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Health Financing Assessment and Policy

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DOI: 10.5539/gjhs.v9n5p131

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 Global Journal of Health Science; Vol. 9, No. 5; 2017
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education

Health Financing Assessment and Policy Analysis toward Universal

Health Coverage: A Systematic Review of Qualitative Research
Minoo Alipouri Sakha1, Arash Rashidian1, 2, Mohammad Bazyar3,, Ali Akbari Sari1,
Shahram Yazdani4 & Abbas Vosough Moghadam5
1
Department of Health Management and Economics, School of Public Health, Tehran University of Medical
Sciences, Tehran, Iran
2
Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences,
Tehran, Iran
3
Department of Health Education, Ilam University of Medical Sciences, Ilam, Iran
4
Department of Medical Education, School of Medical Education, Shahid Beheshti University of Medical
Sciences, Tehran, Iran
5
Health Policy Making Secretariat, Ministry of Health and Medical Education/NCD Research Center, Endocrine
and Metabolism Research Institute, Tehran University of Medical Sciences and Health Services, Tehran, Iran
Correspondence: Arash Rashidian, Department of Health Management and Economics, School of Public Health,
Tehran University of Medical Sciences, Tehran, Iran. Tel: 98-021-8898-9129. E-mail: arashidian@tums.ac.ir,
arash.rashidian@gmail.com

Received: July 31, 2016 Accepted: September 5, 2016 Online Published: September 28, 2016
doi:10.5539/gjhs.v9n5p131 URL: http://dx.doi.org/10.5539/gjhs.v9n5p131

Abstract
Background: The aim of this research was to explore policy options from assessing health financing policies
toward universal health coverage so as to identify issues that need to be addressed and approaches that can
fruitfully be pursued in future policy design.
Methods: We systematically searched the following databases: PubMed, SCOPUS, and COCHRANE up to
January 2016 and included health financing policy assessment toward universal health coverage. These searches of
scientific databases supplemented by the eligible reports available online. Two authors appraised the identified
studies. A thematic and descriptive synthesis of data was undertaken.
Results: Twenty three papers in total served the scope of our review. We categorized dimensions that were
important in health financing assessment to achieve UHC into nine groups as follows: stewardship, Raising
Revenues and contribution methods, risk pooling and financial protection, Resource allocation& purchasing,
human resources, policy stakeholders, Policy content, Policy context, and Policy process
Conclusion: As countries commit to expand universal health coverage, the dimensions identified from the
literature can help policy makers to prioritize competing demands, make rational choices, and adapt their
approaches. Policy transfer and adapting them to local condition help governments make better policy decisions,
and proceed sensibly in the face of challenges.
Keywords: health financing, universal health coverage, systematic review
1. Introduction
Universal health coverage as “the single most powerful concept that public health has to offer” has been defined as
access to all needed health services of sufficient quality, without incurring financial hardship (World Health
Organization [WHO], 2010; Xu, Huang, & Colón-Ramos, 2015). Health financing as one of the structural aspects
of health systems to achieve improved health outcomes, equity, and public satisfaction, play an essential role in
universal health coverage (Stuckler, Feigl, Basu, & McKee, 2010; Tangcharoensathien, Mills, & Palu, 2015). It
includes three interrelated functions: mobilization and collection of funds, pooling of prepaid funds, and allocation
of resources, including purchasing and paying for services (WHO, 2000).
Health care policy makers around the world are faced with increasing difficulties to sustain sufficient financing for
health care (Ekman, 2004). Tens of millions of people the world over either do not have access to health care
services they need or they have to pay for it, which are catastrophic or impoverishing (WHO, 2010). Accordingly,

