How and why do countries make Universal Health Care policies? Interplay of country and global factors

Background An examination of country policy making tends to reveal more complex processes that reflect domestic as well as external pressures and influences. The paper examines the interplay of external and internal, as well as other, factors in universal health care (UHC) decision-making for a select number of countries spanning the income range from low to high income. Methods After developing a conceptual framework to help identify variables to explore in answering our study questions, we reviewed literature on health policies and policy making, especially around the time of the adoption of relevant policies for a number of UHC reform countries, followed by a narrative review of countries for more in-depth study. For more quantitative data, we consulted databases maintained by international institutions. Results We found that, for low-income countries (LICs)/lower-middle-income countries (LMICs), the external environment helps set the policy agenda that drives national priorities and resource allocation decisions, while national actors take the actual decisions consistent with the interests of their constituencies and their goals. The upper-middle-income countries (UMICs) and high-income countries (HICs) in the study were less influenced by externally driven agendas and more by their own internal dynamics. For LICs/LMICs, a country's income level as well as growth record did not appear to play any overt role at the start of the reform, whereas the UMIC/HIC countries were generally at a higher economic stage with steady growth when they initiated the reforms. The use of technical analysis and evidence to guide the UHC reform decisions was much more pronounced in the UMICs/HIC. The findings on alignment of the UHC program to national health priorities were more mixed. On sustainability, the UMICs/HIC were much more likely than LICs/LMICs to phase in their reforms, whether in terms of the geographical extension of coverage, the population groups to be covered or the expansion of the benefit package in the course of time. Conclusions The near-systematic use of scientific evidence by the UMICs/HIC to inform decisions on the path to UHC in contrast to the LICs/LMICs leads to the conclusion that some LICs/LMICs may have made less than optimal resource allocation decisions based on scanty evidence and factors not conducive to sustainability of their UHC efforts.