How has sustainable development goals declaration influenced health financing reforms for universal health coverage at the country level? A scoping review of literature

Global declarations shape public policy priorities and guide development finance flows [1‐3]. The declarations energize governmental processes and provide a reference point that guides national policies toward priority development issues. Therefore, global and regional declarations can be powerful tools for shaping policy and programme response on issues that are of public concern [4]. The United Nations General Assembly (UNGA) meeting in New York in September 2015 under the theme, “Transforming our world: the 2030 Agenda for Sustainable Development”, adopted 17 sustainable development goals (SDG) as the post millennium development goals (MDGs) development blue print [5]. Health is explicitly addressed in paragraph 26 of the SDGs declaration [6]:

To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind...

Achieving universal health coverage (UHC) is one of the overarching targets of the 2030 agenda for sustainable development, under goal 3 (Ensure healthy lives and promote well-being for all at all ages). Universal health coverage is based on the principle that all people should have access to health services they need and do not suffer financial hardship while accessing the services [7]. This implies an effective, efficient and equitable health financing system is a critical and essential component that contributes to achievement of UHC target under the SDG declaration [8‐11]. It is only when resources are adequate, efficiently used and equitably mobilized, pooled and spent that all people can enjoy sustained progress towards UHC [12, 13]. Health financing influences progress on the three UHC goals of equity in the use of health services, quality of care and financial protection through effects on UHC intermediary objectives of transparency and accountability, efficiency and equity in resource distribution [8, 14].

For many countries, achieving UHC require reforms in their health financing systems so that people have financial protection while accessing quality health care [15]. Therefore, a number of countries in the African region have been attempting to reform the way health is financed to ensure sustainable progress towards UHC [15‐19]. However, these attempts, largely spearheaded by Ministries of Health have been slow and intermittent as reflected in the slow and/or forward and backward movements in the reform processes [16, 20‐22]. The process of introducing comprehensive National Health Insurance Scheme (NHIS), for example, has been ongoing in the last 2 to 3 decades in Uganda, Kenya, Zambia and South Africa [16, 20‐24]. In South Africa, Uganda, Kenya and Zambia, Health Insurance Bills were (or have been) drafted, however they have not reached parliament for legislation. In cases where the parliament passed the Act, it never became Law due to failure by the Executive arm of governments to ascent to the Bills or the process took very long [22, 25, 26]. However, the policy landscape where various efforts for strengthening or reforming health financing systems occur may be different with the SDG declaration. This is because health financing reforms are a political process, and SDG is a global political declaration with UHC as one of its targets. Effective, efficient and equitable health financing systems are critical for the achievement of UHC [27, 28]. Therefore, given the overarching importance of UHC as an SDG target, it is likely that the declaration has influenced health financing reforms and if so, lessons on the how and the outcomes of those reforms are relevant for intercountry learning. So far, there has been no comprehensive review of literature on how health financing reform processes have been influenced by the SDG declaration at national level. Therefore, through this study we aimed at contributing towards filling this knowledge gap and more broadly to the 2013 WHO [29] call for evidence based research that inform initiatives to advance UHC.

In this review we explored how global discussions on sustainable development agenda and the SDG declaration influenced health financing reform processes for UHC at the national level. The review indicates that SDG declaration has influenced health financing reforms. The influence is majorly through two ways; (i) putting and sustaining health financing reforms (HFR) for UHC on the national agenda, and (ii) providing enabling context for debating and passing of Health Laws and reviewing of national health policies to strengthen health financing systems for UHC. Since the start of global discussions on sustainable development in 2012 and the eventual declaration on SDG in 2015, the issue of how to sustainably finance health more efficiently and equitably has dominated national discussions or gained momentum [33, 34, 41‐47]. Countries have enacted Health Laws [33, 42], or reviewed and revised national health policies and strategies so that they are in tandem with the international commitment on SDG and UHC [38, 39, 43, 46]. These findings demonstrate the potential of SDG in promoting a more expansive and interrogative approach to creating systems for better health financing. This is through pushing various stakeholders to engage and seek ways of collaborating and finding appropriate mix of legislation, regulation, policies and guidelines to drive sustainable financing for UHC.