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the demographic and epidemiological transitions taking place around the world, aging populations, and greater
prevalence of chronic diseases are major challenges to health. Consequently governments have responded them
through political commitments to adopt legislation mandating universal access to services, regardless of level of
income or ability to pay (Savedoff, 2012; Stuckler et al., 2010).
Countries are at different stages in the development of their health financing systems towards achieving UHC.
While each country has its own unique set of challenges, each country’ experiences would offer valuable lessons
regarding common challenges faced by other countries (WHO, 2010; Ahmed et al., 2013; Gottret, Schieber, &
Waters, 2008; Maeda & Naoki Ikegami, 2014). They have undertaken different policy analysis and health
financing assessment, based on a common analytical framework or a policy analysis model to identify key factors
and different pathways that promote or hinder universal health coverage (Kutzin, 2012). Different disciplines
ranging from economics, political sciences and institutional theories are used to analyze health financing systems
(Stuckler et al., 2010). The political economy and policy process context cause differences in the financial
arrangement of health (Ha, Frizen, Thi, Duong, & Duc, 2014; Maeda & Naoki Ikegami, 2014; May Kyi Lwin,
2015).Considerations of politics and multiplicity of stakeholders shape the decision of a country’s leaders to
commit to UHC (Stuckler et al., 2010; Wang, 2012).
To address the situation, policy makers have suggested a range of different measures, including expanding fiscal
space, increasing government share of spending on health, unification of existing schemes to create a single risk
pool, compulsory membership, reducing medicine prices and promoting rational use, increasing incentives for
quality health care provision, and so on (Ahmed et al., 2013; Annear, Ahmed, Ros, & Ir, 2013; Blanchet & Fox,
2013; Lagomarsino, Garabrant, Adyas, Muga, & Otoo, 2012; Tangcharoensathien et al., 2011; Vian et al., 2015).
Systematic reviews are useful in the development of evidence-based policies and strategies to address the health
financing problems. The objectives of this systematic review are to synthesize the existing evidences documenting
policy lessons to UHC and develop and inform effective financing strategies and policies to achieve it. Findings
from this review will provide a systematic compilation of the best available evidences and lessons to inform
overall health sector planning.
This article is structured as follows: section 2 contains Materials and methods. Results of the review are presented
in Section 3, and a discussion in the last section.
2. Materials and Methods
A systematic search was conducted in January 2016. The study questions addressed in this review are: (1) how
different countries assess or analyze their health financing policies towards achieving UHC, (2) dimensions of the
health financing policies; and (3) which policy options they suggest.
We used conceptual models to provide structure in the problem formulation and data analysis stages of the research
(Bravata, McDonald, Shojania, Sundaram, & Owens, 2005).
Published studies designed with the purpose of analyzing or assessing health financing policies using policy
analysis models or conceptual frameworks are all of potential interest. Published reports other than journal papers
also included. The following databases were searched: PubMed; Scopus and Cochrane Library for peer-reviewed
literature; and Google for gray literature. The search terms for three major databases were based on MeSH
(Medical Subject Headings) and text terms, (see Table 1). For Google searches, the terms used were “health
financing”, “universal health coverage”, “policy” and “framework”.
In addition, an Internet-based search of the official websites of World Bank and world health organization was
conducted to identify national health financing assessments and policy analysis; documents in the bibliographies
of existing materials were also reviewed.
2.1 Selection Process
Studies published between 2000 and 2016 in English were included. Two authors independently screened the titles
and abstracts and studies were considered eligible for inclusion if: 1) It addresses health financing assessment
towards achieving UHC; and 2) it explicitly uses a policy analysis model or conceptual framework. If a document
met these criteria, the bibliographies were reviewed to ensure that all relevant materials were being examined.
Some studies stem from the same reference and here are listed altogether. The critical appraisal of included studies
was done by the CASP Quality checklist.
2.2 Data Extraction and Synthesis
We used standardized data extraction forms to extract data on the key findings and policy considerations. We
adapted thematic framework analysis that had six distinct steps, including familiarization, identifying a thematic
framework, indexing, charting, mapping, and interpretation (Rashidian, Eccles, & Russell, 2008). This method has
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been specifically developed for the analysis of qualitative data. After familiarization with variety of subjects by
reading the included documents and literature, an initial thematic framework was developed through an iterative
process involving a succession of analyses. All data was indexed by one author (MAS) using the themes and
sub-themes in the framework. Finally by rearranging and comparing the relations of concepts and ideas, we
organized the analysis and established patterns within the data. To gather information on policy options, a
descriptive and narrative synthesis of data was undertaken. All options were finally grouped into nine main
dimensions.
2.3 Study Assessment
As Bravata and her colleagues mention “the heterogeneity of studies used to evaluate the financing of health care
can make it difficult to identify a short list of quality features that apply equally well to all relevant studies.”
(Bravata et al., 2005). The overall findings of study quality assessment are summarized in Table 2. In terms of
methodology, all studies have used descriptive analysis. The majority of studies reported policy analysis were of
relatively high quality. Few reports were on health financing assessment, and these were of lower quality.

Table 1. Electronic search strategy

PubMed, January 2016
Results:1475 hits: Search (((((((“Financing, Government”[Mesh]) OR “Financing, Organized”[Mesh]) OR “economics”
[Subheading]) OR “Healthcare Financing”[Mesh]) OR “Economics”[Mesh])) AND (((((“Universal
Coverage/organization and administration”[Mesh])) OR “Universal Coverage/utilization”[Mesh]) OR “Universal
Coverage/economics”[Mesh])
OR universal health coverage)) AND ((((“Health Policy”[Mesh]) OR “Policy Making”[Mesh]) OR “Policy”[Mesh]) OR
“Public Policy”[Mesh])
Scopus, January 2016
Results: 318 hits “health financ*” AND “universal health coverage” AND polic* AND (LIMIT-TO (LANGUAGE,
“English”))
Cochrane Library, January 2016
Results: 72 hits:
#1 “universal health coverage”:ti,ab,kw (Word variations have been searched)
#2 “health financing”
#3 Policy
#4 #1 and #2 and #3

Table 2. Methodological Quality of Included Studies (n =23)

