Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/24569, first published .
Mapping Research Trends of Universal Health Coverage From 1990 to 2019: Bibliometric Analysis

Mapping Research Trends of Universal Health Coverage From 1990 to 2019: Bibliometric Analysis

Mapping Research Trends of Universal Health Coverage From 1990 to 2019: Bibliometric Analysis

Original Paper

1Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran

2Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran

3Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran

4Department of Health Sciences, School of Public Health, University of Genoa, Genoa, Italy

5Department of Health Management and Economics, School of Public Health, Tehran University of Medical Science, Tehran, Iran

6Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

Corresponding Author:

Masoud Behzadifar, PhD

Social Determinants of Health Research Center

Lorestan University of Medical Sciences

Anooshirvan Rezaei Square

Khorramabad, 6813833946

Iran

Phone: 98 9128934237

Email: masoudbehzadifar@gmail.com


Background: Universal health coverage (UHC) is one of many ambitious, health-related, sustainable development goals. Sharing various experiences of achieving UHC, in terms of challenges, pitfalls, and future prospects, can help policy and decision-makers reduce the likelihood of committing errors. As such, scholarly articles and technical reports are of paramount importance in shedding light on the determinants that make it possible to achieve UHC.

Objective: The purpose of this study is to conduct a comprehensive analysis of UHC-related scientific literature from 1990 to 2019.

Methods: We carried out a bibliometric analysis of papers related to UHC published from January 1990 to September 2019 and indexed in Scopus via VOSviewer (version 1.6.13; CWTS). Relevant information was extracted: the number of papers published, the 20 authors with the highest number of publications in the field of UHC, the 20 journals with the highest number of publications related to UHC, the 20 most active funding sources for UHC-related research, the 20 institutes and research centers that have produced the highest number of UHC-related research papers, the 20 countries that contributed the most to the research field of UHC, the 20 most cited papers, and the latest available impact factors of journals in 2018 that included the UHC-related items under investigation.

Results: In our analysis, 7224 articles were included. The publication trend was increasing, showing high interest in the scientific community. Most researchers were from the United States, the United Kingdom, and Canada, with Thailand being a notable exception. The Lancet accounted for 3.95% of published UHC-related research. Among the top 20 funding sources, the World Health Organization (WHO), the Bill and Melinda Gates Foundation, and the National Institutes of Health (NIH) accounted for 1.41%, 1.34%, and 1.02% of published UHC-related research, respectively. The highest number of citations was found for articles published in The Lancet, the American Journal of Psychiatry, and the Journal of the American Medical Association (JAMA). The top keywords were “health insurance,” “insurance,” “healthcare policy,” “healthcare delivery,” “economics,” “priority,” “healthcare cost,” “organization and management,” “health services accessibility,” “reform,” “public health,” and “health policy.”

Conclusions: The findings of our study showed an increasing scholarly interest in UHC and related issues. However, most research concentrated in middle- and high-income regions and countries. Therefore, research in low-income countries should be promoted and supported, as this could enable a better understanding of the determinants of the barriers and obstacles to UHC achievement and improve global health.

JMIR Public Health Surveill 2021;7(1):e24569

doi:10.2196/24569

Keywords



Universal health coverage (UHC) was one of the ambitious, health-related “sustainable development goals” (SDGs) set by the United Nations (UN) General Assembly in 2015, and is one of the top priorities of their 2030 agenda. UHC represents the hope for better health for the world's poorest [1-3]. The World Health Organization (WHO) has defined UHC as a policy for “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” [4].

At least half of the world's population does not have access to full coverage for a package of essential health services [5]. Health expenses lead more than 100 million people worldwide to extreme poverty every year, often forcing people to make intolerably difficult choices between purchasing food for their children and families, paying for child education, or paying for vital health services [2,6].

