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Policy and System Change Context: The paper describes insights into implementation challenges associated with integrated care as a national policy component of Universal Health Care in Ireland. It addresses an international audience by linking universal and integrated care development with the policy implementation literature in complex adaptive health and social care systems. Study Design and Methods: It outlines findings from two literature reviews on change in complex health and social care systems, one of them a systematic review that situates integrated care in the universal health care policy context. We also present findings, including operational and strategic insights on the challenges and opportunities of implementing integrated care from a) a participant online survey across seven pioneer sites and at national programme level, and b) an in-depth case study of integrated care implementation in Ireland over three pioneer sites. Case-data generated from November 2017 to June 2018 at national and pioneer-site levels include initial research co-design discussions, exploratory and elite interviews, workshops, documentary review, participant observation and feedback. Outline Findings: Systematic and literature review findings address methodologies, conditions and competencies for implementation (including collaboration, distributed decision-making, mindset-shifts and leadership styles in complex systems). System-level mechanisms for better patient access, information sharing, and effective functionality are also highlighted. The survey and case study research evidences similar challenges around provider skills and competencies, managing patient access and pathways, and the creation of organisational systems to underpin new service delivery designs. The question of organisational adaptability is critical here for successful system reform outcomes such as positive change management, quality of care and sustained learning for person-centered care. Practical and Policy Relevance: Learning how demonstrator (pioneer) site initiatives and discrete programmes can grow locally, as well as scale more broadly for translation as common discourses, approaches, and buy-in is critical to meet the challenges of integrated care as a key plank of universal healthcare. The paper usefully describes policy implementation challenges from a grounded, complex, whole-of-system perspective.

Numerous undocumented and uninsured foreigners living in Japan have faced barriers when trying to obtain appropriate healthcare services, which have occasionally led to issues with unpaid medical bills to medical institutions. Although information on health and socioeconomic status is essential to tackle such issues, relevant data has been unavailable due to difficulties in contacting this population. This study involved a cross-sectional survey using questionnaires concerning the general demographic characteristics, socioeconomic status, health profiles, information access, and knowledge/attitude/practice of health insurance of Thai nationals living in Japan. The study participants included Thai nationals who lived in Tokyo and the surrounding prefectures. The survey was conducted mainly at public religious events from September 2022 to December 2022. Overall, the questionnaires were obtained from 84 participants, though 67 participants were included in the final analysis after excluding missing variables. There were participants with unspecified visa status (32.8%) and uninsured status (40.3%). Among them, 86.4% expressed positive attitudes towards health insurance. However, multivariate multivariable regression analyses revealed the low insurance practice status among the unspecified visa group (aOR, 0.02; 95% CI, 0.00–0.13). Overall, the results reveal limited access to healthcare services in subgroups of Thai immigrants in Japan.

Background The dynamic intersection of a pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for ‘corruption’ in the LMICs of south and south-east Asia region. ‘Corruption’ works to undermine the UHC goals of achieving equity, quality, and responsiveness including financial protection, especially while delivering frontline health care services. This scoping review examines current situation regarding health sector corruption at frontlines of service delivery in this region, related policy perspectives, and alternative strategies currently being tested to address this pervasive phenomenon. Methods A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted, using three search engines i.e., PubMed, SCOPUS and Google Scholar . A total of 15 articles and documents on corruption and 18 on governance were selected for analysis. A PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was filled-in to complete this report. Data were extracted using a pre-designed template and analysed by ‘mixed studies review’ method. Results Common types of corruption like informal payments, bribery and absenteeism identified in the review have largely financial factors as the underlying cause. Poor salary and benefits, poor incentives and motivation, and poor governance have a damaging impact on health outcomes and the quality of health care services. These result in high out-of-pocket expenditure, erosion of trust in the system, and reduced service utilization. Implementing regulations remain constrained not only due to lack of institutional capacity but also political commitment. Lack of good governance encourage frontline health care providers to bend the rules of law and make centrally designed anti-corruption measures largely in-effective. Alternatively, a few bottom-up community-engaged interventions have been tested showing promising results. The challenge is to scale up the successful ones for measurable impact. Conclusions Corruption and lack of good governance in these countries undermine the delivery of quality essential health care services in an equitable manner, make it costly for the poor and disadvantaged, and results in poor health outcomes. Traditional measures to combat corruption have largely been ineffective, necessitating the need for innovative thinking if UHC is to be achieved by 2030.

