Award Title: Health Financing Fragmentation and Universal Health Coverage in Brazil, Colombia, Mexico and India
Funder: Department of Health and Social Care

Abstract: The way health systems are structured and financed has major implications for the quality and comprehensiveness of the services they deliver, whether patients use those services, how much they cost and who pays, and whether they deliver improvements in health outcomes.  In many low- and middle-income countries (LMICs) health financing is highly fragmented.  This can produce different health sub-systems within a country, each with different organizations, eligibility criteria to access services, benefit packages and premiums, payment systems and mechanisms to manage financial risk across patient populations. This fragmentation can negatively impact health system goals including ensuring access to high quality care to all patients, irrespective of their ability to pay. Patients served by fragmented health systems may encounter significant financial and practical barriers that prevent them from receiving the high quality, co-ordinated, and continuous care they need, with the poor and disadvantaged affected most. Despite high levels of health financing fragmentation in LMICs, there is little evidence on its nature, drivers, consequences, and potential solutions.

Our research programme seeks to fill these evidence gaps through a range of research activities across four countries which have high levels of poverty and inequality: Brazil, Colombia, Mexico and India. Health systems in these countries are fragmented, but the nature and consequences of this varies in important ways. We have worked closely with key stakeholders from government, academia and local community organisations in each country to identify key research priorities that we will address and key questions that we will answer through a program of locally-driven collaborative research. Stakeholders will continue to be involved throughout the research programme to maximize the relevance of the research and ensure that new knowledge generated translates into improvements that benefit both health systems and individual patients. The research is divided into five work packages that aim to: quantify the nature and variation of financing fragmentation in our four focus countries; investigate how financing fragmentation affects health system goals, including improved access and quality of health services at lower cost to patients; to evaluate the impact of key health system reforms on fragmentation and health system goals; to understand the political factors which drive financing fragmentation and how these can be addressed; increase the use of research evidence in health policy and practice. Our research programme is especially focused on understanding the implications of financing fragmentation for vulnerable groups and how health policy can be better designed to improve their health and well-being. A key benefit of our research will be to strengthen research capacity in partner countries, by supporting the development of a future cadre of research leaders and strengthen institutional and societal capabilities to demand, generate, and utilise high-quality policy-relevant research. In the long term, this work aims to support health system strengthening efforts not just in the four countries, but in other countries where health systems are fragmented, by building a body of translatable research practices and outputs with important insights to address fragmentation, reduce inequity in access to high-quality healthcare, and improve the health of vulnerable populations globally.

Lay Abstract: 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.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health Categories: GENERIC HEALTH RELEVANCE