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Global strategies for implementing health financing equity – a state-of-the-art review of political declarations

International Journal for Equity in Health volume 24, Article number: 45 (2025) Cite this article

Abstract

Background

Implementing health financing equity plays a determining role in achieving Universal Health Coverage. For this reason, the global health community stated multiple political declarations to guide health financing equity implementation in countries. The aim of this study was to investigate the global strategies for implementing health financing equity that emerged from political declarations made before 2024.

Methods

Using a state-of-the-art review design, we identified the political declarations from the search of United Nations databases and the snowball search. We used textual and theoretical thematic analysis methods to extract the global strategies of health financing equity implementation that emerged from the political declarations. We grounded the global strategies in the existing practical framework – the Health Financing Progress Matrix of the World Health Organization. We employed a time-based descriptive analysis method to document the results. Quantitative information was used to shape the analysis.

Results

In total, 40 political declarations were included in the review. From these declarations emerged the strategies of targeted, selective, contributive, universal, claims, proportionate, experimental, united, and aggregated financing to implement health financing equity in countries. Thirty nine of the 40 political declarations that labelled the global health community from 1944 until 2023 placed more efforts on duplicating the prevailing strategies. The declarations, categorised into nine groups (target, unity, universality, selectivity, contribution, aggregation, claims, experience, and proportionality-oriented political declarations), were insistent to press countries effectively implement the strategies.

Conclusion

The political declarations proved to be the essential markers of the global health community’s efforts to raise the profile of health financing equity in countries. Although some of the global strategies that emerged from the political declarations have been shown promise in different countries, any global strategy is neither effective nor optimal for providing efficient and sustainable UHC in all countries. This lays the groundwork for careful management and adaptation of the global strategies to the diverse needs of the diverse population.

Background

Extensive research has shown that countries implement differently health financing equity to advance towards Universal Health Coverage (UHC) worldwide [1,2,3,4]. The UHC is globally recognised as a context in which everyone can have quality health services in need at any time and from anywhere without financial constraints [5]. The UHC became a benchmark goal for all countries [5]. Implementing health financing equity plays a determining role in achieving UHC because, by definition, health financing equity consists of disconnecting people’s needs for health services from the ability of such people to produce income and pay for these services – health services are financed by people with the ability to sufficiently produce and pay but accessed, used and consumed by everyone in need regardless of their capacity to pay [2,3,4].

The health financing equity that resembles what we think of today began in the eighteenth century when the global health community observed a disproportional distribution of health problems and resources in the world [6, 7]. On this matter, the global health community stated multiple political declarations to guide health financing equity implementation in countries [1, 2, 6, 8,9,10].

In this study, political declarations are agreements that arise from globally recognised assemblies, conferences, summits, or forums on the global strategies required to implement health financing equity and achieve UHC in countries [11,12,13].

Reviewing the political declarations is of considerable interest because: (i) the political declarations govern countries’ behaviours when implementing health financing equity [13], however, global strategies (referred to here as globally planned actions or normative statements that shape expectations through giving national policy guidelines to ensure sustainable financial coverage [14]) that emerged from the political declarations remained understudied, imprecise, and ambiguous [15, 16]. To illustrate this further, the 1978 Alma Ata declaration on primary health care did talk about equity and community participation where the community resource broadly interprets the capacity of state-facilitated health care institutions are jointly managed by the community [17]. The declaration is recognised as too broad – the specific contribution of community participation for implementing the health financing equity is as understudied [17]. In the similar way, the 2018 Astana declaration committed to prioritising disease prevention and health promotion [18]. In this context, countries of all income levels continue to face challenges in financing primary health care in a way that affects health financing equity throughout the whole health system [17, 18]; (ii) the political declarations are supposed to build on key health issues, nevertheless, evidence shows that health financing inequity that dominates all challenges to country’s health systems [19] remains – health financing inequity is causing death of people on large-scale and, this is expected to persist in countries in the coming decades [20, 21]. A well-known example of persistent health financing inequity is the pro-rich distribution of health financing services in resource limited countries [2]; (iii) as the political declarations often arise from past experiences (e.g., COVID-19 pandemic and the 2023 political declaration on pandemic prevention, preparedness and response [22]),we believe that a health financing equity oriented review of these declarations may offer lessons for further development of health financing equity.

