The political economy of universal health coverage: a systematic narrative review

The uptake and implementation of universal health coverage (UHC) is primarily a political, rather than a technical, exercise, with contested ideas and diverse stakeholders capable of facilitation or resistance-even veto-of the policy uptake. This narrative systematic review, undertaken in 2018, sought to identify all peer-reviewed publications dealing with concepts relating to UHC through a political economy framing. Of the 627 papers originally identified, 55 papers were directly relevant, with an additional eight papers added manually on referral from colleagues. The thematic analysis adapted Fox and Reich's framework of ideas and ideologies, interests and institutions to organize the analysis. The results identified a literature strong in its exploration of the ideologies and ideas that underpin UHC, but with an apparent bias in authorship towards more rights-based, left-leaning perspectives. Despite this, political economy analyses of country case studies suggested a more diverse political framing for UHC, with the interests and institutions engaged in implementation drawing on pragmatic and market-based mechanisms to achieve outcomes. Case studies offered limited detail on the role played by specific interests, though the influence of global development trends was evident, as was the role of donor organizations. Most country case studies, however, framed the development of UHC within a narrative of national ownership, with steps in implementation often critical political milestones. The development of institutions for UHC implementation was predicated largely on available infrastructure, with elements of that infrastructure-federal systems, user fees, pre-existing insurance schemes-needing to be accommodated in the incremental progress towards UHC. The need for technical competence to deliver ideological promises was underlined. The review concludes that, despite the disparate sources for the analyses, there is an emerging shared narrative in the growing literature around the political economy of UHC that offers an increasing awareness of the political dimensions to UHC uptake and implementation.