The goal of universal health coverage is receiving increasing international attention. South Africa is introducing a system of universal health care entitlements to be funded from general tax and additional dedicated tax revenue.
Tanzania is integrating existing health insurance schemes for formal and informal sector workers under the management of a single insurer and is seeking to expand insurance coverage of informal sector workers. In both countries, these financing reforms are being phased in, with an initial emphasis on wide-ranging efforts to improve the delivery and management of health services.
Combined, these reforms intend to reduce existing health system inequalities and improve population, health service and health care cost coverage, i.e. to make progress towards universal coverage. Translating such health financing, service delivery and management reforms into intended changes ‘on the ground’ requires a well functioning monitoring and evaluation system which provides data that allow policies to be improved over time, and consequently strengthen their potential to achieve universal health coverage.
While many questions about the most appropriate design of universal coverage reforms in different contexts remain, even less is known about how to implement reform policies effectively. There is an urgent need to gain detailed insights into reform implementation processes to improve the likelihood of successful health system reform.
This research aims to support the implementation of reforms intended to make progress towards universal coverage in South Africa and Tanzania by monitoring and evaluating the policy processes. Specifically, it seeks to: track policy formulation and planning for implementation; monitor the progress of policy implementation at both the national and district levels, with an emphasis on identifying implementation problems and serving as an ‘early warning system’ for policy makers and implementers; evaluate the impact of interventions aimed at progressing towards the goal of universal coverage; engage with policy makers and implementers at all levels about the research findings throughout the study period; and synthesise the results from the studies in the two countries, and compare these with experiences in other countries, to draw out policy implications on reforms and implementation strategies supporting the achievement of universal coverage for quality health care in low- and middle-income countries.
The UNITAS project will produce a range of methodological and empirical results. In particular, it will provide insights into methods for monitoring and evaluating the implementation of key health system reforms and provide a framework and set of indicators for monitoring progress towards universal coverage. It will demonstrate the usefulness of theory of change evaluation approaches in tracking and assessing complex health system reforms, and in understanding how and why reform implementation processes unfold and with what consequences. It will also produce findings on what types of health system reforms best promote progress towards universal coverage in different contexts and how to strengthen implementation processes to achieve reform goals.
To date, very little attention has been paid to explanatory analysis of health system reform implementation experiences and only a handful of studies have been undertaken with the deliberate goal of supporting policy change. The UNITAS study will make an important contribution by critically examining the implementation process of health system reforms in a way that pro-actively supports policy implementation. It will explore innovative methodological approaches that can be applied in other contexts for monitoring and evaluating reform implementation.
Not only will this study contribute to understanding universal coverage policy implementation bottlenecks in low- and middle-income countries, equally importantly it is intended that the monitoring of implementation of universal coverage policies from the outset will greatly support the process of effective policy implementation in the two countries. This will be facilitated by the strong links between the research teams and policy-makers and implementers. A process of rapid feedback on implementation challenges, interpreting these findings and ways of addressing them in collaboration with policy-makers and implementers, and documenting how subsequent actions enhance policy implementation, will strengthen the likelihood of research being translated into policy and practice.
Ultimately, it is hoped that the UNITAS project will contribute to moving towards universal coverage in both South Africa and Tanzania. Previous research by the UNITAS team has highlighted a range of barriers to accessing needed health care in both countries and constraints to achieving comprehensive financial protection against the costs of health care. Reducing inequalities in financial protection and access to care between groups, and moving towards such protection and access for all on equal terms, will have major implications at a societal level.