Customer engagement refers to the emotional attachment a student experiences as a customer during repeated and ongoing interactions. Engagement occurs through satisfaction, loyalty, and excitement about the brand experience. Organizations engage customers at the point of behavioral change by exploring opportunities for emotional connection through continuous and consistent positive experiences. When customers engage with a brand experience, they feel emotionally connected and excited about the product and the service quality. This study’s purpose is examining the effect of brand experience on customer engagement by using service quality as a mediator variable; this research was conducted by collecting data from 254 students of the iGeneration born in 1995. Overall, 254 students participated in this study. Of them, 172 people or 68% of the total respondents in this study were women, and 82 people or 32% were males. The results show no direct effect of brand experience on customer engagement, and there is a role for service quality mediators that mediate brand experience and customer engagement. The results are discussed, and the implications for the organization are mentioned. In the past few years, we have seen that research on customer attachment is on the rise. Initially, the attachment was in human resource management as a psychological connection to increase employee loyalty ; howeveriGeneration students rather than traditional buyers. According to generation theory  based on variance or variance based-SEM.Respondents in this study were students in Bekasi with an average age of 23–30 years who were engaged in buying online, totaling 254 respondents, from a population of 750, a sample taken with table Krecie with research confidence 95% with alpha 5%. A total of 172 people or 68% of the total respondents in this study were women, and 82 people or 32% of the total respondents were male, so the total respondents were 254 people. All respondents were voluntary, and all respondents received approval of the form by providing information about the purpose of the study.This project involves human subjects. The research protocol was approved and reviewed by academics. Ethical approval is not needed following applicable educational guidelines and regulations. Informed consent from the participants is implied through the completion of the survey.To collect research data, researchers used the Likert-type psychological scale. To measure customer engagement we used two dimensions: cognitive and emotional engagement, proposed by To describe the statistical methods and data using mean, median, and standard deviation to determine the normality of data, multivariate normality testing using SPSS 21 software and testing the hypothesis using data analysis methods were used; we modeled structural equations based on SEM (VB-SEM) variants using AMOS version 24 software. To analyze descriptive statistical data, we underlined the correlation between variables focused on describing or explaining variables. By looking at the correlation between research variables, it is expected to understand the three variables studied to test the hypothesis. Data analysis methods were used to model structural equations based on SEM-based variants (VB-SEM) using AMOS version 24 software.This model is a set of statistical techniques that allows simultaneous examination of a series of relationships. In the SEM, variables that are not affected by other variables are called independent or exogenous variables, whereas other variables that are affected by other variables are called dependent variables or endogen.Based on the path analysis model in Based on data processing results and acceptance criteria on model testing, match sizes determine the overall model’s predicted rate on correlation and a good covariance matrix. It can be seen with the chi-square value of 33,813, where the chi-square value result is small, the better, and the model is good see .The value of chi-squares probability is 0.249 > 0.05, indicating that empirical data are identical to the theory/model. The value of the result, the root mean square error of approximation (RMSEA) is 0.040, indicating that the model is close to fit see . WhereasAdjusted GFI (AGFI) 0.949, Tucker Lewis index (TLI) is a cumulative conformity index by comparing the model tested with the baseline model. TLI is used to address problems arising due to the complexity of the model. The recommended acceptance value is TLI 0.996 > 0.90, and the normed fit index (NFI) measure compares the proposed and null models. The recommended value is NFI 0.99 > 0.90. The comparative fit index (CFI), 0.997, is also an incremental conformity index. The magnitude of an index ranges from zero to one; a value close to one indicates that a model has a good degree of conformity; this index is highly recommended to use because it is relatively less sensitive to sample size and less influenced by the complexity of the model. The recommended acceptance value is CFI 0.997 > 0.90Influence analysis intends to see how strong the influence of a variable is with other variables indirectly, but directly variable BE low. The results of calculations of direct and indirect influence are shown in p). The following calculation results show that the indirect effect of brand experience on customer engagement through quality service is 0.934 (sig.). Because indirect influence is more significant than direct effects, it can be concluded that the service quality mediators play a full role in this study.Through the calculation results in Based on the results of the structural model analysis and the testing of the goodness of fit for this study, the effect of brand experience on customer engagement with service quality as a mediator gave the results that the research had a complete role—the statistical hypothesis testing of the effect of each variable to the other variables as follows. Of the four proposed hypotheses, only three were accepted , and one was rejected (H1).In hypothesis 1, there is no proven influence of brand experience on customer engagement. Although some studies say that brand experience has a significant effect on customer engagement, research conducted by In hypothesis 2, there is a proven positive influence of brand experience on service quality although research value is significant but not quite intense. This result is paradoxical to the finding research of In hypothesis 3, there is a proven positive influence of service quality on customer engagement. From the research we conducted, quality service relationships are very influential and significant to customer engagement firmly. This finding supports several prior studies that find service quality may lead to customer engagement: Finally, in hypothesis 4, there is a proven role of mediator service quality of customer engagement with brand experience, but it is very low. Unlike most service research that models service quality as a predictor of customer attitude and behavior outcomes, this study proposes that the quality of online seller services that students judge plays a role in mediation in customer attachment relationships. There is still little research on quality service as a mediator to customer engagement, so we compared the research from The study proposes that customer-based factors play a dominant role in engaging customers, and customer-based factors serve as mediators. There are several implications in this study. First, this study contributes to empirical customer engagement testing customer online seller-based factors among students with customer engagement. The results are extraordinarily challenging about the similar effects of customers and customer factors on customer engagement. Customer-based factors play a more prominent role in engaging customers. Second, the number of respondents is not too large, so it cannot be generalized to other students. A more significant number of respondents will give better and more accurate results. Therefore, future studies should test with a more significant number of respondents. Third, because respondents are students in generation Z, subjective possibilities must exist. It is hoped that future research can test more mature students or millennials or even customers of Generation X. Differences in views and cultures need to be considered, especially in the culture in Indonesia, and especially the Bekasi area needs to be the next concern in research.It can also be caused by the ongoing Covid-19 pandemic, because of which changes occur in almost all sectors. Similarly, the local culture that influenced Gen Z decided to engage.Similarly, the findings of this study have important implications for the industry of online merchants in Indonesia and abroad. Regardless of the level of service offered to students, particularly among students, marketing efforts to engage customers among students need to be focused on improving customer experience based on customer psychology. In recent decades, service marketing researchers have widely promoted service quality in customer satisfaction and loyalty but have less involved the role of psychology in preparing its programs. The study shows that quality of service plays a role in mediation of customer-based outcomes. Although the results are identical or different with this study, they could be in a small portion or may contradict some of the results of previous studies; precisely, the effect of brand experience on customer engagement has positive but shallow results. It could be due to local cultural differences, considering that Indonesia has many cultures and cultural influences.Furthermore, influence the way of thinking and making decisions for students to engage a customer. In terms of practical implications for the seller and providing an understanding of the attention to its customers, it is essential that the seller firmly understands the role of customer engagement for the continuity of its organization, for it requires awareness and attention for every employee in the seller’s organization to provide services following customer needs. Thus, seller organizations must pay attention to positive effects and experiences regarding the brand of an organization and the behavior of employees when interacting with customers. Because customer engagement does not show up instantly, seller organizations need to expand and improve other experiences that impact customer engagement. Hence, this research can guide seller organizations that want to increase their customer engagement.