The health financing equity is not new in the global health debates [23]. This can be illustrated briefly by various global financing strategies such as targeted, contributive, universal, etc. financing that have long been advised by the global health community to implement health financing equity and achieve UHC [24,25,26]. Nevertheless, the achievement remains ineffective [23]. A classic example of this ineffectiveness is that people with financial constraints when seeking quality health services have globally increased from 12.6 per cent in 2015 to 13.5 per cent in 2019 [27].

Situation is such whereas the global health community set up over time these political declarations with one of the main intentions of pressing countries to implement health financing equity in their respective contexts [23, 28]. Worryingly, there is no much scientific debate that these political determinants of health financing equity implementation (political declarations) [23, 28] have significantly influenced the country-level UHC advancements [29].

Since they are sometimes deemed to ignore the myriad circumstances that enter into the health financing equity implementation in different countries [29], the political declarations remained symbolic in some countries and have received insufficient countries attention when trying to implement health financing equity [23, 28].

The aim of this study was to investigate the global strategies for implementing health financing equity that have emerged from the political declarations made before 2024. This is one of the scarce reviews of political declarations that aimed at implementing health financing equity in the world. This review should significantly aid in the observance of political declarations when implementing health financing equity in countries – the paper tracks the global health community agreements towards health financing equity, and may be useful to align domestic and global health initiatives to close gaps in implementing health financing equity.

Methods

Design

The state-of-the-art (SotA) review was appropriate to address the aim of this study – this design offers a time-based overview of ideas on an interesting topic (which in this study is health financing equity) for future policy considerations [30, 31].

We followed six steps for reporting a SotA review proposed by Barry et al. to perform this review [30] as indicated in the following figure (Fig. 1):

  • The first three steps involved framing the study question, topic and time: what global strategies for implementing health financing equity emerged from political declarations made before 2024? The fourth step was about gathering political declarations using relevant search strategies. The fifth step consisted of analysing and interpreting political declarations from a health financing equity implementation perspective. The last step described the study team’s expertise, which influenced their interpretations of political declarations (reflexivity). Plus, we followed the recommendations for specifying and reporting implementation strategies offered by Enola K. et al., as well as the EQUATOR network [32, 33]. This consisted principally of identifying the global strategies and their emergence/reemergence over time.

Fig. 1
figure 1

Six steps for reporting a SotA review

Source: adapted from [30, 31]

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Search strategies

Countries recognised and accepted health financing equity thanks to the efforts of the United Nations (UN) [6]. For this reason, we conducted a systematic search (at the global level) for the terms “political declaration” AND “health” in four most relevant UN databases including the UN Digital Library: https://digitallibrary.un.org, the World Health Organization’s (WHO) Institutional Repository for Information Sharing (IRIS), which is available at: https://apps.who.int/iris/; the International Labour Organization (ILO) Library, available at: https://labordoc.ilo.org/; and the World Bank (WB) Open Knowledge Repository (OKR): https://openknowledge.worldbank.org. We used the MeSH term “health” instead of “health financing” to broaden the coverage and capture the maximum of political declarations dealing directly or indirectly with health financing.

We exploited the “snowball search”, also known as “citation pearl”, etc. [34, 35] to identify additional political declarations (Fig. 2). This strategy builds on one document (termed here political declaration) that is identified as most relevant to a study topic – the document is designated “pearl” [34, 35]. Here, the “pearl” was the 2023 political declaration on UHC [27] because this was the most relevant latest political declaration that met the inclusion criteria in 2023.

