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Barriers and Facilitators to International Universal Health Coverage Reforms: A Realist Review
Liz Farsaci1, Padraic Fleming1, Louise Caffrey2
1Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
International Journal of Health Policy and Management
|August 6, 2025
Summary
Implementing universal health coverage (UHC) reforms requires understanding country-specific contexts. Cohesive health systems, political commitment, and strong primary care facilitate UHC, while fragmentation hinders progress.
Area of Science:
- Global Health
- Health Policy
- Health Systems Research
Background:
- Universal health coverage (UHC) is a key global health goal, included in the Sustainable Development Goals (SDGs).
- 193 countries are committed to achieving UHC by 2030, necessitating significant health system reforms.
- Implementation faces challenges due to financing, political, social, and cultural contexts.
Purpose of the Study:
- To identify key contexts and mechanisms facilitating UHC reform implementation.
- To uncover barriers impeding progress in UHC reform efforts.
Main Methods:
- Realist review of literature from EMBASE, MEDLINE, and Web of Science (1995-2022).
- Theory-driven searches and realist analysis to develop Context-Mechanism-Outcome Configurations (CMOCs).
- Stakeholder engagement to validate findings on causal pathways and interplay of factors.
Main Results:
- UHC reform implementation is context-dependent.
- Cohesion in health financing, governance, and service delivery facilitates reforms.
- Political commitment, stakeholder communication, and strong primary care are facilitators; fragmentation is a barrier.
Conclusions:
- International experiences offer valuable lessons for UHC reform implementation.
- Findings provide actionable roadmaps for policymakers and health system leaders.
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