The pricing of medicines and health products ranks among the most hotly debated topics in health policy, generating controversy in richer and poorer markets alike. Creating the right pricing structure for pharmaceuticals and other healthcare products is particularly important for low- and middle-income countries, where pharmaceuticals account for a significant portion of total health expenditure; high medicine prices therefore threaten the feasibility and sustainability of nascent schemes for universal health coverage (UHC). We argue that a strategic system of value-based tiered pricing (VBTP), wherein each country would pay a price for each health product commensurate with the local value it provides, could improve access, enhance efficiency, and empower countries to negotiate with product manufacturers. This paper attempts to further understanding on the potential value of tiered pricing, barriers to its implementation, and potential strategies to overcome those.

Background In efforts to advance universal healthcare coverage (UHC) in Nigeria, the federal government empowered sub-national entities such as states to develop and implement their respective state-supported health insurance schemes (SSHIS). This study assessed the coverage and predictors of enrollment in the SSHIS in six Nigerian states. Methods This study used a quantitative cross-sectional design. Respondents were recruited across six Nigerian states with operational SSHIS, corresponding to the country’s six geopolitical zones. These include the Cross River, Enugu, Oyo, Kwara, Sokoto, and Taraba states, representing the South-South, South-East, South-West, North-Central, North-West, and North-East zones respectively. Data were collected from community members in congregate settings such as markets, churches/mosques, schools, bus stations/parks, and healthcare facilities. Descriptive, bivariate, and multivariate analyses were conducted using SPSS version 25. Results The number of study respondents was 3732. The greater majority of the respondents were self-employed 1855 (49.7%) and were living with an average monthly income of < 10,000 naira 1175 (31.5%). Coverage of the state health insurance was highest in the North-Central Kwara State 326 (37.3%), but lowest in the South-Eastern Enugu State 6 (1%). Among beneficiaries, overall satisfaction with the scheme was highest in Oyo State 73 (77.7%), but lowest in Cross River State 16 (32.7%). After adjusting for confounders, several covariates were identified as decreasing the odds of enrolling into the schemes; however, lack of awareness about the scheme was most significant across all the six states. Conclusion Low coverage due to poor awareness, financial barriers, and enrollee dissatisfaction currently affect the SSHIS in Nigeria. To improve enrollment and sustainability, nationwide educational campaigns and consolidation of health insurance schemes are recommended.

Globally, poverty remains a major obstacle to health parity, compromising well-being. This policy analysis aims to examine how poverty affects health inequities and healthcare access in two contexts: Canada, a high-income nation, and Pakistan, a low-income nation. This study employs a grounded approach, integrating a thorough review of the existing critical literature using systematic thematic analysis and synthesis. In Pakistan, chronic underinvestment, rural–urban gaps, inadequate infrastructure, and political instability exacerbate inequities in access to healthcare. Limited coverage, ineffective administrative processes, and gaps in rural healthcare delivery impede growth despite encouraging programs like the Sehat Card and the Ehsaas Program. Conversely, universal healthcare in Canada has lowered financial obstacles to access, but low-income and Indigenous communities are still impacted by service gaps, particularly in dental care, pharmacare, and mental health. Although child poverty rates have been significantly reduced by programs like the Canada Child Benefit, Indigenous children continue to endure disproportionate health risks. Findings underscore a need for equity-driven changes: Pakistan must expand rural health infrastructure and legislate health equity, while Canada should extend coverage to essential but excluded services. Findings underscore the intersecting nature of inequities driven by poverty, gender, geography, and systemic exclusion that highlight opportunities for cross-context policy learning. Canada’s equity monitoring frameworks could strengthen Pakistan’s health data systems, while Pakistan’s community-based Lady Health Worker program offers scalable grassroots models relevant for marginalized Canadian regions. Both countries must prioritize poverty alleviation as a health intervention, integrating justice, sustainability, and accountability to advance global health equity.