Countries differ in the way they address UHC provision based on a wide range of factors, such as political, economic, social, epidemiological, and technical considerations [7,8]. The path to UHC involves important policy choices and inevitable trade-offs [9]. The extent of the impact of a successful UHC implementation is referred to as the “Third Global Health Transition” [10]. Sharing various experiences of achieving UHC, in terms of challenges, pitfalls, and future prospects, can help policy and decision-makers benefit from global good practices and reduce the likelihood of committing errors and wasting resources better allocated elsewhere. As such, scholarly articles and technical reports are of paramount importance in shedding light on the determinants that make UHC achievement possible [11,12].

Nearly all of the Organization for Economic Co-operation and Development (OECD) countries and emerging economies, such as Brazil, China, Colombia, Costa Rica, India, Indonesia, and Russia, have achieved UHC [13]. These countries' experiences can be a major source of evidence of why UHC is desirable and how it should be achieved. Evidence shows a strong relationship between life expectancy at birth and UHC indicators, reflecting the 3 core dimensions of universal health coverage [14]. In moving to UHC, some countries such as Ghana, Indonesia, and Vietnam have increased their UHC indices over time, 1.43%, 1.85%, and 2.26%, respectively, mostly by improving both financial protection and service coverage [15,16].

In recent years, researchers have been using scientometrics, a branch of information science and a subfield of bibliometrics, to quantitatively investigate emerging research patterns in the scientific literature [17]. In addition, scientometrics enables an assessment of trends in article citations and how these indicators and measurements can impact policy and management. Using scholarly databases and visualization technology allows researchers to gain a good understanding of the publication trends related to a given topic [18,19].

To the best of our knowledge, there is a dearth of information concerning research patterns in the field of health care management and, specifically, UHC. Therefore, the purpose of this study is to conduct a comprehensive analysis of UHC-related scientific literature from 1990 to 2019.


Ethics Approval and Consent to Participate

This study was waived from ethical approval because it did not include data on animals or human subjects, and it was based on publicly available data.

Data Sources

This quantitative study was based on medical informatics, data and text mining, and scientometrics techniques [20]. Independently, 2 authors searched Scopus from January 1, 1990, to September 24, 2019. Disagreements between them were resolved through discussion until consensus was reached.

Inclusion and Exclusion Criteria

We limited our search to only scholarly items dealing with UHC, using “universal health coverage” as the keyword. The search was performed without language restrictions. All records relevant to the field of UHC were deemed eligible and, as such, retained in our investigation.

Data Extraction

Data were downloaded in comma-separated values (CSV) format. Independently, 2 authors extracted relevant data, namely, (1) the number of documents published within the study period, (2) the 20 authors with the highest number of publications in the field of UHC, (3) the 20 journals with the highest number of publications related to UHC, (4) the 20 most active funding sources for UHC-related research, (5) the 20 institutes and research centers that have produced the highest number of UHC-related research papers, (6) the 20 countries that contributed the most to the research field of UHC, (7) the 20 most highly cited papers, and (8) the latest available impact factor of journals in 2018 that included the UHC-related items under investigation. Any disagreements between the 2 authors were resolved through discussion until consensus was reached.

Data Analysis

Ad hoc visualization software was used to visualize UHC-related research hotspots, patterns, directions of research development, and other relevant trends, using networks and graphs. All data were imported and loaded into VOSviewer (version 1.6.13; CWTS). For visualization publication density worldwide (ie, publication trends among countries), the open-source tool GunnMap was used [21].


After searching Scopus, a pool of 7224 records was included in our analysis. The increasing publication trend related to UHC from January 1990 to September 2019 is shown in Table 1.

The 20 authors with the highest number of publications in the field of UHC are listed in Table 2. Of the 20 authors, 4 are from the United States, 4 are from the United Kingdom, and 3 are from Thailand.

The network distribution of authors publishing in the field of UHC is shown in Figure 1. The 20 journals with the highest number of publications related to UHC are listed in Table 3. The Lancet accounted for 3.95% of published UHC-related research.