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.NM: study conception and design, data collection, and draft manuscript preparation. NA: analysis and interpretation of result. Both authors reviewed the results and approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This research explored the mediating effect of investment in education and training relating to the innovative culture and organizational performance of medical device companies. We used the Human Capital Corporate Panel data provided by the Korea Vocational Competency Development Institute. In the industrial classification system of panel data, the industries related to medical devices were extracted and conclusively analyzed for 8629 workers and 368 companies. The independent and dependent variables were innovative culture and corporation performance, respectively. Investment in training and education was a mediating variable between the independent and dependent variables. Quantitative data were analyzed using SPSS software. A higher level of organizational satisfaction emerged in an innovative culture. Innovative culture positively affected organizational satisfaction. Further, investment in education and training to promote an innovative culture positively affected organizational satisfaction. Medical device companies should improve their performance by creating an innovative culture. The medical device industry in South Korea largely comprises small- and medium-sized companies (SMEs), which cannot exercise their self-sustaining power because they remain under political protection and have been negligent in their growth and development. The medical device industry belongs to small-scale multidisciplinary production—multidisciplinary and convergence technology ventures in medicine and engineering, high-tech industries in SMEs, high value-added industries in technology-intensive industries, and future industries in the 21st century ,4. MedicThe medical device industry is experiencing a radical change of market scale and technology, based on enhanced living standards and an increased aged population. With an increase in the proportion of elderly patients owing to the rise in the retirement of baby boomers and life expectancy, demand for medical devices for chronic diseases is also expected to expand. The bio-health industry refers to manufacturing, medical and healthcare services, and medical devices. It is a promising new industry that has future growth potential and employment impacts. In the medical device industry, the first mover takes advantage of dominating the market and particularly has greater expectancy effects with active investment in new forms of technology. Major factors contributing to the growth of the medical device market include the aging trend, increased interest in health and improved well-being ,6.Advances in information technology, such as computers and the internet, in the late 20th century influenced the formation of a knowledge-based society. The key component of information technology is knowledge. The core aspect of the industry has been transforming from material-based to knowledge-based, and the significance of knowledge has progressed incomparably over time. Since extensive knowledge is shared and distributed, human resources have become a key element of corporate competitiveness: strong competitiveness of human resources enhances companies’ performance. Companies are actively investing in recruiting, educating, training and developing human resources. Education and training are essential activities for the advancement of both companies and their members.Human resources refers to the knowledge, technological wealth or value that cannot be separated from people . With thIn addition to the education and training of the members for human resource development, one of the factors that organizations must possess is the adoption of innovative change. The innovation culture within a company is known to improve internal and external productivity by facilitating rapid adaptation to changes in the external environment and integration within the organization. Diffusion of new ideas and knowledge activities in an innovative culture inspire members to operate more creatively. In particular, the innovation culture of the organization is essential for the sustainable development of SMEs. Innovation culture is an essential element of successful companies and serves as a source for SMEs to develop new technologies or products that are needed to pioneer new markets .Existing studies related to the performance of medical device companies focus mainly on the research and development (R&D) of these companies, medical device technology commercialization and leader capacity of the companies. There is no comprehensive study on the relationship between organizational culture and organizational performance concerning the development of medical device companies. Therefore, we examined the mediating effects of investment in training and education relating to job satisfaction and the innovative culture of medical device companies. This study further seeks to articulate knowledge and ideas regarding the productive contribution of resources.Organizational culture refers to beliefs, values, norms, customs, and so forth that are predominantly shared by members of an organization, and is an important factor affecting employees’ work-related behavior . OrganizThe concept of organizational culture was established in 1980; thereafter, extensive research has been conducted on organizational culture for more than 30 years, with over 4600 related papers published. Although prior studies on organizational culture have been undertaken, obtaining a single definition of the term is difficult: researchers define organizational culture in diverse ways. Herrison (1972) defined organizational culture as bureaucracy culture, power-oriented culture, matrix culture and atomized culture, while Deal and Kennedy (1982) defined it as a tough-guy culture, macho culture, work hard/play hard culture, bet-your-company culture and the process culture. Quinn (1983) defined the four cultural attributes that organizational culture can have and divided them into human resource development culture, open system culture, hierarchy culture and production-oriented culture. Since then, it has been developed and presented as a competing value framework and used as a tool for diagnosing organizational culture . Among tThis study seeks to develop a discussion based on the competing value framework as a theoretical analysis of organizational culture. Quinn and Rohrbaugh’s competing value framework does not have the best criteria for evaluating the effectiveness of an organization. The core variables presented in various research models on organizational culture are combined to present an integrated analysis framework for organizational culture . Unlike Adhocracy culture focuses on adaptability to the internal environment of the organization, and emphasizes the flexibility of the organization and the creativity of the organization members. The paradigm of the economy is rapidly changing owing to the fourth industrial revolution, and companies are trying to adapt to the environment by changing their organizational culture. Medical device companies closely related to ICT and IoT emphasize flexibility and creativity to cope with real-time changing technologies. Medical device companies should develop medical devices that incorporate new technologies and check changes in stakeholders and government policies to provide them to the market. ICT companies need to grasp technological changes and market trends in real-time; thus, organizational change and innovation and values such as creativity and a challenging spirit should be a top priority. In recent studies, innovative culture emphasizes originality and acceptance of ideas in decision-making. To maintain an innovative culture, organizations are encouraging employees to regularly change and to demonstrate creativity through strengthening their capabilities. Medical device companies are expected to form an innovative organizational culture that encourages creativity through strengthening the capacity of employees to develop new medical devices and adapt to changing environments . In thisInnovation is an activity that creates new value and, to this end, it executes creative thinking within the organization. Innovation is the most efficient way to achieve competitive advantage and sustainable development in the market, and innovative companies are trying to develop their ability to adapt to the market. The creativity of an organization leads to innovation within the company, and the constant learning of the organization affects the growth of the company. When an organizational culture or environment promotes innovation capacity and supports personal growth and development, the organizational culture can be classified as an “innovation culture”. Companies are creating better competitive advantages by utilizing innovation to realize sustainable development. Innovative culture involves using innovation as an important strategic tool in competition by developing internal and external situations such as business improvement and productivity improvement . In an iEmployees can share their values and beliefs concerning the development and pursuit of novel business ideas in an innovative culture, which is of central significance. Recently, companies are paying attention to open innovation to accelerate the innovation culture. Open innovation refers to accepting external knowledge and bringing about innovation in the company. The more employees share various knowledge, the more they can create new value in combination with external knowledge .An innovative culture is defined by the delegation of decision-making powers for employees to pursue their own ideas . OrganizInnovative culture has a positive impact on organization innovation. Furthermore, innovative culture encourages the autonomous innovation activities of individuals; groups and organizations require a province to support innovative activities in the field and need innovative thinking and action from employees . AggarwaHypothesis 1.Innovative culture will influence organizational performance.In an innovative culture, the flexibility and discretion of the members are also important. To cope with environmental changes, we will develop new products or services for survival of correspondence to the external environment through strengthening the capacity of organizational members. In an innovative culture, the organizational change to cope with the new market is the greatest value. Through strategies such as organizational performance, flexibility and human resource development, organizational innovation should be strengthened to create a culture that can secure a competitive advantage . MedicalEducation and training have been recognized as the competitiveness factor of the organization. In particular, to lead innovation, education and training are drivers of change for discovering future growth engines and R&D ,29. SincAccording to a survey on the Supply and Demand of Industrial Technology Personnel (2019) , investmIn the face of global competition, many companies are endeavoring to ensure sustainability and generate effective results. The evolution of economic activity in a knowledge economy demonstrates the value of knowledge or intellectual assets as key production factors in the survival and performance of a company. Acquisition of new skills and education have become key functions. Nurturing experienced employees is an assured way to achieve an edge over other companies. Similarly, developing human resources entails enhancement of knowledge, skills and abilities of employees with the aim of improving performance within the organization. It relates to reorganizing the organizational structure and encouraging the system to promote job performance and motivating members for self-improvement. Through education and training, members of the organization can develop performance skills and address problems or deficiencies in their work performance .Unlike