Fig. 2
figure 2

Selection of political declarations

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To find relevant political declarations from the “pearl”, we manually checked declarations that were cited in the “pearl” text – citation tracking [34, 35]. We continued to search backward citations until any further citation of relevant political declaration had been found. We searched Google for the quoted declarations in the citations string.

We chose the “citation pearl” for two main reasons: (i) the strategy can be effective to master how a piece of knowledge on a researcher’s topic of interest (health financing equity in this study) has evolved [34] – this conforms with the present study aim and design; (ii) the “citation pearl” can be more effective than searching databases in narrowing down relevant literature to a particular topic [34].

We exported the political declarations from both the database and snowball searches into Mendeley software to remove duplicates.

Eligibility criteria

We included political declarations in English or French that met the criteria in table below and made before 2024 (Table 1).

Table 1 Criteria for inclusion and exclusion
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Data extraction

We used textual and theoretical thematic analysis methods, which are both driven by the topic of a researcher’s interest [37, 38].

Using a health financing lens, we performed textual analysis by making descriptive summaries of political declarations – this fits in the purpose of a SotA review [30, 37]. We employed the Scholarcy Article Summariser to generate the descriptive summaries. The scholarcy is an artificial intelligence tool that can be used in academic research to generate automated summary from a text [39].

To perform theoretical thematic analysis, we turned the summaries into health financing equity-related themes referred to here as global strategies. To do so, each author followed four stages: a) asking the Scholarcy to generate a health financing related summary from each political declaration – automated summary; b) reviewing and synthesising by hand the automated summary into five to 15 words; c) extracting manually a health financing-related message from each political declaration, considering the context – human summarisation in no more than 15 words; and d) confronting the human summary with the synthesis from the automated summary to build a global strategy or theme.

We grounded the global strategies on the 19 desirable attributes of the Health Financing Progress Matrix (HFPM) [40, 41] for six major reasons. First, the HFPM is the WHO’s global qualitative framework to appraising health financing strategies in terms of development and implementation. Second, the HFPM pools all the existing health financing strategies in a single framework. Third, the HFPM is certified as a useful tool to summarise, interpret the existing strategies of financing, and provide guidance on the future health financing directions. Fourth, the HFPM can be applied in any context and/or country that aims to implement health financing equity and reach the UHC. Fifth, the HFPM aligns with the political declarations’ focus on global macro-economic governance of health financing equity implementation by providing a framework for assessing and improving health financing systems tailored to each country and global health goals [40, 41]. Sixth, to provide a robust theoretical foundation to the theoretical thematic analysis method used in this study.

The authors synthesised the 19 attributes of the HFPM into nine global strategies of health financing equity implementation: (i) targeted financing aligns benefits package with the available resources and population in need; (ii) selective financing uses a public budget (occasionally supported by external aid) to universalise a specific package of health services in specific health facilities for a specific or whole population; (iii) contributive financing wherein citizens financially contribute to a health insurance scheme in order to have access to comprehensive health services. The richest can contribute for both themselves and the poorest. Although the contribution amount may vary according to income, health services are made available to anybody in need at any time; (iv) universal financing mobilises the general government budget to finance health services as a fundamental right for everyone. All country residents, regardless of social status, have access to the similar package of health services at no or lowest costs; (v) proportionate financing in which a country designs different proportionate shares of financial contribution for different groups of the population depending on income level, as well as different benefit packages for different groups of the population based on needs. The contribution (via taxes, payroll, insurance premiums, user fees, etc.) is relative to the ability to pay, whereas access to one of the various preset benefit packages is determined by needs; (vi) claims financing is founded on self-determination and uprightness of people towards health services. People claim their health services financing needs. The financer or purchaser evaluates the rightfulness of the claim and, if appropriate, grants the funds to the claimant; (vii) experimental financing involves testing new approaches or ideas to finance health services in a more effective way; (viii) united financing (different from diversified financing, which refers to fragmented but well-coordinated financing) includes the joint financing from multiple strategies for an effective coverage – a country combines two or more strategies that work in complementarity rather than in competition to fill each other’s gaps and broaden coverage; (ix) aggregated financing, in which a country adopts one or more of the aforesaid strategies per population group, set of services, and/or geographical area. In this way, people with different statuses have several kinds of work and workplaces that can fit in different strategies within a same country [40, 41].

