No shortcuts to universal health coverage: lessons from accountability initiatives

Member states of the United Nations have prioritised the achievement of universal health coverage (UHC) by 2030, setting it as a target in the Sustainable Development Goals in 2015 and reaffirming this commitment in subsequent declarations in 2019 and 2023.^{1 2} Yet progress towards UHC has stagnated since 2015, with minimal or no improvement in nearly every service coverage area.³ In 2021, about 4.5 billion people lacked access to essential health services.³ Progress in protecting households against financial hardship due to medical expenses has also regressed. The proportion of global populations experiencing impoverishing out-of-pocket (OOP) health expenditure increased by 4.9% at the relative poverty line between 2000 and 2019, and the proportion with catastrophic OOP health spending increased by 3.9% during the same period.³ These indicators present a world moving increasingly off track to reach UHC by 2030.

A major obstacle to progress on UHC is the challenge of ensuring coverage for poor and marginalised populations. Regardless of the selection of schemes employed to advance UHC, governments around the world have primarily relied on public funding to cover services for these groups.4,8 Despite having theoretical public coverage, these recipients are often unaware of what is available to them or unable to navigate the often convoluted processes required for enrolment and care access. These problems have created a serious gap between policy intent and practical implementation. Accountability initiatives are one attempt to close this gap. These efforts are designed to ensure that social health insurance coverage enables real healthcare access among the population it intends to serve and reflects and responds to their evolving needs. Drawing on evidence from Bosnia and Herzegovina, Colombia, Democratic Republic of Congo, Ghana, India, Indonesia and Nigeria, a BMJ Global Health supplement examines a pressing question: to what extent can governmental and non-governmental accountability initiatives adequately target and engage poor and marginalised populations to support efforts towards UHC? From the mixed results reported in the supplement’s seven papers, we can draw several lessons.

First, countries have used a range of tools and approaches to support enrolment in insurance schemes and uptake of health services. These have included information on schemes and entitlements, dedicated personnel to address grievances and direct support to help end-users navigate schemes. A comprehensive cross-cutting analysis from six countries examined to what extent initiatives support UHC policy goals and highlight the strengths and flaws of such initiatives.⁹ Government-run accountability initiatives have achieved successes but also demonstrated common challenges, including low community awareness, limited resources and poor design and implementation capacity.⁹

For example, desk officers for the Nigerian National Health Insurance Scheme provided hospital patients with direct support for navigation and grievance redress, achieving user satisfaction of nearly 80%.⁹ Yet, the programme still suffered from insufficient staffing and absenteeism. Analysis of a Ghanaian government mandate, the National Health Insurance Service Mobile Renewal Service Platform, demonstrated moderate success.¹⁰ The service offered both information on insurance entitlements and a renewal function. While the former was little known to the public, the latter service was used by more than half of all enrollees. Another paper examines a failed Colombian user association mandated by the government.¹¹ These bodies comprised enrollees who wanted to be part of insurer negotiations as an accountability measure for quality and service implementation. However, these associations had a major design flaw. They were delegated to health insurers without incentives to support these groups, leading to low financial investment and community participation in often non-operational user associations. Despite poor efficacy overall, some instances of positive enrollee experiences in user association-facilitated grievance redressal indicated high potential for this government-mandated initiative.

This supplement also shows that when the state-run UHC schemes fail to engage the poor and marginalised, civil society organisations (CSOs) and community action can improve UHC policy implementation with their own accountability initiatives. Due to their longstanding community relationships, CSOs can benefit from greater public trust and more precisely targeted solutions, facilitating more widespread engagement and greater efficacy, often in partnership with government.⁹

The community-organised Self-Employed Women’s Association Shakti Kendras (SSK) initiative in Gujarat, India, exemplifies CSO efficacy.¹² These SSK resource centres were a response to the structural barriers that women face in accessing care. In addition to providing basic health services, they collaborated with the government to help female patients access their public entitlements. Beneficiaries reported increased knowledge and utilisation of entitlements. The initiative’s success was attributed to high community buy-in, thanks to local leadership, access to government systems and flexibility that allowed SSK centres to address a variety of problems. Similarly, a paper assessing community efforts in Indonesia, such as Jamkeswatch, examined underperforming government initiatives for patient navigation and grievance redressal.¹³ Users reported high trust in the activist volunteers and appreciated their ease of access via phone or WhatsApp. In the Republic of Srpska in Bosnia and Herzegovina, a study found that Family Medicine Teams (FMTs), in which a doctor and nurses provided medical care and informal patient navigation, were crucial in helping elderly patients understand and access their insurance entitlements.¹⁴ Although these FMTs lacked training and remuneration for this additional role and were not mandated by the government, FMTs had high community penetration (99%) and trust (96%). They filled a critical gap left by non-functional or absent bodies mandated by the government to provide patient navigation and grievance redressal.

However, the supplement suggests that civil society and community action in accountability initiatives are not a panacea. For example, the FMTs in the Republic of Srpska in Bosnia and Herzegovina were not sufficient to bridge the gaps in service coverage, as they could not address grievances and complained of patient navigation taking time away from important clinical work.¹⁴ Similarly, in Indonesia, the Jamkeswatch volunteers directly negotiated with the government insurance body, yet these informal groups had limited success in improving responsiveness.¹³

Non-governmental accountability initiatives can also fail. In the Democratic Republic of Congo, mutual health organisations (MHO) run the country’s community-based or cooperative health insurance model independently of the government.¹⁵ MHO brokers served as patient navigators and addressed grievances, but they were found to operate with low community awareness and inadequate systems for complaint documentation and redressal. While health insurance was not organised by the state in this case, this CSO accountability effort was ineffective in remedying the insurance scheme’s failures.

Perhaps most importantly, these papers show that accountability initiatives, whether by the government or civil society, cannot fully compensate for weaknesses in the design of UHC schemes or failure of the state to fulfil its responsibilities. Workforce shortages, insufficient financing, lack of commodities, poor referral systems or poor-quality care cannot be remedied through these measures. Moreover, the mixed success of accountability initiatives highlights the tension in targeting approaches for poor and marginalised populations to enable UHC. Even with high levels of insurance scheme enrolment, accountability initiatives cannot necessarily enable poor and marginalised populations to access services or reduce OOP expenditure.⁹

In conclusion, this supplement shows how accountability initiatives can improve the success of UHC schemes. It highlights the useful contribution of civil society and provides guidance on how these initiatives can best be designed and implemented. Yet, it also warns that such flawed schemes make only a marginal contribution to advancing UHC. For success, future schemes will require careful attention to design and resourcing and caution in the use of targeting. Once implemented, flaws are hard to remedy and have long-term impacts, which will further impede progress towards UHC.

The views expressed in this article are solely those of the individual authors, and do not necessarily reflect the views, decisions or policies of the World Health Organization.

Data availability statement

There are no data in this work.