Quality Criterion Agreed Assessment for Each Study
Met Criterion Did Not Meet Criterion Unclear
Was there a clear statement of the aims of the research?
Is a qualitative methodology appropriate?
Was the research design appropriate to address the aims
of the research?
Was the recruitment strategy appropriate to the aims of
the research?
Were the data collected in a way that addressed the
research issue?
Has the relationship between researcher and participants
been adequately considered?
Have ethical issues been taken into consideration?
Was the data analysis sufficiently rigorous?
Is there a clear statement of findings?
How valuable is the research?
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3. Results
3.1 Search Result
The database searches yielded 1865 hits, as shown in Figure 1. The title and abstract of each paper were screened,
resulting in 55 full-text articles that were assessed for eligibility. Google search and citation tracking also resulted
77 documents and 4 reports regarding health financing assessments. The final selection of 23 documents was
examined thoroughly. With regard to methodology, studies have predominantly used descriptive analysis of health
financing policies toward Universal Health Coverage, and there were a variety of frameworks and models used by
journal publications and non-peer-reviewed documents.
3.2 Dimensions of the Health Financing Policies
We categorized all dimensions that were important in health financing assessment to achieve UHC into nine
groups. The main findings regarding our questions are summarized in Table 3.
3.2.1 Stewardship
Some of the included qualitative studies recognized the critical role of stewardship. Stewardship influences the
direction of health policy through regulation.
(a)Strengthening leadership and governance: Studying financing universal coverage in Malaysia shows that good
governance would ensure an adequate focus on the attainment of universal coverage through allocating public
spending on health (Chua & Cheah, 2012). Strengthening the regulatory role of government in health care
provision and taking measures to strengthen the monitoring and enforcement of regulations is of great importance
(Mathauer, Xu, Carrin, & Evans, 2009).
(b) Assuring Value for Money: “balanced approach to prioritizing services and medicines for benefits package
expansion”; “strong negotiation with pharmaceutical companies”
3.2.2 Raising Revenues and Contribution Methods
Resource constraints in achieving or sustaining universal coverage constitutes a major challenge among countries.
Almost all studies showed that all countries, regardless of their socioeconomic status, have problems finding the
fiscal space to finance UHC policies (Antunes, 2009; Inke Mathauer, 2010; Lagomarsino et al., 2012; Maeda &
Naoki Ikegami, 2014; Mathauer et al., 2009; Onoka, Onwujekwe, Uzochukwu, & Ezumah, 2013;
Tangcharoensathien et al., 2015; Tangcharoensathien et al., 2011; Tien, Phuong, Mathauer, & Phuong, 2011). The
poor and the informal sector remain a challenge in many low and middle income countries (Antunes, 2009;
Lagomarsino et al., 2012; Tangcharoensathien et al., 2011; Tien et al., 2011). Some studies highlighted the very
low enrolment compliance in the private sector (Ahmed et al., 2013; Antunes, 2009; Tien et al., 2011).
The four main policy lessons and options of this dimension are as follows:
(a) Modifying enrolment: increasing enrolment in government health insurance; compulsory membership.
(b) Increasing financial stability: Increasing financial stability through stable government subsidies; expanding
the contribution base; reduce leakage and underreporting of income; to develop a financial system for improving
income registration; increase penalties for enrolment evasion; to diversify sources of revenue; and control of tax
evasion.
(c)Promoting the culture of insurance
(d)Expanding Fiscal space: increasing government share of spending on health; introduction of sin taxes (Note 1);
earmarked consumption taxes; extension of taxation base; priority in the government budget for health; earmark
taxes on income, capital and consumption; and value-added tax.
3.2.3 Risk Pooling
Risk pooling and cross-subsidization constitute a major challenge .Some countries like Thailand ensures
cross-subsidization with multiple insurance programs. Other countries achieved cross-subsidization by
consolidation and unification of existing programs into fewer schemes. Equity in contribution rates and
cost-sharing ensure financial protection (Maeda & Naoki Ikegami, 2014).
Main policy lessons and options of this dimension are as follows:
(a) Extending cross-subsidization: unification of existing schemes to create a single risk pool; “cross-subsidization
with multiple programs by standardizing key dimensions of the system and cross-subsidizing”.
(b) Targeted subsidies and exemptions: ensure access to health services for the poor through fee waivers or
vouchers; cover premiums for the poor and other priority groups; fee waiver system

