to us that searching 5 databases on such a topic is adequate and the process of searching additional databases does not usually yield new documents. In searching the electronic databases, we shall combine various conceptual terms for "sustainable development goals" and "health nancing". We will use the Boolean operators 'OR' to combine the terms within each concept and 'AND' to combine the two concepts. We will not use search lter for study type, language (we will use the google translate for non-English articles), country or geographical area in order to nd as many studies on the topic as possible. The search strategy will be validated by a librarian.
Other searches: In addition, we will screen the reference lists of included studies and contact the authors of relevant articles for further information or additional material as necessary; and conduct manual search for relevant articles from publications on websites of WHO, journals (health system reforms, health policy and planning, UHC2030 partnership), and from search engine google scholar. This is likely to yield additional pool of relevant literature.

Pilot search
In order to gauge the viability of this review, a pilot electronic search was conducted on PubMed on 2 nd June 2020 using the search strategy described under Search methods for identi cation of studies above. The search string was as below: -Search: (((((((((((((((((((((((Health Financing Reform*) OR (Health system* nancing)) OR (Health system* nancing reform*)) OR (Health nancing system*)) OR (Health nancing system* reform*)) OR (Financing health system*)) OR (Financing healthcare)) OR (Financing health care)) OR (Health system* reform*)) OR (Health care reform*)) OR (Healthcare reform*)) OR (Health reform*)) OR (Reforming health nancing)) OR (Reforming health system* nancing)) OR (Reforming health care nancing)) OR (Reforming healthcare nancing)) OR (Reforming health)) OR (Reforming healthcare)) OR (Reforming health care)) OR (Reforming health system*)) OR (Reforming healthcare system*)) OR (Reforming health care system*)) OR (Health nancing)) AND (((((((((((((sustainable development goal*) OR (SDG*)) OR (Sustainable development goal*3)) OR (SDG 3)) OR (UN development blueprint)) OR (United Nations development blueprint)) OR (global development agenda)) OR (2030 development agenda)) OR (2030 agenda)) OR (post millennium development goal*)) OR (Post-MDG*)) OR (Post MDG agenda)) Filters: in the last 5 years, Humans The search yielded 692 potential articles and from initial screening of titles and abstracts 69 articles were considered potentially eligible. Of the 69 titles and abstracts, 1 was in Chinese and 1 in Spanish, the rest were in English. Of the 69 articles potentially eligible, we were able to retrieve 68 articles, the exception being the one published in Chinese. The article in Spanish was translated using google scholar. After review of full length articles of the 68 articles, 2 articles were found to meet our eligibility criteria (Table   1). This pilot search process has indicated the potential availability of relevant literature for review.

Study selection
All retrieved articles will initially be exported to EndNote software X9 (36), where duplicates shall be removed. After removing duplicates, the EndNote library will be shared between two reviewers where the selection process will be conducted in two phases. Firstly, the two reviewers will screen the titles and abstracts of identi ed articles independently for potential eligibility and retrieve the full text of articles judged as potentially eligible. Secondly, full text retrieved will be screened by the two reviewers for eligibility using a standardized screening form (attachment 1). Disagreements will be resolved by discussion or with the help of a third reviewer.
Reviewers have undertaken a calibration exercise and re ned the eligibility screening tool using results from a pilot search conducted on PubMed aforementioned. This calibration exercise has been undertaken to facilitate uniform application of eligibility criteria across reviewers. This will enhance the validity of our process and minimize bias in identi cation and selection documents for review. In order to improve transparency of the review process we will depict the overall selection process of documents and reasons for inclusion and exclusion in a ow chart in line with the PRISMA statement (37). The full texts of all relevant studies found to meet the inclusion criteria will be retained for the nal synthesis (38). For articles that will fail to meet the inclusion criteria at the full-text screening phase, reasons for their exclusion from analysis will be documented.

Data extraction
Two reviewers will abstract data from eligible articles independently using standardized data abstraction form adapted from the Joanna Briggs Institute (JBI) data abstraction format (Attachment 2) (39). A calibration exercise will be conducted on a randomly chosen sample to ensure adequate agreement, and disagreement will be resolved by consensus or with the help of a third reviewer if consensus is not reached. Study characteristics to be extracted will include: the bibliographic details of study (study title, author, year of publication), objectives (purpose of the study), study design, setting (country); in uence of SDGs declaration on health nancing reforms; the dimension or aspect of health nancing system reformed; and how Ministries of Health and other stakeholders have used SDGs declaration to drive health nancing reforms for UHC.

Appraisal of studies
We shall not carry out assessment of risk of bias for the included articles for this review. This is because, existing tools for critically appraising of studies for reviews is still contested and have strong limitations, especially for qualitative studies (40). However, we shall assess the quality of the included studies.
Retrieved articles eligible for inclusion will undergo a quality assessment process during the synthesis of results. The quality appraisals will be conducted using the Joanna Briggs Institute's Critical Appraisal Checklists (see attachment 3, an example of the JBI checklist for qualitative studies). Two reviewers will conduct the quality appraisals, where there are disagreements, a third reviewer will be engaged and discussions among the three reviewers will be used to resolve the differences. The results will help us to determine if studies included are consistent with the standard quality appraisal for articles reporting on the type of study. Quality assessment will also be used for judging the relative contribution of each study to the development of explanations and relationships between SDGs declaration and health nancing reforms. It has been noted that poorer quality studies tend to contribute less to the synthesis and therefore, the synthesis becomes ''weighted'' towards better-quality studies (40).

Synthesis and Interpretation of results
We shall use NVIVo and a thematic framework (Attachment 4) to facilitate analysis. Thematic framework synthesis is a qualitative approach that involves selecting, recording and categorizing key issues and themes (41). For each article, the process will involve familiarization with information, identi cation, recording, categorization and interpretation of the in uence of SDGs on health nancing reforms, and how Ministries of Health and other stakeholders have used the SDGs to advance health nancing reforms towards UHC. On the effects of the reform occasioned by SDGs declaration on health nancing system, we will use Kutzin's conceptual framework for analyzing health nancing systems (8). In using Kutzin's framework we shall focus on changes in the organization and/or management of functions of revenue collection, pooling, purchasing and policy on bene ts. The results on the three review questions will be presented narratively.

Discussion
Our reporting will be aligned to the PRISMA guidelines. The report will be shared with relevant stakeholders through workshop presentations, policy briefs and journal publication. We anticipate a limitation related to nding adequate number of studies reporting on reforms in health nancing in countries that have been driven by SDGs declaration. The reform processes usually take time, the SDGs declaration was only effected towards the end of 2015. We shall address this by not restricting search by country, language or study design, and searching gray literature as described under methods. Despite this anticipated limitation, the proposed review will still be a valuable addition to the eld of health policy and systems research as it will be the rst systemic review exploring the linkage between SDGs declaration and health nancing reforms at the national level. The review will also provide information on the methodological and/or empirical gaps in the area. WDO, FS, and CH participated in discussing and developing the idea into a concept. WDO wrote the initial protocol, while FS and CH advised on the search strategy. FS and CH appraised the draft protocol, reviewed and approved nal version for publication. All authors read and approved the nal manuscript.