Table 1. Number of publications related to universal health coverage per year, as indexed in Scopus.
YearNumber of publications
199025
199121
199238
199350
1994103
199570
199653
199770
199877
199973
2000115
200183
200287
2003138
2004129
2005136
2006188
2007266
2008254
2009308
2010251
2011312
2012393
2013398
2014449
2015581
2016628
2017668
2018784
2019525
Table 2. Authors with the highest number of manuscripts related to universal health coverage.
RankAuthor’s nameCountryNumber of publicationsCitationsPercentage (n/7224)H-index
1Tangcharoensathien VThailand4731170.6429
2Atun RUnited States3591210.4848
3Teerawattananon YSingapore3138650.4227
4Chalkidou KUnited Kingdom2322230.3122
5McIntyre DSouth Africa2321970.3127
6Norheim OFNorway23196750.3142
7Ridde VCanada2324550.3124
8Hanson KUnited Kingdom2152680.2839
9McKee MUnited Kingdom21513270.2896
10Mills AUnited Kingdom2194870.2856
11Ataguba JESouth Africa208930.2715
12Shibuya KJapan20588280.2766
13Bello AKCanada1971330.2632
14Kruk MEUnited States1946710.2638
15Woolhandler SUnited States19102410.2647
16Limwattananon SThailand18102410.2447
17Patcharanarumol WThailand187140.2412
18Prinja SIndia1810870.2419
19Reich MRUnited States1835800.2432
20Bhutta ZAPakistan17697580.23114
Figure 1. The distribution of authors publishing research in the field of universal health coverage.
View this figure
Table 3. Journals with the highest number of articles related to universal health coverage.
RankJournalNumber of publicationsPercentage (n/7224)Impact
factor (2018)
Quartile in category (2018)H-index
1Lancet2863.9559.102Q1700
2Health Affairs1522.095.711Q1156
3Plos One1522.092.776Q1268
4BMC Health Services Research1311.81.932Q190
5Bulletin of The World Health Organization1241.716.818Q1148
6Modern Healthcare1201.65aQ49
7International Journal for Equity in Health1151.582.473Q146
8Health Policy and Planning1051.442.717Q180
9Health Policy951.312.075Q179
10Social Science and Medicine931.283.087Q1213
11BMC Public Health821.132.567Q1117
12Vaccine811.114.760Q1164
13Malaria Journal771.062.798Q187
14New England Journal of Medicine751.0370.670Q1933
15BMJ Global Health630.864.28Q121
16Journal of Health Politics Policy and Law540.741.839Q248
17American Journal of Public Health520.710.774Q1236
18Health Systems and Reform510.7
19International Journal of Health Planning and Management500.681.450Q237
20Global Health Action500.681.817Q133

a —not available.

Table 4 shows the 20 most active funding sources for UHC-related research. Among them, the WHO, the Bill and Melinda Gates Foundation, and the National Institutes of Health (NIH) accounted for 1.41%, 1.34%, and 1.02% of published UHC-related research, respectively.

Table 5 lists the 20 institutes and research centers that have produced the highest number of UHC-related research papers.

Table 6 shows the countries that contributed the most to the research field of UHC. Among them, the United States, the United Kingdom, and Canada contributed 2426, 919, and 545 papers, respectively.

Figure 2 shows the density distribution of UHC-related publications among different countries and regions around the world.

The 20 most highly cited papers are listed in Table 7. The highest number of citations was found for papers published in The Lancet, the American Journal of Psychiatry, and the Journal of the American Medical Association (JAMA).

In Figure 3, the network of words, themes, and topics associated with UHC is shown. Among them, the top keywords were “health insurance,” “insurance,” “healthcare policy,” “healthcare delivery,” “economics,” “priority,” “healthcare cost,” “organization and management,” “health services accessibility,” “reform,” “public health,” and “health policy.”