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(c) Regulation of user charges: different ceiling for cost-sharing; lowering cost-sharing ratios and increasing
contribution rates; regulation of user charges for non-covered services; introduction of income-related ceiling on
copayments; restricting copayments for catastrophic health expenditures.
3.2.4 Resource Allocation & Purchasing:
Addressing national health needs, especially those of the poor on one hand and managing increasing healthcare
costs on the other hand doubled the importance of strategic purchasing and cost effectiveness of healthcare
expenditure (Chua & Cheah, 2012). All studies showed that countries adopt measures to secure a comprehensive
benefit package and a fair payment system to secure financial protection. The most common recommendations on
this issue are:
(a) Expanding and adjusting benefit package:
Expand coverage of high-quality services; expand preventive care; infuse the element of cost-effectiveness; reduce
medicine prices and promote rational use, and increase incentives for quality health care provision; develop a
benefit package based on cost effectiveness criteria; “a balanced approach to prioritizing services and medicines
for benefits package expansion”.
(b) Improving contracting mechanism: Regulation of the role of private, commercial health insurance; mandatory
and collective contracting mechanism; introduction of quality-based purchasing mechanisms;
(c) Referral system: Strengthen compliance with the referral system via differentiating cost-sharing; “ban dual
practice while raising salaries for public sector health workers”;
(d) Modifying payment system: put volume control or budget cap for fee for service payment; a combined payment
system; introduction of long-term care insurance; risk-adjusted capitation; Capacity-building for the development
of DRG payment.
3.2.5 Human Resources
Human resources is a critical element to achieve universal coverage (Tangcharoensathien et al., 2011). A synthesis
report indicated challenges in health worker production and distribution (Maeda & Naoki Ikegami, 2014). Some
suggested strategies to face these challenges are: adjustment of workforce profile and skills mix (Chua & Cheah,
2012; Maeda & Naoki Ikegami, 2014) expanding recruitment of mid- and lower-level health workers,
improvements to working conditions, recruiting students from underserved areas, continuing education and
ensuring that curricula include rural service components. Brazil and Turkey implemented Family Health Strategy
and Family Medicine Program (Maeda & Naoki Ikegami, 2014). The three main policy lessons and options of this
dimension are as follows:
(a) Addressing human resources Shortage: ensuring adequate human resources; incorporate a comprehensive
workforce compensation strategy to improve the health workforce skill mix; revisit traditional models of education,
deployment, and remuneration
(b) Ensuring Equitable Distribution of human resources: to regulate the location of providers to avoid
over-concentration; strengthen incentives to focus on general medicine and reduced incentives to specialize
(c) Improving Health Worker Performance: regulatory reforms to ensure quality and appropriate skills of health
workers; safe and supportive work environment; monetary and nonmonetary incentives such as peer recognition
and peer support.
3.2.6 Policy Stakeholders
A recurring dimension which emerged from a number of studies was the role of stakeholders. Most policy analysis
of health financing systems places a considerable emphasis on the power of the employers’ associations, the
insured and medical associations in the health-policy process. One study noted that to involve actors in
policy-influencing activities, the government has taken action to institutionalize a triangular governance
committee includes the public sector, the insured and the provider, to increase social consensus and accountability
for the NHI’s sustainability (Wang, 2012).
Effective engagement of actors: effectively engage policy supporters to overcome challenges in order to facilitate
adoption by stakeholders; early use of stakeholder analysis to avoid potential pitfalls and obstacles in policy
implementation
3.2.7 Policy Content
Some health financing assessments investigated that absence of rules, inadequate rules, and conflicting or
non-aligned rules hinders the attainment of universal health coverage.

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Institutional design and capacity: revision of the law with regard to the administrative requirements and
transparency measures; ongoing review and revision of policy proposals; “investing in the institutional capacity to
use expenditure management during the design phase”.
3.2.8 Policy Context
Several studies and reports are published with a focus on political economy. UHC was high on the agenda of the
countries “following a period of financial crisis in Indonesia, Thailand, and Turkey; at the time of
redemocratization in Brazil; and during the post–World War II reconstruction efforts in France and Japan” (Maeda
& Naoki Ikegami, 2014)
socio-economic and political context: investment in health after economic growth although economic growth is
not a necessary prerequisite for adoption of UHC policies; develop health financing system within the particular
macro-economic, socio-economic and political context of the country; consideration of national context.
3.2.9 Policy Process
The studies related to policy process analysis showed that political will and stakeholder’s position are pivotal for
successful implementation of a policy agenda and for securing financial support from powerful actors. One study
noted that lack of comprehensive communication strategies to articulate the policy and absence of a stakeholder
management strategy were supposed to be the main factors that led to the failure of national health insurance
implementation in Kenya (Abuya, Maina, & Chuma, 2015). Two studies also showed that the process toward UHC
has been incremental, requiring learning-by-doing approach and gradual and repeated adjustments (Basaza,
O’Connell, & Chapčáková, 2013; Ha et al., 2014).
(a)communication strategies: Adequate communication strategies to articulate the policy; enhance transparency
and “develop governance structures to institutions mandated to provide leadership in the reform process to
overcome opposition”; appreciation of the position of certain powerful actors and factors that help to push health
care reform onto the agenda; Contain opposition to UHC through negotiation
(b) Incremental policy processes: facilitate the UHC policy implementation process by financial and managerial
autonomy of social security institution; support UHC at the highest political level; plan a long-term systematic
plan; set comparable indicators to assess outcomes and make midcourse corrections in policy and implementation;
consideration of national context, the sequencing of reforms and the time-scale appropriate for achieving universal
coverage.

