Health financing policies during the COVID-19 pandemic and implications for universal health care: a case study of 15 countries

Background The COVID-19 pandemic was a health emergency requiring rapid scal resource mobilisation to support national responses. The use of e ective health nancing mechanisms and policies, or lack thereof, a ected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health nancing policies adopted in 15 countries during the pandemic, develop a framework for resilient health nancing, and use this pandemic to argue a case to move towards universal health coverage (UHC). Methods In this case study, we examined the national health nancing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health nancing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health nancing. Findings Resilient health nancing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain scal space for health to move towards UHC while building on resilient health nancing structures that can better prepare health systems for future health emergencies. We observed that ve key nancing policies were implemented across the countries— namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, e cient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure e cient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement. Interpretation Our ndings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health nancing policies robust and need to politically commit to public nancing mechanisms that work to prepare for future emergencies and as a lever for UHC.We thank the management team of the Bill & Melinda Gates Foundation and the Saw Swee Hock School of Public Health (National University of Singapore, Singapore) for all the administrative support given. This research was funded by the Bill & Melinda Gates Foundation (Investment ID INV-005598)