The authors organised three online meetings to compile and revise each other’s global strategies deduced from the political declarations. If the authors identified different strategies (where the declarations are linked to different strategies of financing), they debated until they reached a consensus. The EQUATOR Network’s scale for expressing agreement [33] was used to measure the authors’ consensus on each strategy. The scale has nine points, with one denoting “strongly disagree” and nine denoting “strongly agree” [33].

Practically the first author presented the global strategies deduced from each political declaration. Each author had to secretly fulfil the nine-point scale for each presented strategy, considering the content of the political declaration. There was consensus on a strategy when all of the authors selected 7–9. The global strategies that received this score were immediately considered final. Strategies with a score of less than 7 from at least one author were subjected to revision. This implies that if more than one global strategies emerged from one political declaration, the authors retained the more consensual strategy.

Data analysis

We used a time-based descriptive analysis of the global strategies to help understanding. This involved describing the strategies in a language that is compatible with the existing literature on the HFPM [42,43,44,45,46].

For the validity of this analysis [47], the authors compared their results with the other illustrative studies chosen randomly from different countries of the world (discussion).

Some quantitative information (e.g., the prevalence of global strategies in political declarations) was included to shape the analysis.

Results

The figure illustrates that 40 of the 19 806 political declarations initially identified were included in the review. This stresses the rigorous methods applied to guarantee the relevance and quality of the selected political declarations.

Global strategies

Table 2 shows that implementing health financing equity involves multiple optional strategies from the global health perspective.

Table 2 Time-based overview of political declarations and emerging global strategies of health financing equity implementation
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From 1944 until 2023, multiple global strategies emerged in an iterative way (except the strategy of proportionate financing) from 40 political declarations to move the world closer to UHC.

The most prevalent (occured10 times) and common global strategy was targeted financing. This strategy has been emerged in the global health world first in 1994, and reemerged in 1995,2000, 2001, 2002, 2005, 2012, 2014, 2022, and 2023 with the purpose of suggesting countries to direct gradually funds to the most vulnerable people, services, and/or geographical areas [27, 48, 54, 56,57,58, 68, 70,71,72, 74, 76, 86].

The other popular strategy in the global health community was united financing, which has occurred seven times in 1945, 2005, 2008, 2011, 2015, 2016, and 2019 to highlight the importance of financing health in a joint and complementary way amongst eventual multiple strategies of financing in place for an effective coverage [49, 53, 61, 64, 67, 84].

The strategy of universal financing has been repeated six times in 1944, 1948, 1976, 1995, 2002, and 2015 as one of the key focusses to ensure services and financial coverage for all, regardless of needs or particularities [55, 69, 73, 80, 83, 85].

Selective financing has been replicated five times in 1990, 2005, 2011, and twofold in 2018, to emphasise the necessity of choosing best providers from specific locations to purchase health services for a specific group of the population (from whom, where and for whom to purchase health services?) [51, 59, 66, 77].

The strategy of contributive financing has been appeared four times in 1972, 1978, 1987, and 1992 with the aim of narrowing gaps between the poor and the rich in terms of financing and quality services coverage, and increase the accountability of the population in services utilisation and consumption [78, 79, 82].

Aggregated financing occurred three times in 2008, 2014, and 2019 to stimulate countries to track the financial flows amongst multiple existing strategies of financing and ensure that all of those strategies remain coherent with equity in population, services, and geographical coverage [50, 63, 65].

The strategy of claims financing has been emerged twofold in 1973 and 1993 with the aim of financing health services after they are delivered and consumed [75, 81].

