Health Financing Fragmentation and Universal Health Coverage in Brazil, Colombia, Mexico and India

Health financing fragmentation is a major challenge to advancing UHC and achieving health equity in LMICs. Financing fragmentation can compromise healthcare coverage and system efficiency, increase costs through service duplication, and result in diverse benefit packages to different population segments. From the patient’s perspective, navigating multiple providers across different healthcare delivery systems can affect access, co-ordination, and continuity of care and can compromise safety, quality, and efficiency.

People experiencing poverty and disadvantage are affected most. Despite high levels of health financing fragmentation in LMICs, there is little evidence on its nature, drivers, consequences, and potential solutions.

Our four-year research programme will be rooted in Brazil, Colombia, Mexico and India, which are global exemplars for studying how financing fragmentation impacts health system goals, including UHC. We will undertake a multi-disciplinary programme of policy analysis and evaluation research, drawing on methodologies from health economics, health services research, political economy, and population health sciences.

Our overall aim is to improve understanding of the nature and impacts of health financing fragmentation in LMICs to inform future health system strengthening efforts and drive progress towards UHC. Five connected work packages (WP) that use a range of epidemiological, statistical, econometric, and policy analysis methods to analyse locally collected and collated data will examine health financing fragmentation from different perspectives: WP1 will quantify fragmentation across countries nationally and sub-nationally using novel metrics; WP2 will investigate the impact of fragmentation on health system goals (including UHC) during ‘normal times’ and during COVID-19; WP3 will evaluate multiple health policy innovations affecting health financing fragmentation–both retrospectively and prospectively; WP4 will examine the political determinants of health financing fragmentation; WP5 centres on stakeholder engagement to build capacity to close the evidence-to-policy gap.

A key cross-cutting focus is on the implications of financing fragmentation for marginalised groups and identifying lessons to improve health equity.

Each LMIC partner led the development of their own research plans through extensive CEI activities. We have planned for a series of CEI activities throughout inception, implementation, evaluation, and dissemination to ensure regular community engagement in the research process for each WP and country. We believe this to be essential to strengthening final research outputs and health and policy outcomes by ensuring that all research is locally driven and owned, and transparently and inclusively produced.

Capacity strengthening at individual, organisational and network levels is a priority in our research programme and is a dedicated focus in our Theory of Change model. Capacity strengthening needs have been locally identified and are integral to research planning.

Our research programme will deliver robust policy-relevant research on health financing fragmentation that is locally-demanded and contextually relevant to community stakeholders. Our knowledge mobilisation and capacity building activities will ensure that these outputs translate into sustained impacts on research environments and policy making, strengthened health systems and improved health and well-being of vulnerable populations.