Table 3. Dimensions and policy options emerging from the Included Studies
Dimensions policy actions/Lessons References
1 Stewardship Strengthening leadership and governance (Chua & Cheah, 2012),(Mathauer et al., 2009) ,
“Ensuring Value for Money” (Antunes, 2009), (Maeda & Naoki Ikegami, 2014)
2 Raising Revenues Modifying enrolment (Tangcharoensathien et al., 2011), (Lagomarsino
and contribution Increasing financial stability et al., 2012), (Ahmed et al., 2013), (Mathauer et
methods al., 2009),(Mathauer, Cavagnero, Vivas, & Carrin,
promoting culture of insurance
2010), (Antunes, 2009), (Maeda & Naoki
Expanding Fiscal space Ikegami, 2014), (Annear et al., 2013), (Tien et al.,
2011), (Briggs, 2013)
3 Risk pooling and regulation of user charges (Ahmed et al., 2013), (Blanchet & Fox, 2013),
financial protection cross-subsidization (Mathauer et al., 2009), (Maeda & Naoki
Ikegami, 2014), (Tien et al., 2011), (Briggs, 2013)
targeted subsidies and exemptions
4 Resource Expanding and adjusting benefit package (Tangcharoensathien et al., 2011), (Chua &
allocation and Improving contracting mechanism; Cheah, 2012), (Vian et al., 2015), (Mathauer et al.,
purchasing 2009),(Mathauer et al., 2010), (Tien et al., 2011),
strengthen compliance with the referral
(Maeda & Naoki Ikegami, 2014), (Briggs, 2013)
system
Modifying payment system
5 Human resources Addressing human resources Shortage (Tangcharoensathien et al., 2011), (Chua &
Ensuring equitable distribution of human Cheah, 2012), (Maeda & Naoki Ikegami, 2014),
resources (Mathauer et al., 2009)

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Improving health worker performance

6 Policy stakeholders Management of conflict of interest (Wang, 2012), (Onoka et al., 2013)
Engage actors effectively (Abuya et al., 2015), (Basaza et al., 2013)
7 Policy content Institutional design and capacity (Abiiro & McIntyre, 2012), (Basaza et al., 2013),
(Maeda & Naoki Ikegami, 2014)
8 Policy context importance of socio-economic and political (Vargas & Muiser, 2013) , (Ibrahimipour et al.,
context 2011), (Annear et al., 2013), (Maeda & Naoki
Ikegami, 2014)
9 Policy process Improving communication strategies (Abuya et al., 2015), (Ha et al., 2014), (Pillay &
Incremental policy processes Skordis-Worrall, 2013), (Vargas & Muiser, 2013),
(Ibrahimipour et al., 2011), (Lagomarsino et al.,
2012), (Ahmed et al., 2013)

Table 4. Characteristics of Studies Included in this Review

Author, year Country Study design Data Collection Methods
1 Wang(2012) Taiwan Qualitative official documents and 62 social network interviews
Comparative case
2 Onoka et.al(2013) Nigeria document reviews and 48 in-depth interviews
study
Abiiro and 28 in-depth interviews, 6 focus group discussions
3 Ghana Qualitative
McIntyre (2012) and a review of media reports on the policy issue
retrospective policy
4 Abuya et.al(2015) Kenya document reviews and seven in depth interviews
analysis
review of literature sources including academic
literature,
Pillay and
5 Skordis-Worrall South Africa case study media coverage and government and NGO reports
(2013) among others; key
informant interviews
review of literature, institutional and other
Vargas and Muiser
6 Costa Rica qualitative research documents, and in-depth interviews with key
(2013)
informants
Literature review of published documents, technical
reports, policy briefs, and memos obtained from
7 Basaza et.al (2013) Uganda case study
Uganda’s Ministry of Health and other unpublished
sources; Formal discussions
30 in-depth interviews, 4 focus group discussions,
8 Ha et.al (2014) Vietnam qualitative research
expert consultancy, and 420 secondary data review
review and synthesis of the published literatures and
seven countries documentary other
9 Viroj et.al (2011)
in southeast Asia analysis
government unpublished documents
Ibrahim pour et.al
10 Iran qualitative study Twenty-five semi-structured interviews
(2001)
review policy documents and 18 semi-structured
11 Annear et.al (2013) Cambodia qualitative study
key informant interviews
Chua and Cheah
12 Malaysia case study Review of secondary data
(2012)
nine developing
Lagomarsino et.al
13 countries in Descriptive study Review of secondary data
(2012)
Africa and Asia
review of key health financing policy documents
14 Ahmed et.al (2013) Lao PDR qualitative approach
and 17 semi-structured key informant interviews
qualitative approach:
Blanchet and Fox Vermont; United
15 prospective 64 semi-structured stakeholder interviews
(2013) States
stakeholder analysis