Experimental financing has been endorsed two times in 2011 and 2023 with the goal of testing on the fields novel strategies to move ahead in terms of effectiveness and quality in coverage [22, 60].

The most innovative strategy that has emerged from political declarations was proportionate financing because the strategy emerged once in 2008. Within this strategy, coverage may vary amongst different demographic groups according to needs – those in greater needs receive more coverage (in both services and financing) and vice-versa [62, 87].

Political declarations and financing strategies – linkages

The Table 3 indicates the main linkages that the authors established between the political declarations and the global strategies of financing. These linkages resulted from the confrontation of the automated and human summarisation of the political declarations. The linkages helped the authors in determining what types of global strategies were, by consensus, appropriate.

Table 3 Linkages between the political declarations and global strategies of financing
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In accordance to this table, a package of political declarations are linked with each of the nine global strategies.

A range of one to 10 political declarations were in each package.

Discussion

Political declarations

This study found 40 political declarations from which emerged the global strategies of health financing equity implementation from 1944 until 2023 [22, 27, 48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87]. The statement years of these declarations (Table 2, column 3) indicated that health financing equity has long been a foundation for the political declarations to force countries to move closer to UHC. Comparison of these findings with those of the study of Yao et al. confirms that even before the first political declaration in 1944 [85], health financing equity was always one of the conditions for countries striving to develop their health systems [6]. Health financing equity has become one of the prerequisites to UHC attainment in countries [1,2,3,4,5].

The results of this study demonstrated that except the 2008 political declaration on financing for development [62], the remaining 39 political declarations placed more efforts on duplicating the prevailing strategies – these declarations were insistent to press countries effectively implement the strategies. However, we believe that when under pressure, countries may sometimes behave in ways that do not help solving the targeted issues. This also corroborates the observation from the Horton R’s study, which showed that the political declarations focus more on recycling the ancient strategies, and often do not align with reality of the moment in different contexts [28].

The global strategies

The present study found nine global strategies that labelled the nine groups of political declarations for implementing health financing equity from 1944 until 2023 [22, 27, 48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87].

Targeted financing

The first group of ten political declarations was target-oriented. The repeated adoption of targeted financing in the last four decades (10 times from 1994 until 2023) underscores the importance given by the global health community to this strategy in implementing health financing equity – this crucial global strategy directs funds where they are most needed first. The ten target-oriented political declarations demonstrated that targeting should principally involve priority-setting. In this regard, we estimate that countries can use the available resources to target which services are achievable first for whom and/or in which geographical areas. Nonetheless, findings from Medicaid study (public insurance for low-income people in the United States of America) have proved that the strategy of targeted financing is weakened by its lack of universality [88]. For example, many African countries such as Nigeria and Eritrea applied targeted financing during the last decades and have never reached health financing equity [2, 89].

United financing

The second group of seven unity-focussed political declarations favoured the strategy of united financing to mainly address the governance issues via regular concertation efforts amongst stakeholders. This strategy that has been adopted seven times from 1945 until 2019 highlights the complementarity function that should label the governance of the health financing equity implementation. The complementarity function may help multiple strategies in place strengthening each other and broaden coverage. This result goes in line with findings reported in Thailand and Malaysia (Asia) [25]. Thailand combined targeted, contributive, and selective financing to fill gaps from each strategy since the 2000s [24, 25]. This combination filled benefits package and health spending gaps from targeted, contributive, and selective financing. So, the country is now recognised as one of the advanced countries in achieving UHC [24, 25]. By combining contributive and universal financing [90], Malaysia reached roughly 100% population coverage [91]. Contributive financing shifted focus on designing and enforcing standards to broaden service coverage. As reimbursement was conditional on reaching standards in Malaysia, services were gradually made available, especially in remote areas [91]. When effectively managed, contributive financing can fill gaps in service coverage, whereas universal financing may close gaps in population coverage [90, 91].

