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The link between UHC reforms and health system governance: lessons from Asia

Krishna Hort (Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia)
Rohan Jayasuriya (School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia)
Prarthna Dayal (Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia)

Journal of Health Organization and Management

ISSN: 1477-7266

Article publication date: 15 May 2017




The purpose of this paper is to examine how and to what extent the design and implementation of universal health coverage (UHC) reforms have been influenced by the governance arrangements of health systems in low- and middle-income countries (LMIC); and how governments in these countries have or have not responded to the challenges of governance for UHC.


Comparative case study analysis of three Asian countries with substantial experience of UHC reforms (Thailand, Vietnam and China) was undertaken using data from published studies and grey literature. Studies included were those which described the modifications and adaptations that occurred during design and implementation of the UHC programme, the actors and institutions involved and how these changes related to the governance of the health system.


Each country adapted the design of their UHC programmes to accommodate their specific institutional arrangements, and then made further modifications in response to issues arising during implementation. The authors found that these modifications were often related to the impacts on governance of the institutional changes inherent in UHC reforms. Governments varied in their response to these governance impacts, with Thailand prepared to adopt new governance modes (which the authors termed as an “adaptive” response), while China and Vietnam have tended to persist with traditional hierarchical governance modes (“reactive” responses).


This study addresses a gap in current knowledge on UHC reform, and finds evidence of a complex interaction between substantive health sector reform and governance reform in the LMIC context in Asia, confirming recent similar observations on health reforms in high-income countries.



The authors would like to acknowledge Associate Professor Bui Thi Thu Ha of the Hanoi University of Public Health, who provided material for case study on Vietnam and contributed to earlier drafts; and Associate Professor Helen Dickinson and Professor Jon Pierre, whose paper on governance in high-income country contexts provided the initial ideas for this paper. Initial work on developing a conceptual framework and literature review was funded by a grant from the Melbourne School of Government at the University of Melbourne. The funders played no part in the conduct of the study or the preparation of this paper.


Hort, K., Jayasuriya, R. and Dayal, P. (2017), "The link between UHC reforms and health system governance: lessons from Asia", Journal of Health Organization and Management, Vol. 31 No. 3, pp. 270-285.



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