NIHR HPSR-RL: Health Financing Fragmentation and Universal Health Coverage in Brazil, Colombia, Mexico and India The way different health systems in different countries are organised, financed, and managed have major implications for the healthcare services different people have access to, the quality and scope of these services, how much they have to pay, and how effective these services are at improving and protecting their health. In many low- and middle-income countries, health systems are fragmented. This means there may be separate health systems covering different populations, different organisations providing competing or overlapping services, different service packages offered to different people, and be diverse and complex mechanisms for paying for different services.

Health system fragmentation affects how efficiently, effectively, and equitably health services function. This project will carry a broad range of research to understand health system fragmentation and how fragmentation affects the health system functioning. The research will include collecting and analysing data from four study countries (Brazil, Colombia, India and Mexico) as well as assessing fragmentation globally. It will examine whether different types of fragmentation affect how well health systems perform.

The project will also involve a deep-dive analyses on specific policy reforms related to fragmentation in each country and will understand the impacts on services and population health. Surveys and bespoke data collection activities will support these analyses. It will also study the political and economics determinants of fragmentation and understand why different health systems are fragmented differently and what policy options are available to improve performance.

This project is being jointly led by Imperial College London and the Institute for Health Policy Studies in Brazil with four collaborating institutions – the National University of Colombia, , the Center for Health Systems Research of the National Institute of Public Health in Mexico, O.P. Jindal Global University in India, and the University of York in the UK. These institutions cover the four main study countries where the work is being carried out (Brazil, Colombia, India and Mexico) with support from the UK. The project will run from Oct 2022 to Sept 2026.

This work aims to generate knowledge and evidence to improve health systems and inform policies. In the long run, it aims to strengthen health systems to improve their functioning and improve population health and well-being. 1. Collate data from multiple sources to quantitatively measure the fragmentation of health financing systems in Brazil, Colombia, India and Mexico;
2. Understand the nature of health financing fragmentation and how this varies within and between health systems in the four countries;
3. Assess whether fragmentation is associated with progress towards health systems goals including universal health coverage, quality, improved health and financial protection;
4. Understand how factors such as local governance arrangements and major events such as COVID-19 have affected health system fragmentation and related achievement of health system goals;
5. Evaluate recent health system reforms in Brazil, Colombia, India and Mexico and measures health system and health impacts;
6. Document key political and institutional drivers of health financing fragmentation and identify enablers and hurdles for policy reform;
7. Strengthen collaborations between collaborating institutions and build capacity for longer-term health systems research;
8. Engaged communities and stakeholders throughout the research to foster uptake and increase policy relevance.