Table 4. Most active funding sources for universal health coverage (UHC)-related research.
RankName of InstituteNumber of publications
1World Health Organization102
2London School of Hygiene & Tropical Medicine97
3Harvard School of Public Health74
4University of Toronto65
5Harvard Medical School47
6University of Cape Town45
7Johns Hopkins Bloomberg School of Public Health39
8Imperial College London34
9Centers for Disease Control and Prevention33
10Thailand Ministry of Public Health30
11University of California, San Francisco26
12Johns Hopkins University24
13University of Oxford22
14University of Washington, Seattle22
15University of Witwatersrand21
16Harvard University21
17Columbia University in the City of New York20
18The World Bank19
19UCL18
20University of Melbourne17
Table 5. Highest producing institutes and research centers for universal health coverage research.
InstituteNumber of publicationsPercentage of total
Organisation Mondiale de la Santé3885.35
London School of Hygiene & Tropical Medicine2693.71
Harvard School of Public Health1942.67
University of Toronto1642.26
Harvard Medical School1472.02
University of Cape Town1121.54
Johns Hopkins Bloomberg School of Public Health1041.43
Imperial College London1041.43
Centers for Disease Control and Prevention1021.4
Thailand Ministry of Public Health981.35
University of California, San Francisco931.28
Johns Hopkins University891.22
University of Oxford871.2
University of Washington, Seattle861.18
University of Witwatersrand791.09
Harvard University781.07
Columbia University in the City of New York751.03
The World Bank, USA731
UCL690.95
University of Melbourne680.93
Table 6. Countries and regions that contributed the most to the research field of universal health coverage (UHC) during 1990-2019.
CountryNumber of UHC-related research papers contributed
United States2426
United Kingdom919
Canada545
Switzerland469
India395
Australia370
South Africa299
Thailand285
Brazil219
China215
France205
Japan181
Italy176
Netherlands173
Germany161
Spain158
Belgium149
Mexico131
Taiwan129
Kenya120
Figure 2. Density of publications related to the research field of universal health coverage worldwide.
View this figure
Table 7. Most cited papers related to universal health coverage.
No.TitleYearJournalNumber of citations
1Evidence-based, cost-effective interventions: How many newborn babies can we save?2005Lancet933
2Social consequences of psychiatric disorders, I: Educational attainment1995American Journal of Psychiatry

729
3Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development2015Lancet716
4Socioeconomic Inequalities in Health: No Easy Solution1993JAMA696
5Hepatitis B virus infection: Epidemiology and vaccination

2006Epidemiologic Reviews615
6Persistence of use of lipid-lowering medications: A cross-national study1998Journal of the American Medical Association

550
7Early appraisal of China\'s huge and complex health-care reforms2012Lancet541
8Applying an equity lens to child health and mortality: More of the same is not enough2003Lancet485
9Taiwan\'s new national health insurance program: Genesis and experience so far2003Health Affairs

458
10Varicella disease after introduction of varicella vaccine in the United States, 1995-2000

2002Journal of the American Medical Association427
11Does universal health insurance make health care unaffordable? Lessons from Taiwan2003Health Affairs

406
12Maternal and child health in Brazil: Progress and challenges2011Lancet402
13Establishment of a universal size standard strain for use with the pulsenet standardized pulsed-field gel electrophoresis protocols: Converting the national databases to the new size standard2005Journal of Clinical Microbiology

400
14Help-seeking and access to mental health care in a university student population2007Medical Care

369
15Policy statement: Recommendations for the prevention of pneumococcal infections, including the use of pneumococcal conjugate vaccine (Prevnar), pneumococcal polysaccharide vaccine, and antibiotic prophylaxis

2008Pediatrics

348
16Explaining income-related inequalities in doctor utilisation in Europe2004Health Economics345
17Access to care, health status, and health disparities in the United States and Canada: Results of a Cross-National Population-Based Survey2006American Journal of Public Health325
18The history and principles of managed competition1993Health Affairs

317
19Socioeconomic Disparities in Preventive Care Persist Despite Universal Coverage: Breast and Cervical Cancer Screening in Ontario and the United States1994JAMA310
20Policy relevant determinants of health: An international perspective2002Health Policy307
Figure 3. Network of the most used keywords related to universal health coverage.
View this figure

Principal Findings

This study quantitatively assessed the publication trend related to UHC over the past 19 years. UHC-related publications have been on the rise in recent years, and this seems to be the major focus of researchers, given the important role that UHC can play in improving equity in access to health services and provisions. UHC can enable important achievements in the health sector worldwide. The growth of health-related scientific publications in the field of policy and management, and especially UHC, reflects the global interest and participation of different stakeholders, including researchers, in identifying the different dimensions and determinants that can make it possible to achieve UHC.