Universal financing

There is a group of six universality-oriented political declarations that supported the strategy of universal financing. This strategy has been endorsed six times from 1944 until 2015 to emphasise the need for a sensitive approach of financing to everyone – reaching everyone without exception. The universality-oriented declarations advocated the removal of out-of-pocket from the health systems as one of the expert ways to implement health financing equity. However, findings from multiple Brazilian studies (Latin America) revealed poor quality of coverage as one of the main effects of removing out-of-pocket to establish universal financing. To illustrate this further, all legal residents in Brazil have equal and free access to public health services [92]. Consequently, Brazil faces over-crowdedness at the points of health services – this lowers quality of coverage [92,93,94,95]. This implies that universalising population coverage can de-universalise (decline) coverage in quality health services, and vice-versa [92,93,94,95].

Selective financing

A group of five selectivity-driven declarations defended the strategy of selective financing to address inefficiencies throughout allocating resources on high-impact areas and/or population. The strategy appeared five times as one of the cost-effective strategies in 1990, 2005, 2011, and 2018. Contrarily, existing evidence show that regardless of its form, selective financing conflicts with the universality character of health financing equity [96, 97]. For example, a study undertaken in sub-Saharan Africa illustrate that many countries applied the strategy of selective financing in the form of selective free health care in public health facilities for pregnant women – this misaligned with universality [96]. Such a kind of misalignment has been observed in other countries such as India (Asia). This said, India focused on controlling few diseases that were more morbid and fatal, and for which effective treatment was available [97].

Contributive financing

The four contribution-founded declarations endorsed four times in 1972, 1978, 1987, and 1992 the strategy of contributive financing as one of the fundamental strategies to enhance the accountability of the population in health services utilisation and consumption. Existing studies indicated that many countries from all income levels such as Germany, Belgium, France, Japan, Netherlands, Russia, some countries from Latin America and Sub-Saharan Africa adopted a mandatory contributive financing to develop an assisted accountability of the population in addressing health financing inequity [2, 98]. Worryingly, the study of Geloso et al. showed that the mandatory financing excels in addressing linear inequities of health financing (e.g., a compulsory payroll deduction in order to make a deadlier disease treatment financially available for every employee) and fails to address complex inequities of health financing [99].

The mandatory financing can also weaken economic system of a country and harm progress on health financing equity [99]. For example, employees can compensate payroll deductions by doing informal activities. To clarify this further, contributive financing is not fully mandatory in Ghana, a country deemed as successful in strategic purchasing for health financing equity in Africa [100]. Nevertheless, contributive financing pushes some Ghanaian employees into tax evasion (e.g., by doing extra informal activities) ranging from 4 to 14% of GDP [100, 101]. The study of O’Hare et al. found that 1% of tax evasion in a country is indirectly responsible for 1% of health coverage loss [102].

Contributive financing, when democratic (voluntary), gives people direct control over their health spending (unassisted accountability), however this strategy has sometimes no positive effect on out-of-pocket [100, 103]. Senegal is one of the countries frequently referred to in the literature as having mastered contributive financing in francophone Africa [104]. A survey on the Senegalese financing system revealed that, whether compulsory or democratic, contributive financing remains subject to poor acceptability by the population [104].

The strategy of contributive financing appeared almost successful in high-income countries and nearly unsuccessful in resource-limited countries [98,99,100,101,102,103,104]. From this standpoint, countries should neither disregard or purblindly implement contributive financing, but rather manage it carefully.

