Examining the roles, relationships and power dynamics shaping universal health system policy processes in high- and upper-middle-income countries: a scoping review.

backgroundPolicies for universal health systems aim to provide equitable access to quality healthcare. However, achieving this remains a complex goal in high and upper-middle-income countries. Despite widespread efforts, universal health system reforms vary significantly, shaped by historical, political, and economic contexts. Understanding the policy process, including the roles of various actors and institutions, is essential to improving policy effectiveness and achieving equitable health systems. This scoping review examines the literature on policy processes, stakeholder influences, and contextual factors shaping policies for universal health system reforms.

methodsA systematic search of peer-reviewed and grey literature from 2014 to 2024 was conducted using five academic databases and Google Scholar. Seventy-four studies focused on policies for universal health systems in high and upper-middle-income countries. Data was examined in two phases. First, a descriptive analysis explored the geographic and economic contexts of the studies and their representation across stages of the policy cycle, including agenda-setting, formulation, adoption implementation, and evaluation. Topp et al.'s framework was then used to examine the influence of key actors, focusing on their relationships, power sources, and societal expressions of power.

resultsThe review revealed significant geographical disparities, representing only 30% of eligible countries. Most studies focused on early policy stages, with limited attention to implementation and evaluation. A predominance of qualitative research facilitated contextual insights, yet the underrepresentation of quantitative and mixed methods approaches restricted opportunities for integrated analysis. Crises and ideological shifts were drivers of policy momentum, catalysing changes in universal health system reforms. Governments played a central role, supported or contested by civic groups, professional associations, and academia. Media often influenced public discourse and policy perceptions, amplifying or challenging reform narratives. Persistent challenges included fragmented systems, equity-efficiency tensions, and definitional ambiguities, undermining policy coherence and sustainability.

conclusionsThe review underscores the need for a broader 'universal' framework for understanding health system reform and prioritising equity, quality, and sustainability. Adaptive health systems, robust institutions, and standardised frameworks to address political, economic, and ideological barriers are crucial. Future research must evaluate equity impacts, refine policy design, and explore mechanisms to align reforms with universal health system principles and goals.