Undoubtedly, relying on scholarly publications can improve the performance of the health sector to achieve UHC-related goals. The rigor of the scientific method, if properly followed, can lead to fundamental changes in all areas of life, including health. Bibliometrics-based literature reviews can play an important role in examining the process of scientific publications and orienting researchers in this field [22].

From 1990 to 2019, scholarly publications in the field of UHC have been gradually increasing, especially after 2015 when policy and decision-makers have given particular emphasis to achieving UHC as one of the SDGs. Political commitment and support on this issue has contributed to the prioritization of UHC and put it on the policy and research agenda [23].

This investigation shows that authors from the United States, the United Kingdom, Canada, and Thailand produced the highest number of publications related to UHC. Scientists from the United States, the United Kingdom, and Canada have done research on the possible ways to achieve UHC goals in collaboration with various stakeholders, including health care policy and decision-makers. Thailand is one of the countries working hard to improve its health sector by making profound reforms. Since 2002, despite economic-financial problems and political instability, proper support for UHC has provided Thai citizens with a good level of health services and provisions. Therefore, researchers in this country have tried to disseminate their experiences and practices in the field of UHC to other countries around the world [24].

Usually, researchers aim to have their scientific findings published in prestigious journals so that their papers can have the highest exposure in terms of impact and receive adequate attention and citations from other researchers [25]. The Lancet, which has a high impact factor and plays an important role in influencing and shaping future scientific research, has published the highest number of articles related to UHC. Also, journals in the fields of health care policymaking, decision-making, and management have attracted authors' interest in submitting papers. UHC is a major topic because of its impact on all aspects of health [26].

The WHO, the London School of Hygiene and Tropical Medicine, and the Harvard School of Public Health were among the institutions and research centers that played a major role in supporting UHC-related research. The WHO's institutional nature makes it naturally interested in topics such as UHC, as it strives to provide the best evidence for a given health-related issue. The London School of Hygiene and Tropical Medicine is also one of the most prestigious institutions that, in recent decades, has promoted UHC-related studies, especially in lower-income countries, to improve health in these countries and achieve UHC goals. It strives to empower researchers in the field of health and provide high-quality public health education, as does Harvard School of Public Health.

It is important to note that, in the last decades, these two institutions have become prominent in the fields of health policy and management, indicating that they play an important role in developing UHC-related issues.

Limitations

Despite strengths such as methodological rigor, transparency, and reproducibility, this study has some limitations that should be properly recognized. Its major limitation is the use of a single bibliographic database (Scopus). As such, results should be replicated utilizing other major scholarly databases like PubMed/MEDLINE or Web of Science.

Conclusion

The findings of our study showed an increasing scholarly interest in UHC and related issues. However, most researchers were from the United States, the United Kingdom, and Canada, with Thailand being a notable exception. Research in low-income countries should be promoted and supported, as this could enable a better understanding of the determinants of the barriers and obstacles to UHC achievement and improve global health.

Authors' Contributions

MB, LD, and NLB conceived of the premise for this paper. MB, MM, AB, and MKG designed the research. MB, LD, AB, NLB, and MA conceived of the methodology. MB, LD, NLB, and AB performed the data analysis, graphics, and data interpretation. MB, LD, MM, AB, MKG, and NLB wrote and submitted the manuscript.

Conflicts of Interest

None declared.

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SDGs: sustainable development goals
UHC: universal health coverage
UN: United Nations
WHO: World Health Organization


Edited by T Sanchez; submitted 24.09.20; peer-reviewed by HA Gorji, S Vatankhah, M Saran; comments to author 29.09.20; revised version received 15.11.20; accepted 02.12.20; published 11.01.21

Copyright

©Mahboubeh Khaton Ghanbari, Masoud Behzadifar, Leila Doshmangir, Mariano Martini, Ahad Bakhtiari, Mahtab Alikhani, Nicola Luigi Bragazzi. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 11.01.2021.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license information must be included.