in the past, knowledge and skills of an employee have now become a significant factor influencing the competitiveness and performance of the company, and human resources have become an important source of competitive advantage. Consequently, companies are emphasizing commitment and investment in developing human resources, and enormous amounts are invested in education and training worldwide . CompaniEducation and training refer to the systematic acquisition and development of the requisite knowledge, technology, and attitudes to appropriately perform tasks or to enhance employees’ performance. Through diverse types of education and training, the knowledge of employees can be enriched, and essential information can be actively shared between the members. Further, an environment in which members can recognize opportunities for self-development in the future can be cultivated. The productivity of human resources influences corporate performance. Human resources in an organization are acknowledged as a source of competitive advantage; hence, the development and management of intangible resources is growing steadily—not only at the corporate level, but also at the individual and national level. This is because the development of human resources is expected to accomplish considerable improvement in the knowledge, ability, skills, and organizational performance through the education and training of the members .Human resources are extremely intricately connected to a country’s economic and social growth at a macro level. The higher the level of economic and social culture, the higher the level of human resources, such as managers and technical workers, and the greater the degree to which human resources, compared with funds and material resources, contribute to organizational performance. Therefore, the higher the economic and cultural level, the greater the value of successful human resource management, such as securing and developing high-quality human capital . As suchSome claim that investment in education and training does not directly affect organizational performance . As suchHypothesis 2.Education and training investment will influence organizational performance.Companies that pursue innovative culture intend to create an organizational culture that can lead to innovative and creative ideas through investment in education and training. Innovative cultural companies will invest more in education and training as they continue to engage in processes that enable their employees to generate the best value through educational programs on new technologies and roles. Investment in education and training is focused on changing the internal organization in a flexible and innovative direction, and thus enhancing management performance . Hence, Improving employee performance is essential for an organization to achieve a competitive advantage. However, to accomplish this objective, an organization should ensure that its employees are satisfied with their work.Kulachai and colleagues  have conWithout enhancing individual performance, it is challenging to improve the performance of an organization and is not desirable for an organization to persist. Therefore, the link between individual and organizational performance improvement must always be well-harmonized. These organizational achievements are described in a variety of ways, and the following are examples from various scholars .Some believe it is simply how content individuals are with their respective jobs, whether they appreciate the job or its individual aspects or facets, such as the nature of work or supervision. Locke  describeOrganizational satisfaction was argued as a predictor of a company’s potential success, and the results demonstrated that the organization’s satisfaction was closely linked to employee absenteeism and productivity. Byun and Kim  also argIn short, job satisfaction is the degree to which individuals like their jobs . Mutual Hypothesis 3.A company’s education and training investment will mediate the relationship between organizational culture and organizational performance.Companies that pursue innovative culture intend to create an organizational culture that can create innovative and creative ideas through investment in education and training. Innovative cultural corporates will invest more in education and training as they continue to engage in processes that enable their employees to generate the best value through educational programs on new technologies and roles. Investment in education and training is focused on changing the internal organization in a flexible and innovative direction. Through this, it enhances management performance ; hence, Based on the theoretical background discussed above, we sought to grasp the mediating effect of education and training investment relating to innovative culture and organizational performance of medical device companies. For this purpose, innovative culture, organizational performance and organizational satisfaction were established as the independent variable, dependent variable and sub-concept, respectively. In addition, investment in education and training was established as the mediating variable between the independent and dependent variables. The research model is illustrated in The current study used the Human Capital Corporate Panel (HCCP) data provided by the Korea Vocational Competency Development Institute. Beginning with the first survey in 2005, the HCCP Survey has been conducted every two years and now presents the seventh survey results. The research on the HCCP data can identify the quantitative and qualitative level of South Korean corporate workforce, and it can grasp the process and contents of accumulating human resources in a company. HCCP data are accumulated by companies and workers, and the questionnaire consists of items on general management, human resource management, workforce status, human resources development and R&D. The survey of workers consists of participation, the effects of education and training, corporate culture and job satisfaction.Data from the fifth (2013) to the seventh (2017) years were used to analyze the mediating effects of investment in education and training relating to innovative culture and organizational performance of medical device companies. Data samples were provided to industries relevant to medical devices extracted from the industry classification system for panel data . RecentlOrganizational performance was measured with the organizational satisfaction provided by HCCP data, which utilizes a 5-point Likert scale. In addition, innovative culture was measured with the response to the innovation-oriented organizational culture among HCCP data, which also utilizes a 5-point Likert scale. The mediating variable, education and training investment, was measured as the total amount of investment in education and training, which was converted to logarithmic values.Results were analyzed with SPSS 25.0 . First, a correlation analysis was conducted to determine the relationship between each variable. Second, a reliability analysis was conducted to verify the validity and reliability of the variables. Third, a regression analysis was performed to examine the causal relationship between innovative culture and corporate performance and analyze the mediating effect of investment in education and training.To examine the relationship between variables, a correlation analysis was conducted, and the results are indicated in 2 value was less than 0.05, which was judged to be appropriate for the factor analysis model. The cumulative proportion was 88.67%, which was judged to be high in the explanatory power of the two components, and all the factor loadings exceeded 0.4, satisfying the validity of the measurement variables. Cronbach’s α was 0.857; thus, the questionnaire was deemed to have good reliability.For the validity and reliability verification of variables, exploratory factor and reliability analyses were conducted; main component analysis was used as a factor extraction method, and varimax rotation was used . The KaiA regression analysis was conducted to verify the effectiveness of education and training investment relating to the effect of innovative culture on organizational satisfaction .Model 1 represents the relationship between the dependent variable, which is organizational satisfaction and innovative culture, and Model 2 indicates the relationship between investment in education and training and organizational satisfaction. Model 3 indicates the relationship between innovative culture, investment in education and training and organizational satisfaction.2 value increased to 12.8% in Model 1, 15.1% in Model 2, and 15.6% in Model 3, and the interaction of innovative culture and educational training investment was significant. Investment in education and training mediated the relationship between innovation culture and organizational satisfaction.The RAs illustrated in Model 1, innovative culture positively affected organizational satisfaction. As presented in Model 3, investment in education and training to promote an innovative culture positively affected organizational satisfaction.This study identified how innovation culture influences corporate performance, notably the satisfaction of employees, relating to investment in education and training. First, the innovative culture of medical device companies had a positive effect on organizational satisfaction. This is consistent with studies that indicated a higher level of job satisfaction among employees of corporates with innovative cultures . CompaniSecond, investment in education and training of medical device companies positively affected organizational performance. This is similar to the findings of a study that showed that a trained workforce is needed to maintain a competitive advantage in the global economy . InvestmThird, the organizational culture of medical device companies had a positive effect on organizational performance by mediating the association of investment in education and training. This differs from previous results that showed that the more companies form a clan culture, the higher the organizational performance through education and training as compared with companies that employ an innovative culture .As a result of the study, it was found that the investment in education and training of medical device companies plays a mediating role between the company’s innovative culture and organizational performance. This indicates that continuous investment in education and training is necessary to create an innovative culture and to satisfy workers’ job satisfaction to improve the organizational performance of medical device companies. As the medical device industry needs to be sensitive to diverse fields and ever-changing technologies, businesses must be able to respond flexibly to a rapidly changing environment. Government regulations, ethical values and cost effectiveness must also be considered as the value of multi-stakeholder conflicts. In response, medical device companies are fostering an innovative culture that emphasizes flexibility and outward-facing change. In addition, it is an important factor in the development of new products to secure a competitive advantage in the industry, and for employees to embrace innovative values and produce new products, investment in education and training can improve the organizational satisfaction of workers and increase organizational performance.This study was intended to suggest a strategic direction for the rapidly growing medical device industry, but it has the following limitations. It did not solve the problem of endogeneity between variables. Most of the studies that empirically analyze causality, such as this study, test the hypothesis by assuming a unidirectional effect with the dependent variable and the independent variable. However, endogeneity can occur if variables are determined interdependently. Ullah et al. (2017) said that regression analysis can cause endogeneity problems and lead to incorrect interpretation of the results. Additionally, in general, various methods such as two-stage least squares (2SLS), fixed-effects models, generalized method of moments (GMM) and dynamic panel GMM are used to solve the endogeneity problem . Therefo