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Analysis of household budget survey data and

policy documents, a review of administrative law,
16 Vian et.al (2015) Moldova qualitative approach Focus groups,
interviews, and a policy dialogue with key
stakeholders
17 Briggs (2013) Ireland qualitative approach review of documents; interviews
Analysis of secondary data and review of
Mathauer et.al
18 Korea qualitative approach administrative law and policy documents; in depth
(2009)
interviews
Analysis of secondary data and review of
Mathauer et.al
19 Nicaragua qualitative approach administrative law and policy documents; in depth
(2010)
interviews
Analysis of secondary data and review of
Antunes et.al
20 Cambodia qualitative approach administrative law and policy documents; in depth
(2009)
interviews
Analysis of secondary data and review of
21 Tien et.al (20110 Vietnam qualitative approach administrative law and policy documents; in depth
interviews
review of key health financing policy
documents ;Analysis of secondary data and review
22 Maeda et.al (2014) 11 countries case study
of administrative law and policy documents; in
depth interviews
24 developing
23 Cotlear (2015) case study Review of systematic data
countries

Figure 1. Search Process and Study Selection

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4. Discussion
To our knowledge this is the first systematic review of health financing policy analysis and assessment toward
universal health coverage. 23 articles were identified. We had two main objectives that we discuss in turn: (1) what
assessment or policy analysis studies of health financing toward universal health coverage have been done and
what did they imply? (2) And what are the policy options for health financing toward universal coverage?
Results from the studies included in this systematic review suggest that different issues in health financing systems
should be considered to pave the way toward achieving universal health coverage. We have synthesized, using the
thematic framework, these issues in nine dimensions. Most included studies assessed health financing using a
conceptual or analytical framework. Some other studies analyzed health financing policy using a policy analysis
model.
A range of challenges in financial functions and political issues toward UHC was highlighted. It has become clear
that international experiences help implement policy options by supporting them to learn about the “how” of the
policy process, involvement of stakeholders, articulation of policies and consideration of political economy status
to achieve UHC.
In recent years there has been a growing body of literature in favor of putting more emphasis on political economy,
pressure group’s role, and lobbying which influences health financing policy towards universal coverage (Carrin,
Mathauer, Xu, & Evans, 2008). Health financing functions needs to be supported by transparent legislations and
regulations with implicit policy options that ultimately promote sustainability of revenues, ensure risk pooling
arrangements, and rationalize health spending both in the public and private sectors (Abiiro & McIntyre, 2012;
Ahmed et al., 2013; Maeda & Naoki Ikegami, 2014).
While as one of the main components of the health system it is crucial to retain health financing functions, the
necessity of interacting with stakeholders and effective leadership to ensure adequate public spending on health
should be taken into consideration. Top-level political negotiation between the ministry of health and the ministry
of finance on one hand and the public sector, the insured and the provider, on the other hand will increase social
consensus and sustainability of resources (Chua & Cheah, 2012; Wang, 2012). Considering the position of human
resources in health systems, it is supposed that improving access to health services requires well-trained and
motivated health workers (Maeda & Naoki Ikegami, 2014). And finally, while some policy options have been
successful in some settings, it should be noted that the policy context of each country is unique and apply lessons
from elsewhere cautiously.
The main strength of this systematic review is the inclusion of a wide range of qualitative studies that investigate
different aspects of health financing policy. Our analysis has some limitations. First, we undertook a review of
literature through a policy framework that emphasized on contextual forces, content, the role of actors, and the
policy process of financing that drive UHC achievement. Furthermore, our literature review was limited to articles
and research focused on assessing health financing through different conceptual frameworks. As a result, broad
health financing research not reviewed here. Second, as Bravata and her colleagues mention “Topics related to
health care financing pose inherent challenges for systematic reviews. Problem formulation may be difficult, and
the common quantitative approaches for meta-analysis may not be applicable.”
Acknowledgements
This research is part of the thesis on “Policy analysis of universal health coverage financing in Iran “which was
supported by Tehran University of Medical Sciences (TUMS). We would like to express our sincere gratitude to
Dr.Arab and Nastaran Fazeli for their comments on an earlier version of the manuscript.
Authors’ Contributions
M.A.S. contributed to design, methods, review and writing; A.R. contributed to design, methods, review and
writing; A.A.S. contributed to design and review; A.V.M. contributed to methods and review; SH.Y.contributed to
methods and review; and M,B contributed to design and writing.
Competing Interests Statement
We confirm that the manuscript has been read and approved by all named authors and that there are no other
persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors
listed in the manuscript has been approved by all of us.
References
Abiiro, G. A., sin McIntyre, D. (2012). Achieving universal health care coverage: Current debates in Ghana on
covering those outside the formal sector. BMC international health and human rights, 12(1), 25.
http://dx.doi.org/10.1186/1472-698x-12-25
139
gjhs.ccsenet.org Global Journal of Health Science Vol. 9, No. 5; 2017