The outcome of the SDG declaration influence can be observed in changes (or proposed changes) to the organization and arrangement in health financing functions and policies. Countries such as Korea and China, where population coverage is over 90% are focusing on two of the three dimensions of UHC i.e., increasing the number of services covered and the extent to which a service is covered (depth of financial coverage), and not merely proportion of population coverage with basic health care. China and Korea are examples of countries demonstrating that UHC in journey, even when majority of population is covered with basic health care, breadth and depth of coverage can still be improved. The SDG declaration has provided a catalyst for the needed improvements [8, 49].

In terms of revenue collection, countries such as China, Republic of Korea and Indonesia are looking at covering the poor and indigent via general tax revenue. In addition, China is encouraging growth of commercial insurance schemes to supplement public health insurance scheme. Philippines is using Sin Tax (earmarked) to cover the premium for the poor while Indonesia is utilizing a Law that compels government to allocate a specific percentage to health sector budget. Zambia wants to develop national health insurance scheme as a way to supplement government general tax revenue and donor funding. In all these maneuvers by countries to improve available funding for health, the attainment of UHC as one of the SDG targets is being cited. However, as has been noted by Kutzin and WHO [8, 14, 50], it is prudent for governments to appreciate that all the revenues come from the people, in one way or another. Therefore, the focus should be on equity and efficient pooling and use of these resources.

Increasing the share of total public spending devoted to health, or increasing the level of compulsory prepaid revenues for health, strategic purchasing, minimizing fragmentation of risk pools, and simplification and promotion of the benefit package to increase people’s awareness of their benefits are pointers of reforms in health financing directed towards UHC [8]. Most of the reviewed articles point to the fact that countries’ changes to health financing functions are towards UHC. However, aspects such as encouraging commercial health insurance, as in China or explicit introduction of insurance scheme as a supplement to government and donor funding, as indicated for Zambia’s case may run counter to UHC aspiration and needs to be undertaken with caution.

Ministries of health and stakeholders within the health sector have leveraged on the SDG declaration to pursue health reforms through lobbying [45], and strategic engagement of stakeholders to generate political and financial support and buy-in into the reforms [43, 46]. The successful use by Ministries of Health and other stakeholders of government commitments to international agenda seems to depend in part on the leadership capacity and the ability to demonstrate that the health objectives are in tandem with overall national development plan and global aspirations. As Agyepong [51] argues, strong leadership and administrative capacity is required within countries to determine, design and implement contextually appropriate policies for UHC.

Given the political nature of reforms, approaches that make a political leader recognized or appear to be behind the reform such as including their name in the reform is another strategy that may work in some contexts, for a whole of government buy-in. This can be seen in the case with Republic of Korea and in the Philippines [41, 43, 44]. Active engagement of sub-national governments and other stakeholders by Ministries of Health can smoothen the process of introducing new health financing policies, as the case of India demonstrates [46]. The UHC2030 partnership [52] argues, “parliamentarians, ministers and local government officials play a major role [in] promoting, financing and implementing UHC, and their commitments and actions are critical for global commitments to be translated into local solutions”.

Global declarations can be used as tools for lobbying, negotiation, re-strategizing and political mobilization. The SDG declaration has influenced reforms in health financing towards UHC by putting the issue on the national agenda, providing reference for the passing of national Laws to facilitate better health financing, and causing countries to revise their national health financing policies. The effects of these are observable in the processes or outcomes in health financing functions and polices including seeking alternative approaches to revenue collection and earmarking of revenue for health, improving pooling arrangements such as reduced fragmentations, pursuance of strategic purchasing methods, expanding coverage with a focus of all the three dimensions of UHC; population coverage, financial coverage and number of services paid through pool funds.

A critical gap in literature is the documentation of how the stakeholders, including Ministries of Health have used the declaration as opportunity to cause change in health financing towards UHC. Most authors only report on outcomes, while neglecting, what explains what happened; an aspect that are better appreciated through getting the perspectives of stakeholders through interviews. There is need for studies to document the countries experiences for shared learning on how the stakeholders in the health sector including Ministries of Health are utilizing global declaration; the SDG to foster desired reforms from their perspectives.