In this paper, we review lessons learned about Universal Health Coverage (UHC) in middle-income countries, with specific reference to achievements and challenges observed during recent years in four middle-income to upper-middle-income countries – Mexico, Turkey, The Republic of Korea and Ukraine. Three of these countries – Mexico, the Republic of Korea, Turkey are members of the Organization for Economic Cooperation and Development (OECD). Ukraine has aspired to join Western institutions like the OECD since its independence in 1991The research included a combination of cross-sectional and longitudinal reviews of both statistical and contextual data, available from both published sources and available “grey literature” reports.e constitutional guarantees and national health legislation are often a necessary but do not constitute a guaranteed path to success without accompanying institutional measure to secure sustainability  and supply and demand constraints in service provision and consumer/patient behavior. De facto, in most countries expansion in health insurance coverage does not happen “with the stroke of a pen” but require years of commitment and efforts to change the supply and demand after critical legislation has been enacted. Fourth, two major approaches dominate: incremental and “big bang” health system reforms.Based on the research, we conclude the following. First, reaching UHC is achievable in middle-income and upper-middle-income countries. It is not an unattainable goal reserved for upper income countries. Second, successes and failures are evident both in the case of countries that pursue a contributory health insurance path to UHC and those that pursue a core government funding path. Third, the devil is often in the detail. De jurWe caution against the pitfalls of over-attribution from drawing too strong conclusion from individual longitudinal country experiences (“over-determinism”) and over-generalization from broad sweeping cross-sectional statistical analysis (“reductionism”). Every country is different and needs to find its own path towards UHC considering their contextual specificities, learning from the achievements and failures of others, but not try to copy their experiences. Most countries that are members of the Organization for Economic Cooperation and Development (OECD), with the exception of Mexico, Turkey and the USA have succeeded in this quest. And some countries that are not yet formally part of the OECD like the Ukraine have succeeded despite continued macro-economic challenges. [Faced with illness, disability and death, people throughout history, at all income levels – rich or poor – and from all cultural backgrounds have in the past and continue today to aspire to overcome their ailments and restore good health. Systems-wide changes, that allow affordable access to needed health care at the time of illness, has been a major theme for health care reform throughout the 20llenges. .Earlier contributions to this special issue of the Journal have summarized the broader principles of Universal Health Coverage (UHC), its complexity and the pitfalls of automatically equating UHC with achieving universal and affordable access to health care when needed. We will build on this story by looking at the experience of middle-income countries more broadly, and specifically at the well documented experience of Mexico -4, The RSince a comprehensive review of all the different dimensions of UHC would not be possible in a short journal article, we focused our analysis on three dimensions of UHC that have appear to pose major constraints in reaching what could be considered universal access to health services at the time of illness and acceptable financial protection against its impoverishing effects, namely: (a) political and economic sustainability of the reforms: (b) demand-side constraints; and (c) supply-side constraints.why, how, when and to what effect” policies (or lack of such policies) by governments and other groups were successful in advancing the UHC agenda or created impediments [The research included a combination of cross-sectional and longitudinal reviews of both statistical and contextual data, available from both published sources and “grey literature” reports which were retrieved from open source data repositories, including those from the World Health Organization (WHO), the World Bank and national policy documents. We analysed “ediments -19. In pPolitical sustainability. Reaching UHC requires a sustained effort over long periods of time and typically there are periods of lack of progress and even of reversal. We would describe the reforms, focusing on question of political sustainability in our four countries, including the links to economic sustainability.Demand-side issues. A crucial demand-side question in the last stage of UHC is how to deal with the informal sector when expanding UHC. The four countries studied have health systems that include social health insurance. In these countries there were two paths followed to cover the informal sector: The Republic of Korea and Turkey pursued a contributory path for the informal sector, developing mechanisms to raise revenues from informal sector families (in addition to providing tax subsidies). By contrast, Mexico decided not to collect revenues from the informal sector and to cover all families not included by the formal sector social security schemes into a tax-financed system. Another important demand-side challenge for these countries relates to financing and population aging.Supply-side issues. Three topics will be discussed regarding the last step in universality. The emphasis on primary health care, the policy regarding pluralism of providers; and the search for solutions to the scarcity of human resources for health.The following thematic reviews summarize progress made in Mexico, the Republic of Korea, Turkey and Ukraine in moving towards UHC during the past decades, including some of the challenges these countries face in the future in completing the UHC process.th largest economy in the world, with a nominal GDP of US$1.22 trillion and a population of 120 million. Mexico experienced a rapid industrialization and modernization during the past century. The creation of a Social Security System in the 40s providing pensions, medical and social services was one of the major signs of progress. Private formal workers and civil servants enjoyed access to affordable and good quality services. The Minister of Health oversaw public health programs and the provision of medical services based on a national network of primary health clinics and hospitals. There was medical progress in the cities along with urbanization; there were nursing ad medical schools in every State and the National Institutes of Health were prestigious institutions. Despite this progress; the maternal and child health indicators were performing poorly and below what was expected for the economic development experienced in the 60s and 70s. The economic crisis forced the implementation of health systems reforms. There were three distinctive health reforms in Mexico; the first was an administrative reform intended to decentralize functions and devolve health facilities to the states. The second, a service provision reform targeting the rural poor by implementing a model of community engagement and mobilization. More recently, a health financing reform introduced health insurance by targeting the informal sector.Mexico, the second-largest economy in Latin America, is the 15the Republic of Korea, since the introduction of health insurance to the workers in large business in 1976, it was incrementally extended to workers in smaller business along with a series of pilots for the informal sector. The informal sector in rural areas joined the health insurance in 1988, and the universal coverage of population was achieved in 1989 when the informal sector in urban areas were covered. In 2000, all insurance funds were merged into a single insurance system. Since then, health reforms continued, eg, incremental expansion of benefits package, positive listing of medicines based on HTA , pilots of case-based payment, introduction of long-term care insurance, etc.In Turkey introduced comprehensive changes simultaneously in health system functions of organization and governance, financing, resource management, and service delivery to address inadequate and inequitable health financing, human resources and physical capacity [In 2003-2013, as part of the Health Transformation Program aimed at achieving UHC, capacity ,9.Prior to the Health Transformation Program, Turkey had a fragmented, inadequate and inequitable social insurance system. The Social Insurance Organisation for blue-collar workers who were in formal employment was established in 1945. This was followed in 1949 by the creation of the General Employees Retirement Fund for retired civil servants and their dependents and the Active Civil Servants Insurance Fund (covering civil servants in work and their dependents). In 1960, coinciding with the introduction of a new constitution, UHC became a state objective and was included in the 5-year state plans. In 1965, Active Civil Service Fund established to extend health insurance to civil servants in employment, financed by the Ministry of Finance from general budget revenues. In 1971, Bağ-Kur, the social insurance scheme for self-employed craftsmen, tradesmen, artisans, other self-employed, such as seasonal workers, and organized groups, was established. In 1980, Bağ-Kur offered health insurance to its beneficiaries. The addition of Bağ-Kur to the three other social insurance schemes meant that only citizens on low incomes and those in the informal sector who could not afford to pay for social insurance did not have coverage. In 1992, the Green Card Scheme, a non-contributory health insurance scheme for households outside the formal social insurance schemes was introduced as an interim measure until the creation of a unified health insurance scheme. However, unlike the other four insurance schemes, in its first 10 years the Green Card scheme was administered by the Ministry of Health, but without an organised insurance system and a system for means testing low-income families. In effect it functioned as a means of providing funding for uninsured individuals with low-incomes