Abuya, T., Maina, T., & Chuma, J. (2015). Historical account of the national health insurance formulation in
Kenya: experiences from the past decade. BMC Health Services Research, 15(1), 1.
http://dx.doi.org/10.1186/s12913-015-0692-8
Ahmed, S., Annear, P. L., Phonvisay, B., Phommavong, C., Cruz, V. d. O., Hammerich, A., & Jacobs, B. (2013).
Institutional design and organizational practice for universal coverage in lesser-developed countries:
Challenges facing the Lao PDR. Social Science & Medicine, 96, 250-257.
http://dx.doi.org/10.1016/j.socscimed.2013.01.019
Annear, P. L., Ahmed, S., Ros, C. E., & Ir, P. (2013). Strengthening institutional and organizational capacity for
social health protection of the informal sector in lesser-developed countries: A study of policy barriers and
opportunities in Cambodia. Social Science & Medicine, 96, 223-231.
doi.org/10.1016/j.socscimed.2013.02.015
Antunes, A. F. (2009). Summary Report The Health Financing System Assessment In Cambodia.
Basaza, R. K., O’Connell, T. S., & Chapčáková, I. (2013). Players and processes behind the national health
insurance scheme: a case study of Uganda. BMC Health Services Research, 13(1), 1.
http://dx.doi.org/10.1186/1472-6963-13-357
Blanchet, N. J., & Fox, A. M. (2013). Prospective political analysis for policy design: Enhancing the political
viability of single-payer health reform in Vermont. Health Policy, 111(1), 78-85.
doi.org/10.1016/j.healthpol.2013.02.012
Bravata, D. M., McDonald, K. M., Shojania, K. G., Sundaram, V., & Owens, D. K. (2005). Challenges in
systematic reviews: synthesis of topics related to the delivery, organization, and financing of health care.
Annals of internal medicine, 142(12_Part_2), 1056-1065. http://dx.doi.org/10.1016/j.healthpol.2013.02.012
Briggs, A. D. (2013). How changes to Irish healthcare financing are affecting universal health coverage. Health
Policy, 113(1), 45-49. http://dx.doi.org/10.1016/j.healthpol.2013.07.022
Carrin, G., Mathauer, I., Xu, K., & Evans, D. B. (2008). Universal coverage of health services: tailoring its
implementation. Bulletin of the World Health Organization, 86(11), 857-863.
http://dx.doi.org/10.1590/S0042-96862008001100015
Chua, H. T., & Cheah, J. C. H. (2012). Financing Universal Coverage in Malaysia: a case study. BMC Public
health, 12(1), 1. http://dx.doi.org/10.1186/1471-2458-12-s1-s7
Ekman, B. (2004). Community-based health insurance in low-income countries: a systematic review of the
evidence. Health Policy and Planning, 19(5), 249-270. Http://dx.doi.org/10.1093/heapol/czh031
Gottret, P. E., Schieber, G., & Waters, H. (2008). Good practices in health financing: lessons from reforms in low
and middle-income countries. World Bank Publications.
Ha, B. T., Frizen, S., Thi, L. M., Duong, D. T., & Duc, D. M. (2014). Policy processes underpinning universal
health insurance in Vietnam. Global health action, 7.
Ibrahimipour, H., Maleki, M.-R., Brown, R., Gohari, M., Karimi, I., & Dehnavieh, R. (2011). A qualitative study of
the difficulties in reaching sustainable universal health insurance coverage in Iran. Health Policy and
Planning, 26(6), 485-495. Http://dx.doi.org/10.1093/heapol/czq084
Inke Mathauer, E. C., Gabriel Vivas and Guy Carrin. (2010). Health financing challenges and institutional options
to move towards universal coverage in Nicaragua.
Kutzin, J. (2012). Anything goes on the path to universal health coverage? No. Bulletin of the World Health
Organization, 90(11), 867-868. http://dx.doi.org/10.2471/BLT.12.113654
Lagomarsino, G., Garabrant, A., Adyas, A., Muga, R., & Otoo, N. (2012). Moving towards universal health
coverage: health insurance reforms in nine developing countries in Africa and Asia. The Lancet, 380(9845),
933-943. http://dx.doi.org/10.1016/S0140-6736(12)61147-7
Maeda, A., Edson Araujo, Cheryl Cashin, Joseph Harris, & Naoki Ikegami, A. M. R. R. (2014). Universal Health
Coverage for Inclusive and Sustainable Development: A Synthesis of 11 Country Case Studies: Directions in
Development. http://dx.doi.org/10.1596/978-1-4648-0297-3.
Mathauer, I., Cavagnero, E., Vivas, G., & Carrin, G. (2010). Health financing challenges and institutional options
to move towards universal coverage in Nicaragua. Background paper24 for the World Health Report: Health
Systems Financing: the Path to Universal Coverage.
Mathauer, I., Xu, K., Carrin, G., & Evans, D. B. (2009). An analysis of the health financing system of the Republic
140
gjhs.ccsenet.org Global Journal of Health Science Vol. 9, No. 5; 2017

of Korea and options to strengthen health financing performance. Geneva, WHO.

