---
title: "Governance strategies to advance universal health coverage cut across the entire health system"
description: "At its heart, universal health coverage (UHC) is about people getting the health services they need, when they need them, without suffering financial hardship."
type: "NewsArticle"
publisher: "Daily Maverick"
site: "https://www.dailymaverick.co.za"
section: "Sponsored Content"
author: "South African Medical Research Council (SAMRC)"
author_url: "https://www.dailymaverick.co.za/author/south-african-medical-research-council/"
canonical_url: "https://www.dailymaverick.co.za/article/2026-09-21-governance-strategies-to-advance-universal-health-coverage-cut-across-the-entire-health-system/"
published: "2026-09-21T14:00:00"
lang: "en-ZA"
word_count: 1240
---

# Governance strategies to advance universal health coverage cut across the entire health system

> At its heart, universal health coverage (UHC) is about people getting the health services they need, when they need them, without suffering financial hardship.

By South African Medical Research Council (SAMRC) · Published 21 September 2026, 16:00 SAST

## Content

Turning that promise into reality, however, is complex.

Health systems are made up of many interconnected parts, including financing and service delivery to the health workforce, leadership and accountability. Progress towards UHC therefore depends not only on expanding services or improving financial protection, but also on how well these different parts are governed and how effectively they work together.

UHC is a global health priority and forms part of the Sustainable Development Goals for 2030. But achieving UHC involves more than expanding coverage. It also requires decisions about what resources are allocated, who is accountable for implementation, how different people in the system work together, and how communities and patients are involved in the decisions about the health system and the services that affect them.

For South Africa, these questions are particularly important. The country is working towards UHC, with the National Health Insurance Act signed into law in 2024 representing a commitment to health-system reform and efforts to address longstanding inequalities in healthcare access.

How these reforms are governed is central to their implementation.

Countries pursuing UHC do so within very different political, institutional, financing and service-delivery arrangements. Yet face similar governance challenges. These include fragmented systems and poor coordination, weak accountability and transparency, limited participation in decision-making, corruption, and gaps in institutional and managerial capacity.

These challenges can occur throughout the health system from national ministries to provincial, district and clinic levels.

Although the importance of governance for UHC is widely recognised, much of the literature has examined individual governance problems or interventions separately. This makes it difficult to understand the broader range of approaches countries are using as they reform their health systems.

We, a group of South African and Australian researchers, led by the Health Systems Research Unit of the [South African Medical Research Council](https://www.samrc.ac.za/research/intramural-research-units/HealthSystems)and The George Institute for Global Health, wanted to better understand what countries are actually doing to address governance challenges as they move towards, or seek to maintain, UHC.

We therefore conducted a scoping review to identify and describe the governance strategies that countries have used during UHC reforms. We followed good-practice methods and searched four electronic databases including studies describing strategies used to address health-system governance challenges at any level of the health system. We then used established frameworks, the Mikkelson Lopez and World Health Organization health-system building blocks, to organise and analyse the evidence.

Our review included 27 studies from 21 countries across all income settings. The countries were England, Ireland, Costa Rica, Mexico, Argentina, China, India, Bangladesh, New Zealand, The Gambia, Nigeria, Ghana, Ethiopia, Kenya, Tanzania, Rwanda, the Democratic Republic of the Congo, Malawi, Zambia, Lesotho and South Africa. The range of countries gave us an opportunity to look at governance approaches across different geographical, political and health-system settings.

We presented these findings this week at the **18th World Congress on Public Health in Cape Town**.

### **Governance does not sit in one part of the health system**

One thing that stood out: **governance is not one part of but cuts across the whole health system**.

We identified governance challenges across four interconnected areas: health financing, leadership and governance, service delivery and the health workforce.

Most of the challenges we found related to health financing, followed by leadership and governance, service delivery and the health workforce.

Across these areas, countries were using strategies that changed how decisions were made, including who participates in decision making, how different people interested in the health system and services coordinate with one another, how accountability is strengthened, how incentives are structured and how institutional capacity is built.

This matters because governance is sometimes understood mainly as leadership at the top of the system.

Our findings suggest a much broader picture.

Governance is also about the everyday arrangements that determine how responsibilities are shared, how resources move through the system, how decisions are made and how people and institutions are held accountable.

### **What are countries actually doing?**

We found a wide range of approaches.

Within **leadership and governance**, countries used strategies such as decentralising governance from national to district levels, inclusive and participatory planning, partnerships and multi-stakeholder engagement.

Within **health financing**, approaches included strategic purchasing, pooled insurance arrangements, performance-based payments and stronger mechanisms for financial accountability.

For the **health workforce**, strategies included decentralised decision-making, competency-based leadership development, clearer definition of roles and responsibilities, and formal agreements between different professionals.

Within **service delivery**, strategies focused on multi-stakeholder coordination, community participation and strengthening mechanisms for monitoring and accountability.

Importantly, these strategies rarely appeared in isolation.

A financing reform, for example, may also require changes in accountability, leadership, health-information systems, workforce roles or coordination between different levels of the health system. This is one reason why UHC reform can be so challenging: changes in one part of the system often have consequences elsewhere.

### **Much of the real work happens outside of national level**

Another important finding was where these strategies were being implemented.

Many were designed at national level, often by Ministries of Health. But implementation frequently took place at district levels, where national policies are translated into everyday decisions about services, staff, resources and communities.

The groups involved or affected included the public, patients and health managers, as well as government departments and district-health teams responsible for implementation.

National policy can set the direction, but much of the practical work of making health reform succeed happens closer to where services are organised and delivered.

### **What does this mean for South Africa?**

Our review does not point to one governance model that every country should follow.

Instead, countries used **different combinations of strategies in response to their own governance challenges**.

For South Africa, this is particularly relevant as we aim for more equitable systems that meet the needs of all South Africans.

Questions about financing cannot be separated from questions about leadership, workforce capacity, service delivery, accountability or the relationships between national, provincial and district levels of the health system.

Bringing together the experiences of countries that have already undertaken UHC reforms gives policymakers and health-system stakeholders a clearer picture of the range of approaches that have been tried and the settings in which they have been used.

It also helps move the conversation about governance away from broad principles alone and towards the practical question of **how health systems can organise people, resources, responsibilities and relationships in ways that support reform**.

There is still much we need to understand.

Knowing that a governance strategy has been used does not automatically tell us it will work in another setting, or why it succeeds in one context and struggles in another.

Further research is needed to understand fully how these strategies are implemented, what helps or hinders their implementation, and under what conditions they achieve their intended outcomes.

For countries working towards UHC, including South Africa, perhaps the most important lesson from the evidence is that governance cannot be treated as a stand-alone issue.

**It runs through the entire health system – and making universal health coverage work requires different parts of that system to work together.**

Our other partners in this work were: Office of AIDS and TB Research, SAMRC; Department of Public Health Medicine, University of Pretoria; School of Family Medicine and Public Health, University of the Western Cape; and Department of Medicine and Division of Epidemiology and Biostatistics, Stellenbosch University. **DM**

*Authors: Hlengiwe Moloi and Tamara Kredo, Health Systems Research Unit, South African Medical Research Council*