who could not meet hospital inpatient costs. Consequently, the uptake of the Green Card scheme was poor due to limited coverage of benefits – only 2.3 million people accounting for 20% of those eligible were registered under the scheme. While the Green Card Scheme provided coverage of the cost of part of inpatient care it did not so for outpatient services, medicines and diagnostic investigations. As a result, the beneficiaries incurred large amounts of out of pocket expenditures.The health system reforms introduced as part of the Health Transformation Program in Turkey expanded health insurance and service coverage for the country as a whole, but especially for the poorest population, and provided financial risk protection for those who could not afford health care services. The rapid scale-up of health service provision and access was made possible by expanding health insurance coverage and benefits, increasing the size of the health workforce and improving its distribution through contracting, scaling up primary health care services and strengthening emergency medical services. Strategic use of the private sector by enabling the beneficiaries of health insurance (other than Green Card holders) to access private sector providers helped to rapidly scale-up health care services and to enable expanded access.Ukraine is the second largest country by land size in Europe after the Russia Federation. In 2016, The Ukraine had a population of 44.4 million; 15% less than that in 1991, when the country gained independence from the Soviet Union, due to a combination of below-replacement birth rate and emigration. Key population health indicators fell after independence, they have since recovered to improve slightly compared with pre-independence levels, with more rapid improvements since 2010. Life expectancy is 64/78 for men/women (low by European standards) The probability of dying under five is 9 per 1 000 live births in 2017 (good compared with low- to middle-income countries elsewhere in the world). And probability of dying between 15 and 60 of 264/298 for men/women (which is very high by European standards). High mortality rates in the general population are mostly attributable to cardiovascular, cerebrovascular diseases and cancer.th century, Ukraine was a rural area largely ignored by Russia, Austria and Germany. Unlike other Central European countries like the Baltic States, Czechoslovakia, Hungary, Poland and Romania, prior to the Bolsheviks Revolution in 1917, Ukraine did not have any health insurance like the Sickness Fund System in Germany or Friendly Societies like in England. The state had little involvement in health care which was mainly a private domain between doctors and patients.During the 19The Russian Civil War devastated Ukraine. It left hundreds of thousands homeless, and 500 000 people were killed. Many more died from the Russian famine of 1921 . Nevertheless, Bolsheviks were committed to full employment and housing as well as free health care, education and social-security benefits. With the stroke of the pen, the Ukraine and other Soviet Bloc countries joined New Zealand as the first European country to introduce UHC – at least on paper.Unfortunately, facts on the ground in the Ukraine were very different. First, most of these policies were sharply reversed by the early 1930s under the brutal regime of Joseph Stalin. Second, by the time republics like Ukraine recovered from the adverse effects of the policies under Stalin, they were quick to discover a wide range supply, demand, and performance issues in their health systems that were typical of the planned economic model of funding and production.Ukraine, like other countries in the Union of Soviet Socialist Republics  slowly introduced a totally state-run health system — the Semashko model – which was based on centralized planning and delivery of health care services, comprising an integrated and hierarchically network of government health care services for all citizens. All the health workforce became state employees. In principle, the system was intended to prioritize primary health care, with links to specialist and hospital care. It was designed to be a uniquely “coherent, cost-effective system for funding and delivering health care for the population” – precisely what many health system reformers today strive for.In reality, it took until the 1960 for more economically advanced countries like the Baltic States, Czechoslovakia, Hungary, Poland and Romania to reach anything near universal free health care for all. And it took much longer for others in the Soviet Union like Russia, Belarus and Ukraine to reach a similar coverage, largely due to supply constraints – time to build up the infrastructure, especially in expansive rural regions and train enough doctors and nurses. And the Soviet planned economic model was not good at responding to the dynamics of supply and demand forces. It led to an overshoot with more hospital beds and staff being trained than much richer Western European countries.Although effective during the expansion phase from the 1930 to the 1960s, by the early 1980s the Soviet Union had four times the number of doctors and hospital beds per head compared with the USA. It became both financially and politically unsustainable. As a result, the quality of medical care deteriorated well below western standards. Many medical treatments and diagnoses relied on unsophisticated, substandard and insufficient equipment. The system was plagued by shortages in and outdated drugs. Facilities had low technical standards and the health workforce had mediocre training. The physical facilities suffered from chronic low standards of hygiene, food and linen. Although, special hospitals and clinics were available for the Nomenklatura nomenklatura (Communist leadership), even these were far below Western standards.Mexico, recent reforms included administrative overhauls intended to decentralize functions and devolve the operation and financing of health facilities and hospitals to the 32 States. In the 1980s the Mexican economy suffered its worst recession ever and the government had no reserves to repay an accumulating national debt. The WB lent under the condition that Mexico reduce its social expenditure on health and education and also moved forward with decentralization and privatization of health services. There were multiple objectives of the administrative reform including transferring fiscal responsibility to states, municipalities, and users in order to free the central government’s resources and thus repay public debt. This reform was planned to decentralize the MoH by transferring financial responsibilities to the States; however, failed in devolving also adequate decision-making authority [In uthority . The oppMexico that occurred in the late 80s. The context was a country with indigenous communities left behind of the country rapid urbanization and industrialization. Health services were provided in cities and the rural poor was socially excluded and underserved. There was no progress in reducing maternal, infant and child mortality and the government decided to implement inclusive social policies. The reform focused on implementing a new model of service provision with strong community engagement, social mobilization and culturally sensitive. This program operated under the presidency to coordinate all the ministries to achieve community development. The program was known as the Coordinación General del Plan Nacional de Zonas Deprimidas y Grupos Marginados (COPLAMAR). This was a federal funded program that provided high impact basic social and health services free of charge with strong emphasis on community participation. The program was the social branch of IMSS  funded by the federal government and using the expertise, management, administrative platform, information systems, procurement and supply chain for medicines and medical products to support an efficient operation and affordable national program for rural communities (Alvarez 1989). At the center of the integrated health service provision model a physician and nurse assistant covered four communities with a population of up to 5000. Voluntary health workers, traditional healers and rural supervisors were central to this model. The model was supported by new infrastructure; 3025 medical posts and 62 rural hospitals, surgery and integrated family medicine unit. The new model increased health coverage to 10 million people living in rural and disperse communities. Community participation was key to ensure the success of the program. Improved coverage levels for family planning, vaccination, oral rehydration, treatment of pneumonia, parasitosis and tuberculosis, malaria and institutional deliveries had enormous impact. The health condition of indigenous communities was improved along with national health indicators. A reduction in outpatient visits was observed along with an increase in community health promotion and preventive activities. IMSS-COPLAMAR was able to increase coverage to 15% of the population out of the 75 million population in the 1980s and reduce maternal and infant mortality.The next was a supply-side reform in Mexico. It consisted in introducing a voluntary health insurance scheme targeting the poor and the informal sector. Before Seguro Popular was implemented, there were health coverage gaps mainly among the urban poor and the informal sector. The scheme also intended to provide financial protection, reducing out of pocket and catastrophic expenditure to alleviate poverty. This new reform advocated universal coverage through an insurance-based system in which the premium for the poorest people was subsidized by the government and in which public and private institutions compete to capture clients. The government strengthened its stewardship function by regulating the system, financing the services for the poor, monitoring performance and ensuring patient and consumer protection. The Law was enacted in 2004 and the objective was to provide access to an explicit package of services for people excluded from Social Security. Until the end of 2019, the scheme was covering more than 1000 health conditions including 618 surgical procedures and 670 medicines free of charge. The 2019 operating budget was reported in US$ 4 billion and the number of enrollees 53.5 million people. The scheme was voluntary, and an attractive feature of the insurance scheme was based on the premise that funding follows the patient.In 2003, a demand-side health reform was implemented in Mexico started a counter-reform to regain centralized political and fiscal power. During the first year, the new government made legislative changes and dismantle Seguro Popular and replace it with the Mexican Institute of Health and Wellness. In February of 2020, 23 out of the 32 government states had signed framework agreements to receive resources from the federal level and coordinate the operation of the new institution. The arguments provided for the change is that the new institute will be able to “centralize the funding and increase health coverage”, enrollment is not mandatory so all citizens will have access to all health services. However, without enrollment or defined benefits, it is going to be difficult to plan for success, match the supply to the