May Kyi Lwin, M. X., & Xinhua, Z. (2015). Comparative Study on Health Care System between Myanmar and
China According to World Health Organization (WHO)’s Basic Health Blocks. Science Journal of Public
Health, 3(1), 44-49. http://dx.doi.org/10.11648/j.sjph.20150301.18
Onoka, C. A., Onwujekwe, O. E., Uzochukwu, B. S., & Ezumah, N. N. (2013). Promoting universal financial
protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria.
Health research policy and systems, 11(1), 1. http://dx.doi.org/10.1186/1478-4505-11-20
Pillay, T. D., & Skordis-Worrall, J. (2013). South African health financing reform 2000–2010: Understanding the
agenda-setting process. Health Policy, 109(3), 321-331. http://dx.doi.org/10.1016/j.healthpol.2012.12.012
Rashidian, A., Eccles, M. P., & Russell, I. (2008). Falling on stony ground? A qualitative study of implementation
of clinical guidelines’ prescribing recommendations in primary care. Health Policy, 85(2), 148-161.
http://dx.doi.org/10.1016/j.healthpol.2007.07.011
Savedoff, W. D. (2012). Transitions in Health Financing and Policies for Universal Health Coverage. Results for
Development Institute. Washington DC.
Stuckler, D., Feigl, A. B., Basu, S., & McKee, M. (2010). The political economy of universal health coverage.
Paper presented at the Background paper for the global symposium on health systems research. Geneva:
World Health Organization.
Tangcharoensathien, V., Mills, A., & Palu, T. (2015). Accelerating health equity: the key role of universal health
coverage in the Sustainable Development Goals. BMC medicine, 13(1), 1.
http://dx.doi.org/10.1186/s12916-015-0342-3
Tangcharoensathien, V., Patcharanarumol, W., Ir, P., Aljunid, S. M., Mukti, A. G., Akkhavong, K. Mills, A. (2011).
Health-financing reforms in south East Asia: challenges in achieving universal coverage. The Lancet,
377(9768), 863-873. http://dx.doi.org/10.1016/S0140-6736(10)61890-9
Tien, T. V., Phuong, H. T., Mathauer, I., & Phuong, N. T. K. (2011). A health financing review of Viet Nam with a
focus on social health insurance. Geneva: World Health Organization.
Vargas, J. R., & Muiser, J. (2013). Promoting universal financial protection: a policy analysis of universal health
coverage in Costa Rica (1940–2000). Health Research Policy and Systems, 11.
http://dx.doi.org/10.1186/1478-4505-11-28
Vian, T., Feeley, F. G., Domente, S., Negruta, A., Matei, A., & Habicht, J. (2015). Barriers to universal health
coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments. BMC
Health Services Research, 15(1), 1. http://dx.doi.org/10.1186/s12913-015-0984-
Wang, G.-X. (2012).A network approach for researching political feasibility of healthcare reform: The case of
universal healthcare system in Taiwan. Social Science & Medicine, 75(12), 2337-2344.
http://dx.doi.org/10.1016/j.socscimed.2012.09.005
WHO. (2000). Health systems: Improving performance. Geneva.
WHO. (2010). The world health report 2010—Health systems financing: The path to universal coverage. Geneva
Xu, Y., Huang, C., & Colón-Ramos, U. (2015). Moving toward Universal Health Coverage (UHC) to Achieve
Inclusive and Sustainable Health Development: Three Essential Strategies Drawn from Asian Experience:
Comment on “Improving the World’s Health through the Post-2015 Development Agenda: Perspectives from
Rwanda”. International journal of health policy and management, 4(12), 869.
http://dx.doi.org/10.1016/j.socscimed.2012.09.005

Note
Note 1. A tax on substances or activities considered sinful or harmful (as tobacco, alcohol, or gambling).

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Appendix
Appendix 1. Data information extraction sheet
Information Remarks
Author(s)
• Name(s):
• Country or region:
Study
• Year:
• Overall aim/purpose
• Research/analytical question(s):
• Type* (Research, Evaluation, Policy analysis):
• Methodology:
_ Data gathering: Survey, Interviews, Focus group discussions,
Review of key documents, Observation)
_ Data analysis: Qualitative analysis; discussion of outcomes:
• Data:
_ Primary/Secondary:
• Findings:
-Policy options
- Comments:

Copyrights
Copyright for this article is retained by the author(s), with first publication rights granted to the journal.
This is an open-access article distributed under the terms and conditions of the Creative Commons Attribution
license (http://creativecommons.org/licenses/by/4.0/).

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