SUPPORT-SYSTEMS (53) The Lancet: The politics of universal health coverage

26 May, 2022

Our discussion is looking at the question: How can decision-making processes for health systems strengthening and universal health coverage be made more inclusive, responsive and accountable?

This new paper in The Lancet provides a political science perspective on national policymaking and universal health coverage. Citation, summary, selected extracts, and a comment from me below.

CITATION: The politics of universal health coverage

Carmen Jacqueline Ho et al. The Lancet 2022

Published: May 17, 2022 DOI:


The UN has declared universal health coverage an urgent global goal. Efforts to achieve this goal have been supported by rigorous research on the scientific, technical, and administrative aspects of health systems design. Yet a substantial portion of the world's population does not have access to essential health services. There is growing recognition that achieving universal health coverage is a political challenge. However, fundamental concepts from the political science discipline are often overlooked in the health literature. This Series paper draws on political science research to highlight the ways in which politics can facilitate, or stymie, policy reform. Specifically, we present a framework of analysis that explores how interests, ideas, and institutions shape universal health coverage. We then examine key considerations relating to the implementation of relevant policies. This Series paper shows that a political understanding of universal health coverage is needed to achieve health for all.


'There is an urgent need for action — but policy reform does not occur simply because evidence accumulates about the severity of the issue or the benefits of policy change. Although evidence is undeniably important and should form the basis of health policies, governments routinely make decisions that are inconsistent with scientific and technical evidence. Therefore, achieving universal health coverage should also be viewed as a political challenge...

'Advocates for universal health coverage must:

- Understand that universal health coverage is a political challenge; it reflects the contestation of political interests, prevailing ideas and beliefs, and the decisions that are mediated through political institutions

- Support disadvantaged groups in building political power and amplify their voices

- Craft a normative commitment to universalism in health coverage and convince opponents of universal health coverage that access to health care benefits everyone

- Recognise that effective political strategies will vary across different national contexts

- Distinguish between universal health coverage policy design and policy implementation, and address the specific challenges in both...

'Political actors often seek to maximise their own interests... Governments tends to prioritise the demands of groups with political power...

'In response to multiple, often overlapping, forms of societal injustice, social movements have emerged. These grass-roots movements are not based on socioeconomic class or workplace profession but are motivated by rights-based causes. Representing the interests of historically marginalised groups, such as women, racialised groups, people with disabilities, and the LGBTQ+ community, individuals have mobilised in broad social movements and pursued collective action to push for policy change. Political actors, acting individually or collectively, can use windows of opportunity — crucial junctures in the political process — to accelerate a preferred policy agenda. These windows of opportunity are created in various ways. For example, sudden, attention-grabbing events can draw attention to the need for government action and create an exogenous opportunity for actors to mobilise and push through health reform...

'Ideas held by policy makers... can have a substantial effect on health policies. Policy makers' beliefs about the root causes of poor health will shape public policy...

'In Kerala, India, a shared identity between different groups — a sense of we-ness — contributed to progressive social policies that improved health outcomes... Similarly, in Malawi, cross-ethnic social ties have facilitated trust and cooperation among diverse groups...'

'A host of factors need to be aligned for universal health coverage to become a reality, including health systems knowledge, medical expertise, economic and fiscal capacity, and technical policy making skills, among others...'

COMMENT (NPW): The above is a reminder of the complexity of the challenge for civil society organisations. As we explored in a previous HIFA discussion on country-level policymaking, evidence is just one aspect to consider. That said, evidence is of course critical and central for evidence-informed policymaking. I look forward to hear your thoughts on how civil society organisations create new evidence and highlight existing evidence, and how they then communicate such evidence in a way that either supports evidence-informed policymaking (or, conversely, distorts policy towards the interests of the group that the CSO represents).

Best wishes, Neil


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HIFA profile: Neil Pakenham-Walsh is global coordinator of the HIFA global health movement (Healthcare Information For All - ), a global community with more than 20,000 members in 180 countries, interacting on six global forums in four languages in official relations with WHO. HIFA brings stakeholders together to accelerate progress towards universal access to reliable healthcare information. Twitter: @hifa_org