demand, and balance revenue to expenditures and money to pay for explicit health care benefits. There is limited information about operations and service delivery under the new system; however, the new institution eliminates a model where the funding follows the patient and payments are based on results. The new government reintroduced a traditional model where the MoH is in charge of financing and delivering services and funding is allocated to state health care networks regardless of the results and services provided. There is no separation of functions and the MoH is the steward, regulator and provider of services. Opposite incentives will be observed under the new funding model as compared to Seguro Popular in terms of efficiency, productivity and quality of care. Still many challenges remain in achieving integration of the system, equity, efficiencies and quality of care.A new government in The Republic of Korea achieved universal coverage of population in 1989 and merged its insurance funds into a single insurer in 2000. The presidential election triggered and expedited the extension of health insurance for universal coverage of population. President Chun Doo-Whan and the presidential candidate of the ruling party, Roh Tae-Woo, were former military generals and wanted to obtain political support by proposing universal health insurance coverage [coverage . The impAfter the NHI achieved universal coverage in 1989, the NHI system consisted of more than 350 not-for-profit insurance funds. NHI consisted of three different types of funds: health insurance for employees and their dependents; health insurance for school and government employees and their dependents; and health insurance for the self-employed. Because the ability of farmers to pay their contribution was limited, many insurance funds for the self-employed, especially those in rural areas, suffered chronic fiscal deficits. Facing the fiscal instability of self-employed funds, the government introduced a risk-sharing mechanism of cross-subsidy among insurance funds, based on catastrophic medical expense and the proportion of the elderly. However, fiscal deficit in the health funds for the self-employed continued, and there was an increasing concern over inequity among insurance funds.The break-down of the former policy equilibrium with multiple insurance funds was driven by the first progressive government in almost 50 years . With thTurkey, several factors contributed to the creation of an enabling context that made possible the transformation of the health system, including sustained leadership, political support for reforms, including from the Grand National Assembly, the Council of Ministers and most importantly from the citizens who had expectations of improved right to health and access to health care services, and effective targeting of expanded health insurance and services to the poorest segments of the population, and strategic use of available resources  to achieve scale [In ve scale ,9.Turkey, the introduction of major reforms in coincided with a period of political stability when one of the political parties was able to achieve parliamentary majority, and sustained economic growth, which enabled the government to increase health expenditures at an average yearly rate of 9.1% [In  of 9.1% ,9.Ukraine, the reform process since collapse of the Soviet Union in 1991 has been slow [In een slow .Successive governments in the former Soviet Union and countries in Central and Eastern Europe countries, tried to overcome funding and other shortfalls of the Soviet health care system. Most turned to health insurance  and tried to modernize the service delivery system by reintroducing market mechanism reaching a supply and demand equilibrium, rather than rely on centralized planning and they had during the Communist era.Ukraine has been different from the rest of the former Communist countries. Although Ukraine, like many of the Soviet Republics embarked on an aggressive program of economic, political and social transformation, the rapid economic marketization and hyperinflation that followed independence caused severe economic hardship in Ukraine which also affected the health sector.In this respect, Ukraine did not put on the table a health insurance  and marketizing option for changes in funding and service. This makes the Ukraine unique as a case study because an ongoing debate in many of the other countries is that maybe it was the introduction of health insurance and market mechanisms that lead to many of their current problems rather than the legacy of the past. In the Ukraine, there have been no major fundamental reform of the system.But until very recently, Ukraine, that began in 2010, have tried to strengthen primary and emergency care, downsize the number of hospital beds and shift from an inputs to outputs based reimbursement model. But conflict and political instability have made implementation slow and in many cases impossible. Instead, the focus has been on humanitarian priorities arising from conflict in the Crimea.More recent health reforms in Ukraine has focused on decentralization in the service delivery system rather than marketizing reforms. Although decentralization has passed functional and managerial powers to the 27 regions and the local level, it has not given the lower levels of the system autonomy to take decisions over funding or the service delivery model. Restructuring of the service delivery system has been constrained by constitutional provisions that prohibit the reducing of the existing network of publicly owned health care facilities. As a result, the private sector in the Ukrainian health system has remained small, mainly of privately practicing doctors, diagnostic facilities pharmacies and dental services. Capacity planning has remained centralized and input-based, insensitive to supply and demand forces.Since the transition in the 1990s, Mexico, For Republic of Korea, there has been a progressive expansion of coverage over time. From the very beginning, health insurance adopted dependents coverage, in which dependents were covered when family head joined health insurance. Historical increase in population coverage in the Republic of Korea is close to 100 percent. In the Turkey, in 2003, 2.3 million (20% of those eligible) had registered with Green Card Scheme. By 2006, 8 · 3 million people were registered, and by 2011, when the Green Card scheme benefits package became comparable to other types of insurance, the number of enrollees increased to 9 · 1 million. To enable this expansion, the health expenditures in Turkey rose from 4.1% of the gross domestic product in 2002 to 6.1% in 2010. Between 2000 and 2010 public-sector funding increased from 63.0% of total health expenditures to 75.2%, one of the highest among middle-income countries [In Ukraine reached de jure and de facto UHC in the 1960-70s. But over time, because of erosion in the quality of health care out of pocket expenditure has increased, especially since the economic reforms of the early 1990s. As a result, although on paper the Ukraine still offers UHC to its citizens in reality coverage is in terms of financial protection is much lower. Furthermore, since the transition in the 1990s government commitment to the health sector as a percentage of GDP has also dropped and out of pocket expenditure increased.The Most recent data for Ukraine in 2016, shows that following the civil war, it has dropped and out-of-pocket expenditure increasing from its level of 42.3% in 2012, to over 50 percent . Despite providing universal access to health care at no cost in principle, residents are therefore ending up spending significant amounts of money out-of-pocket when needing health care. And many of the problems in service delivery and supply described above remain have remained in Ukraine while improved in countries like the Baltic States, Czechoslovakia, Hungary, Poland and Romania.Ukraine, the health system continues to offer the population universal access to health care at no cost, in reality, the population bears a significant part f the burden through out-of-pocket expenditure. This leads to ineffective protection from the risk of catastrophic health care costs and the structural inefficiency, despite what may at first glance seem like a fair and progressive system of financing.In Ukraine, both during the latter part of the Communist period and today, comes from general government revenues raised through taxation . Payroll taxes, insurance premiums and personal income tax is not a significant contributor to total revenues. Unlike most other countries from the former Soviet Bloc, the use of contributory social health insurance – although debated – has not been introduced in Ukraine as a source of health care financing. Out-of-pocket payments account for most other health expenditure and is a major source of hardship for both lower-income and other population groups. Voluntary private health insurance schemes, plays a marginal role, contributing less than 1 percent to total financing of the health sector. Although at first sight it may seem that this would be a progressive funding system, this is undermined by the size of the informal economy (up to 40% of GDP).The financing of health care in The history of these countries shows that the challenge in the last mile of UHC involves: coverage of the poor and of the informal sector and unification or network integration of health systems. The following sections describe these challenges and identify a rapidly developing additional challenge related to the aging of populations.In Turkey, Mexico and The Republic of Korea, the initial steps were aimed at covering wage-earners in the private formal sector and in the public sector. In Ukraine, the soviet system was declared overnight as having universal coverage; in practice it initially had better coverage for urban and better-off populations. ,9,25. ThThe last mile is about covering the poor and the informal sector. In Turkey and Mexico, these populations were initially covered by public providers that provided variable quality of health care services and required high out-of-pocket payments. So, in Turkey and Mexico the poor and the informal sector already had access to these services, and the reforms to cover them with insurance took a long time and only gained strength once equity and financial protection concerns became important. In the Republic of Korea, the need to provide insurance coverage to the poor and the informal sector was more basic, as there existed very few public providers, so insurance was needed to provide access for these populations to private providers. While in Turkey and Mexico the time-lag between the creation of insurance schemes for the private formal sector and those of the poor took a long time , in The Republic of Korea the lag was only two years.All countries studied perceived unification or network integration of the health systems as part of the quest for UHC. Unification and network integration are always difficult to achieve. In these countries, “unification” is sought by developing a single payer (in other countries it is achieved through network integration– as in Germany).Mexico remains fragmented. The original vision of the reform was a unified system that would cut across all of the Mexican health