Institutional assembly under constraints: pathways to universal health coverage in Brazil, Rwanda, and China

Area of Science:

• Global Health
• Health Systems Research
• Comparative Health Policy

Background:

• Classical health system models are often developed in high-income settings.
• Developing countries face unique challenges in pursuing universal health coverage (UHC).
• Existing frameworks may not fully capture the complexities of UHC pathways in diverse national contexts.

Purpose of the Study:

• To examine UHC strategies in Brazil, Rwanda, and China, moving beyond traditional high-income models.
• To introduce and apply the concept of 'institutional assembly under constraints' as a framework for understanding UHC.
• To analyze how fiscal capacity, labor markets, and administrative reach shape health system development.

Main Methods:

• Comparative case study analysis of Brazil, Rwanda, and China.
• Examination of health financing, provision, and governance mechanisms in each country.
• Application of the 'institutional assembly under constraints' framework to interpret findings.

Main Results:

• Brazil: Tax-funded public financing ensures free access, but limited spending creates a dual public-private system.
• Rwanda: Subsidized community-based insurance extends coverage, but relies on donor and household contributions.
• China: Segmented insurance schemes achieve scale but result in regional fragmentation.
• All cases demonstrate distinct 'institutional assembly under constraints', blending global frameworks with local innovation.

Conclusions:

• No single UHC pathway is universally applicable; context is critical.
• Health systems are built through selective adaptation and innovation within specific constraints.
• The 'institutional assembly under constraints' framework offers valuable insights into UHC development in resource-limited settings.