Aggregated financing

A group of three aggregation-oriented political declarations endorsed the strategy of aggregated financing to curb fragmentation in the health systems. That said, this strategy has been emerged in 2008 and reemerged in 2014 and 2019 to deal with coherence amongst multiple strategies of financing in place and alleviate fragmentation in population, services and/or geographical coverage. In line with this finding, previous studies specified that Canada is one of the emerging countries in UHC that adopted aggregated financing and reached the UHC service coverage index of 89% [105, 106]. Each Canadian province has its own strategy comprising universal, selective, or contributive financing, or a combination of two or more strategies [106, 107]. Canada teaches that aggregated financing can lead to UHC, however, the cost-effectiveness of quality services delivered to achieve the UHC is widely compromised [106, 107]. This means that implementing aggregated financing may result in a cost-ineffective UHC [106, 107]. In the current resource-constrained world, we believe that countries need to implement health financing equity in pursuing not only effective but also efficient UHC.

Claims financing

Two claims-based political declarations encouraged the strategy of claims financing as a pathway to economic cooperation. Claims financing has been endorsed twofold in 1973 and 1993 to ensure that the financed health services comply with the UHC standards – this may increase efficiency and effectiveness [75, 81]. The declarations indirectly considered meeting UHC standards as a human right (Table 3) – less progress on UHC may occasionally imply a form of human rights violation (throughout corruption for example) or omission in countries with insufficient public accountability. Research conducted in Australia give some lessons, worth considering in claims financing [108,109,110]. Since claims are subject to control before approval for payment (providers must achieve quality indicators established by the government), the quality of health services is good but limited to preset indicators [111]. Providers in Australia are free to claim payment for health services delivered – this frequently leads to inefficient payment (probably false claims) [109,110,111]. As opposed to Australia, implementing claims financing in the United Kingdom led to less health spending and low levels of unmet financing needs compared to many other high-income countries [112].

Other research shown that claims financing has been executed in resource-limited countries in the form of performance-based incentives to promote providers skills in quality health services provision [113]. Claims financing entailed incentivising those who remarkably achieve the intended UHC standards [113]. Multiple research efforts have proven that increasing incentives in resource-limited countries may result in transitory progress, posing a sustainability issue [113, 114].

Experimental financing

The strategy has been adopted by two experience-based political declarations in 2011 and 2023 in seeking effective and quality coverage. The declarations highlighted that risks management is of importance in offering effective and quality coverage. On this regards, research conducted in China offer greater conclusions. The country executed universal financing for essential services to reduce the incidence of impoverishing health spending observed in prevailing strategies. This resulted in significant but insufficient intended equity outcomes (e.g., zero impoverishing health spending) [115]. After, China applied contributive financing, which also failed to avoid impoverishing spending [115]. Now, the country moved to aggregated financing [115] – a study in the United Kingdom validated that if not closely managed, implementing aggregated financing can result in socio-geographic inequities [98].

Proportionate financing

This sole innovative strategy that has emerged from the 2008 proportionality-oriented political declaration on financing for development emphasised the need for efficient, effective and sustainable way of financing health services by categorising both benefit packages and financial coverage [62, 87]. Such a kind of strategy has been observed in Sweden (Europe), where services coverage varies differently across the population depending on health needs – financial coverage is universal, but on a scale proportional to the level of the needs of the population [116, 117]. The study of Francis-Oliviero F. et al. found that this innovative strategy has not yet clear guidelines of implementation. Subsequently, the strategy is not largely executed all over the world [118].

Strengths and limitations

This study employed manual citation tracking in addition to the database search to identify political declarations – no citation graph was possible to present the citation network because the political declarations have no bibliographic references on which the graph is normally created. The manual citation tracking proved to be more objective than other scholar search strategies [119, 120]. Together, the two search strategies used may ensure the generalisability of the political declarations reviewed. These search strategies are replicable to guarantee transparency.

The search strategies did not yield all political declarations made until 2023. The results stressed duplications in the global strategies that emerged from the political declarations. In this regard, we are convinced that the missed political declarations could offer no additional relevant information to the declarations reviewed. As illustration, it is known that political declarations relating to one disease are selective [36].

