Institutional assembly under constraints: pathways to universal health coverage in Brazil, Rwanda, and China

This paper examines how Brazil, Rwanda, and China have pursued universal health coverage (UHC) beyond classical health system models developed in high-income settings. We introduce the concept of institutional assembly under constraints, offering a complementary framework for understanding UHC pathways in developing countries, where no single trajectory universally applies. Brazil’s health system ensures free access at the point of care through tax-based public financing, but limited government spending has produced a dualised system of public and private provision. Rwanda extends coverage to informal and low-income populations through subsidised community-based insurance under strong government stewardship, though the system remains heavily reliant on donor support and household contributions. China employs segmented insurance schemes administered by local governments, integrating payroll-funded coverage for formal-sector workers with publicly subsidised residence-based schemes, achieving rapid scale but embedding regional fragmentation. These cases reflect distinct processes of institutional assembly under constraints, in which health systems are constructed through selective borrowing from classical frameworks combined with institutional innovation rooted in historical legacy, all bounded by fiscal capacity, labour-market structure, and administrative reach.