sector, but that idea was abandoned due to resistance from powerful labor unions at the IMSS. Also, as IMSS was perceived as being inefficient, there was reluctance to expand its role with new responsibilities. A special challenge to integration in Mexico is that IMSS (and the agency providing coverage to civil servants) are not really insurers; they own their own hospital network; hence the challenge of unifying insurance also would require the unification of the public hospital network with the hospital networks of these two institutions; hundreds of unions would oppose this.The Republic of Korea managed the unification process faster than the other countries, from creation of the initial fund to unification in only 22 years. Before unification, there used to be 350 autonomous schemes. For the formal sector they were based on the workplace, for the informal sector they were based on place of residence. Unification was a reform promoted by a progressive government in year 2000. In addition to the equity objective , it also was motivated by a fiscal problem: Prior to unification, the informal sector schemes received fiscal subsidies for many years; after unification government hoped for improved fiscal sustainability through a nation-wide risk pooling.Turkey for years there was a national goal of unification –it was codified in the 1982 constitution and the 1987 basic health law—but unification only occurred three decades later, in 2011. The hardest challenge to unification was the Green Card . On the path to unification, its benefits were significantly improved, which lead to a large increase in enrolment and made it an important political tool. The scheme was initially managed by the MoH and the Ministry was reluctant for many years to transfer this responsibility to the Social Security Agency. As in The Republic of Korea, unification also meant an equalization of the benefit package and a tax reform that equalized contributions (as % of income) [In Ukraine unification and network integration was the foundation of the communist system of health services. The Union of Soviet Republics  which slowly introduced a totally state-run health care system – the Semashko model – throughout the union – including the Ukraine - which was based on centralized planning and delivery of services, comprising an integrated and hierarchically network of government health care services for all citizens. All staff became state employees. In principle, the system was intended to prioritize primary care, with links to specialist and hospital care. It was designed to be a uniquely “coherent, cost-effective system for funding and delivering health care for the population” – precisely what many health care reformers today strive for. To a large extent, this system remains today, although there is now also some network integration of independent health care providers that have been established since the transition in 1990.In the Countries all over the world are making decisions about how to provide insurance or subsidies for the poor. What can be learned from these countries?In all countries, the financing of health insurance or direct services or the poor is financed by a subsidy from government . What varies across countries is the way insurance coverage is financed for the informal sector or they are given direct access to free services.Mexico, Seguro Popular was originally conceived as a contributory/subsidized scheme. The draft law for SP included a premium scaled according to income class with the lowest two deciles exempt from paying; revenue collection would be a responsibility of state governments who would also receive a transfer from the Federal Government. In practice, the states decided to exempt the population from paying a premium and provided waivers to increase enrollment. The states had an incentive to do so as they received more money as transfers from the federal government for each additional enrollee they reported and there were no mechanisms for the federal government to monitor what matching was being provided by the states.In Republic of Korea, initially the government provided financial support for hospitals to open in rural areas; it also provided a partial subsidy, which was about 50% of the health insurance contributions of the self employed. Today, the self-employed pay contributions estimated on data related to income and property tax (collection is done by the NHIS). There is a controversy over the use of property value to set contributions or whether property is an adequate measure of the capacity to pay. The policy is aiming now to transition into income-based contributions for both formal sector employees and the self-employed, but the incomes would include all sources of income, including financial incomes.In the Turkey, the coverage of the informal sector was achieved through (i) Bağ-Kur, which enabled the extension of social insurance coverage to citizens beyond those in the formal sector and who could afford to pay for social insurance and (ii) through the Green Card Scheme, a non-contributory scheme for households with incomes below the national minimum and for families on social assistance. The poor are defined by per capita income with a simple rule: total household income/members of household less than one third of the minimum wage. For the non-poor, Turkey developed a sophisticated system to determine contributions for the self-employed. Contributions are proportional to a scoring system that depends in the taxable estimated income and on the value and size of property it occupies and on the size and age of the cars it owns.In Ukraine, the Semashko model is funded through budget transfer from the government not through insurance [In the nsurance . RecentlPopulations in all the countries reviewed are aging very rapidly, and older people tend to spend more in health care and very old people  also develop disabilities and require Long-Term-Care. Are they looking for new way to raise revenues or make payment to adapt to the trend to population aging?Mexico, there is no specific insurance scheme for long-term care, and specialized institutions for long-term care are few. Long-term care is provided either by health care providers in hospitals or at home by family members.In Republic of Korea, a Long-Term Care Insurance (LTCI) was created in 2008 to provide coverage for facility- and home-based long-term care for older people who pass the eligibility test based on functional and cognitive disability [In the sability . It is aTurkey, there is no specific insurance scheme for long-term care, and specialized institutions for long-term care are few. Long-term care is provided either by health care providers in hospitals or at home by family members.In Ukraine although the main funding for long-term care in the Ukraine is the state budget, recently an increasingly popular long-term care funding option in The Ukraine is to use mortgage contracts provided by commercial entities.In the Mexico, Seguro Popular (SP) was instrumental in developing a strong network of PHC providers. The essential package of services funded by SP prioritized services that were delivered at the PHC level. Between 2001 and 2011, almost 2000 ambulatory health care clinics were established, and 4000 facilities were renovated or equipped [In equipped . By 2012equipped .Republic of Korea has a hospital-centric health system, with limited role for PHC. Most medical school graduates undertake residency training to become board-certified specialists, many of whom establish private clinics in the community. However, hospitals in The Republic of Korea, which have large outpatient departments, compete with physician clinics in the community. The role of PHC in The Republic of Korea may have been further undermined by the introduction of health insurance which enabled beneficiaries to access hospitals thanks to reduced financial barriers. Even though there was lower co-payment for physician clinics and higher co-pay for outpatient care in hospitals, beneficiaries preferred to access big hospitals.The Turkey introduced a family medicine-centered PHC model, with family practices contracted to provide an expanded set of prevention services, women and childcare, mobile services, home-care for patients unable to travel to clinics, and those in nursing homes, prisons, and child-care centers [In 2005, the Health Transformation Program in  centers ,9,29. By centers . Expansi centers . Out-of- centers . User sa centers ,9, and t centers .Ukraine reflects the centrally planned normative standards for inputs with predominance of hospitals, rather than the epidemiological transitions that required strong PHC for managing chronic illness. In 2000, reforms introduced a new model for basic care based on Western concepts of PHC underpinned by family medicine principles. Family doctors/general practitioners, provide up to 60 percent of basic care, working in family medicine polyclinics or polyclinic departments. Reforms beginning in 2010, tried to prioritize PHC as a strong gatekeeper in the health system, to reduce unnecessary use of specialist services and self-referral to hospitals, but weak PHC means patients bypass PHC level to access hospitals – often using inducements and gratuities.The evolution of the health system in Mexico, health reforms that introduced Seguro Popular fostered public-private partnerships. While some States emphasized provision of health care services in public facilities others used strategic purchasing as an opportunity to expand engagement of private sector in provision of clinical and nonclinical services, as well as retail pharmacy services. However, enabling policies were needed to fully achieve plurality of accredited public and private providers.In Republic of Korea has a pluralistic health system. The introduction/expansion of health insurance encouraged entry of new private health care providers, which currently account for more than 90% of all hospitals in the country. The national health insurance applies the same purchasing conditions  for both public and private providers. Public hospitals tend to provide services covered by health insurance, while private hospitals also provide large volume of uninsured services, which are typically very profitable because those services are not subject to fee scheduling/regulation.The Turkey, creation of pluralistic provision of health services was an explicit strategy of the HTP to use available capacity to scale up UHC, and to secure new and additional investments in the health sector. The number of private hospital sector expanded substantially after 2005 to accommodate increased patient volumes that followed strategic purchasing by Social Insurance Organisation of health care services for insurance beneficiaries from accredited private hospitals. By 2010, the Social Security Institution had contracted with 421 private hospitals  to provide diagnostic and curative care and complex emergency services . The volume of hospital services  provided by the private sector increased from 5.7 million  in 2002, to 59.1 million  in 2011 [In Ukraine, dissatisfaction with the rigidity and low quality of the public system, have prompted patients to increasingly seek care from private health care providers , private diagnostic centers, clinics and pharmacies. While