Background Expanding access to equitable health insurance is an important lever towards the overall strategy for achieving universal health coverage. In Nigeria, health insurance coverage is low with a renewed government action on increasing access to and coverage of high-quality healthcare services to citizens, particularly for the vulnerable and poor population. Therefore, our study co-creates the priorities for expanding health insurance in Nigeria, focusing on key policy reforms, public advocacy, and innovative financing strategies to ensure broader and more equitable coverage for the population. Methodology We employed a Delphi approach methodology through strategic health insurance meetings with a diverse multidisciplinary panel of 125 stakeholders including representatives of accredited Health Insurance Maintenance Organizations, Heads of States Social Health Insurance Agencies, Development Partners representatives, academics, government officials, national health insurance authority expanded management team and experts in health insurance across all the states of Nigeria to recommend specific actions towards health insurance expansion and universal health coverage in Nigeria. Results The participants/panels were able to come up with a consensus on 66 priorities for health insurance expansion in Nigeria working with stakeholders within the Nigerian health insurance ecosystem across the 36 states and Nigeria’s FCT. From these priorities, seven priority areas and 17 themes were derived that should be considered by the government, policymakers, regulators, and practitioners to deepen health insurance penetration in Nigeria. These seven priority areas that have been identified include enrolment, equity, organizational health and structure, data and technology, quality, market efficiency, and citizen engagement. Conclusion The priorities identified for health insurance expansion in Nigeria will go a long way in shaping health insurance. We hope that government, policymakers, regulators, and practitioners in the health ecosystem will use these social policy actions to set priorities for increasing health insurance coverage and address inadequacies to accelerate the drive towards the attainment of UHC by 2030.

Background Policies for universal health systems aim to provide equitable access to quality healthcare. However, achieving this remains a complex goal in high and upper-middle-income countries. Despite widespread efforts, universal health system reforms vary significantly, shaped by historical, political, and economic contexts. Understanding the policy process, including the roles of various actors and institutions, is essential to improving policy effectiveness and achieving equitable health systems. This scoping review examines the literature on policy processes, stakeholder influences, and contextual factors shaping policies for universal health system reforms. Methods A systematic search of peer-reviewed and grey literature from 2014 to 2024 was conducted using five academic databases and Google Scholar. Seventy-four studies focused on policies for universal health systems in high and upper-middle-income countries. Data was examined in two phases. First, a descriptive analysis explored the geographic and economic contexts of the studies and their representation across stages of the policy cycle, including agenda-setting, formulation, adoption implementation, and evaluation. Topp et al.’s framework was then used to examine the influence of key actors, focusing on their relationships, power sources, and societal expressions of power. Results The review revealed significant geographical disparities, representing only 30% of eligible countries. Most studies focused on early policy stages, with limited attention to implementation and evaluation. A predominance of qualitative research facilitated contextual insights, yet the underrepresentation of quantitative and mixed methods approaches restricted opportunities for integrated analysis. Crises and ideological shifts were drivers of policy momentum, catalysing changes in universal health system reforms. Governments played a central role, supported or contested by civic groups, professional associations, and academia. Media often influenced public discourse and policy perceptions, amplifying or challenging reform narratives. Persistent challenges included fragmented systems, equity-efficiency tensions, and definitional ambiguities, undermining policy coherence and sustainability. Conclusions The review underscores the need for a broader ‘universal’ framework for understanding health system reform and prioritising equity, quality, and sustainability. Adaptive health systems, robust institutions, and standardised frameworks to address political, economic, and ideological barriers are crucial. Future research must evaluate equity impacts, refine policy design, and explore mechanisms to align reforms with universal health system principles and goals.

A wider range of social protection services, including social insurance and social assistance, are gaining global attention as a key driver of improved health service coverage and financial protection among vulnerable populations. However, only a few studies have investigated the associations between social protection and universal health coverage (UHC). Therefore, we conducted a literature review on relevant international organizations with respect to this topic. We found that many international organizations consider the wide range of social protection services, including social insurance and social assistance, essential for achieving UHC in 2030. In specific health programs, social protection is considered an important service to promote health service access and financial protection, especially among vulnerable populations. However, discussions about social protection for achieving UHC are not given high priority in the World Health Organization. Currently, the coverage of social protection services is low among vulnerable populations in low- and middle-income countries. To address this issue, we employed the metrics recommended by the migrant integration policy index (MIPEX). Based on our findings, a conceptual framework was developed. We expect this framework to lead synergy between social protection and health systems around the globe, resulting in healthy ageing.

Objectives A substantial number of low and middle income countries (LMICs) have implemented health sector reforms in the last 40 years, and the majority of them have included some degree of decentralization of the health system as part of the wider reform. This review will provide an updated and comprehensive assessment of the effects of decentralization in LMICs. Methods We conducted a systematic review of published and grey literature till May 2015, following standard methods. Results 54 qualitative, quantitative and mixed methods studies conducted in 26 countries were included in the review. We found positive and negative effects of decentralization of health systems in LMICs. Whereas decentralization of governance, financing and service delivery, have been shown to have positive effects on the system; decentralization of resource management has been challenging in several settings. Conclusions Overall, lessons learned from LMICs suggest that factors such as adequate mix of technical skills at the local level to perform decentralized tasks, effective decentralization of decision-making to the periphery, and political leadership are key factors for a successful decentralization.