The declarations reviewed were from grey literature (not peer-reviewed). These declarations were validated by globally recognised assemblies, conferences, summits, or forums attended by academics, Member States, policy makers, etc. The final texts of political declarations were subjected to validation by attendees after initial drafts were prepared by experts [12]. Validation by participants is one of the ways to scientifically approve knowledge [47]. It seems clear that the political declarations should raise no concern about peer-review.

A state-of-the-art review is vulnerable to subjectivity [30]. The authors’ meetings allowed for critical debates to mitigate the risk of biased interpretations.

The study excluded the political declarations that focused on one disease. We recognise that in situations where the health system as a whole is weak or when a quick action is required to contain a more serious disease, such political declarations may be useful as a stopgap guideline.

We are uncertain that all of the conclusions made from the 40 political declarations support the opinions of the participants in the general assembly, conferences, summits, or forums that validated the declarations. Although all of the political declarations cannot have the uniform and universal interpretation in all contexts, we acknowledge that further studies using primary data from the attendees should complete the present study.

For practical considerations, we compared findings from this study with evidence from studies conducted in other countries with different contexts. While the study did not discuss results using evidence from all countries, we are certain that countries from all income levels (high, middle, and low) were represented, and that the results are feasible.

Reflexivity

The authors have expertise in health financing acquired through experience (in their country of origin) and/or training. The reflexions derived from the authors’ expertise. The first author has considerable expertise in health financing equity and confessed to dominating the study process. None of the authors participated in the country studies and experiences used to discuss and validate the findings. However, we acknowledge that what is reported in papers cannot always mirror reality in the field. The authors had an outsider position and could not mediate the findings with field experiences in each country. Any country-specific context has influenced this review – although findings can be interpreted differently in different contexts, they have an acceptable level of objectivity.

Conclusion

The present study confirmed that political declarations are the main markers of the global health community’s efforts to raise the health financing equity profile in countries. The study found nine global strategies for implementing health financing equity, which are all imbedded in 40 political declarations. These declarations have been categorised into nine groups based on the financing strategies they favoured and adopted: target, unity, universality, selectivity, contribution, aggregation, claims, experience, and proportionality-oriented political declarations. The nine global strategies that labelled the global health community from 1944 until 2023 included targeted, united, universal, selective, contributive, aggregated, claims, experimental, and proportionate financing. Whereas some of these strategies have been shown promise in different countries, health financing inequity persists in countries. Hence, any global strategy is neither effective nor optimal for providing efficient and sustainable UHC in all countries. This lays the groundwork for careful management and adaptation of the global strategies to ensure that the strategies effectively address the diverse needs of the of the diverse population.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

HFPM:

Health Financing Progress Matrix

ILO:

International Labour Organization

IRIS:

Institutional Repository for Information Sharing

OKR:

Open Knowledge Repository

UHC:

Universal Health Coverage

UN:

United Nations

WB:

World Bank

WHO:

World Health Organization

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Acknowledgements

To the reviewers and editor for their insightful remarks and thorough reading of the manuscript.

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  1. Independent Researcher, Brussels, Belgium

    Alexandre Nimubona

  2. Health Care Supply and Demand, Ministry of Health, Bujumbura, Burundi

    Innocent Yandemye

  3. Public Health Department, Universite Sagesse d’Afrique, Bujumbura, Burundi

    Chartière Nigaba

  4. Epidemiology Section, Médecins Sans Frontières Belgique, Nairobi, Kenya

    Beatrice Abura

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A.N. initiated, conceptualised, designed, and led the study process; drafted the initial and final manuscripts. I.Y. commented and added ideas. C.N. suggested some changes. B.A pre-reviewed the manuscripts and suggested inputs. All of the authors revised, edited, and approved the final manuscript.

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Nimubona, A., Yandemye, I., Nigaba, C. et al. Global strategies for implementing health financing equity – a state-of-the-art review of political declarations. Int J Equity Health 24, 45 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12939-025-02404-7

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International Journal for Equity in Health

ISSN: 1475-9276

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