inpatient care has remained primarily public, private ambulatory services are mostly outside the public funding streams, accounting for a large share of the out-of-pocket payments that comprise 50 percent of total health expenditures in Ukraine, with adverse consequences for equity, efficiency and financial risk protection.In Mexico health reforms have enabled investments in hospitals to upgrade medical equipment and in developing telemedicine networks that is used in rural areas with mixed successes.In The reforms in the Republic of Korea, Mexico, Turkey, and the Ukraine utilised technology variously.Republic of Korea has invested substantially in new health technologies for diagnosis and treatment, especially in the hospital sector, which often causes concerns for demand inducement in a private sector-dominated health system. Health insurance organization is a leading agency for IT as all providers submit claims electronically, and the insurer extensively uses ICT-based claim review and assessment, dissemination of provider performance, real-time drug utilization review (DUR), etc.The Turkey, reforms coincided with substantial investment in new health technologies for prevention, diagnosis and treatment. Nationwide electronic medical records were introduced in PHC centres and in hospitals for tracking activities and for claims processing. New IT systems have enabled patients to book hospital appointments through Internet. Emergency response for medical emergencies was strengthened through the use of advanced communication, transport and medical technologies [In nologies ,9.Ukraine has extensive health infrastructure and human resources, a legacy of the Soviet Semashko health system, investments in new health technologies have been sub-optimal due to fiscal constraints.While In the four study countries, the use of tele-medicine has been muted, and task shifting of responsibilities to new cadres of health professionals limited.Mexico. Households rely mainly on family networks and private sector services for a few privileged families that can afford such care.In Mexico, Turkey and The Ukraine, policies for establishing a long-term care insurance and sector are less well developed than The Republic of Korea. There is little formal long-term-care in Republic of Korea in 2008, the number of LTC providers rapidly expanded, from 2600 in 2009 to 5000 institutions, mostly in urban areas, while the number of home-based care agencies increased from 11 900 to 12 900 [Following the introduction of long-term care insurance in the o 12 900 . The numTurkey there is no specific insurance scheme for long-term care, and specialised institutions for long-term care are few. While the Ministry of Health provides home-care services, and municipalities, especially in metropolitan areas, have begun to provide services for social care, the existing scale and scope of services are not adequate to meet current and future needs. Long-term care is provided either by health care providers in hospitals or at home by family members [In  members .Ukraine, cash allowances are available to the elderly and providers of care for the elderly persons living alone. In 2014, there were 290 public nursing homes financed by local government providing care for more than 51 000 people (of whom 44 000 were adults). In addition, special hospital departments for elderly provide long-term care to elderly with chronic illness, while 32 hospitals provide care for war veterans and war invalids. However, the LTC capacity is not enough to meet current and future needs.In “Rome Wasn't Built in a Day, But They Were Laying Bricks Every Hour.” . Likewise, in most countries expansion in health insurance coverage does not happen “with the stroke of a pen” but require years of commitment and efforts to change the supply and demand after critical legislation has been passed. Two major approaches dominate: incremental and “big bang” reforms . Many coThroughout the world, the move towards UHC has frequently been like a Tango: two steps forward and one step back. Once can apply the 20:80 rule to this process . Often dAlthough progress often punctuated by overlaps and setbacks, overall there has been steady progress towards expanded coverage – starting at 20 percent or less of financial protection in low-income countries and topping-out at around 80 percent. There is no country in the world that either historically or today ever achieved 100 percent de facto coverage, even if de jure they passed a “big bang” reform on paper.All the countries we reviewed for this paper, have already passed through the steep part of the S curve and now find themselves at the upper part where progress is slower and more painful – it is much easier going from 40- 60 percent coverage than from 80 to 100 percent coverage. See There are many lessons that can be learned from the experience of the four countries we have showcased in this study.Some notable highlights that we want to emphasize include:1. Middle income countries like Mexico, the Republic of Korea, Turkey, and Ukraine demonstrate the UHC is not an “unattainable utopian dream” but can be realized in developing not just developed countries, even if reaching 100 percent may be an elusive goal even in the OECD where most countries exclude some marginal groups . Furthermore, when comparing Universal Health Coverage in the Ukraine with Mexico, the Republic of Korea and Turkey, there does not seem to be any evidence government tax funded financing provides a better road to UHC than mixed systems. See 2. The hardest period is often either at the start of the reform process and when countries are very poor and have few resources and capacity to design and implement complex reforms and at the end of the reform process when counties are richer and capacity is much higher. During the steep part of the S cure supply and demand issue related to service delivery is often a major problem . Later at the upper flat part of the S cure, maintaining the social cohesion needed to achieve a national consensus on redistribution and political sustainability becomes a bigger problem.3. “Many roads lead to Rome”. Different countries choose different paths. Debate often focusses on the ideological preferences rather than substance, like insurance vs general revenue funding, freedom of choice vs compulsory social contracts and hospitals vs primary care. In reality, it may be striking a balance and doing things well (the how) that this at least if nor more important than the technical details (the what). Yet most UHC policy reforms focus precisely on the “what” not the “how”.4. Failure to reach 100 percent coverage often has to do with – at least in part – lack of access to services especially in rural areas or lack of service mix  And at times it may be a function of demand or lack of demand for services. Providing free access to health services for everyone through various forms of subsidies does not mean that people will choose to use them. Perceptions of quality, choice of alternatives, cultural factors and many other consumer preferences may be as important in influencing demand as price.5. Affordability is often a topic that has been used by critics to undermine UHC reforms. Level of GDP and overall wealth of a country seems to be a more significant determinant of levels of spending on health care than the policy contents like UHC. All four countries demonstrated increased spending over time as their economies grew. See The following are some of the major economic sustainability concerns often heard during health insurance reforms.Expanding coverage did not seem to lead to greater overall health care expenditure compared with other countries. Although hard to prove and even harder to disentangle from other causal factors, none of the following commonly heard arguments against UHC seemed to be true:that it would be financially unsustainable to the public sector that increase spending would have a negative impact on economic growth as a wholethat expansion in coverage would put an upwards cost pressure on the health sector through an increased health care wage bill, increased consumption (frequency and number of users) and increased prices (ie Exp=PxV)that increased taxes  lead to tax avoidance and increase in informal sector employment.De jure constitutional guarantees and national health legislation are often a necessary but do not guaranteed path to success without accompanying institutional measure to secure sustainability  and supply and demand constraints in service provision and consumer/patient behavior. Finally, we caution against the pitfalls of over-attribution from drawing too strong conclusion from individual longitudinal country experiences and over-generalization from broad sweeping cross-sectional statistical analysis. Every country is different and needs to find its own path towards UHC, learning from the achievements and failures of others, but not try to copy their experiences.Based on the review, we conclude the following. First, reaching UHC is achievable in middle- and upper middle-income countries. It is not an unattainable goal reserved for upper income countries. Second, successes and failures are seen both in the case of countries that pursue a contributory health insurance path to UHC and those that pursue a core government funding path. The devil is often in the detail. We have come a long way in better understanding the complex multi-dimensional nature of UHC. More research is needed however to fully understand all the nuances of the UHC process in middle-income countries. Additional quantitative and qualitative studies are needed, both longitudinal and cross-sectional to generate evidence to better understand the introduction and scale-up of UHC, and the factors which enable or hinder UHC.Based on the research, we conclude the following.First, reaching Universal Health Coverage (UHC) is achievable in middle-income and upper-middle-income countries. It is not an unattainable goal reserved for upper income countries.Second, successes and failures are evident both in the case of countries that pursue a contributory health insurance path to UHC and those that pursue a core government funding path.Third, the devil is often in the detail, however:De jure constitutional guarantees and national health legislation are often a necessary but do not constitute a guaranteed path to success without accompanying institutional measure to secure sustainability  and supply and demand constraints in service provision and consumer/patient behavior.De facto in most countries expansion in health insurance coverage does not happen “with the stroke of a pen” but require years of commitment and efforts to change the supply and demand after critical legislation has been enacted.incremental” and “big bang” health system reforms.Fourth, two major approaches dominate: “We caution against the pitfalls of over-attribution from drawing too strong conclusion from individual longitudinal country experiences (“over-determinism”) and over-generalization from broad sweeping cross-sectional statistical analysis (“reductionism”). Every country is different and needs to find its own path towards UHC considering their contextual specificities, learning from the achievements and failures of others, but not try to copy their experiences.