Varying universal health coverage policy implementation states: exploring the process and lessons learned from a national health insurance pilot site

# Background Worldwide efforts have increased to understand what works in policy implementation, for whom and under what circumstances (context) are health policies useful and effective. All countries are striving towards Universal Health Coverage (UHC). Reforms are being implemented to ensure no-one is left behind. # Methods We draw on our experiences of tracking implementation of policies aimed at achieving UHC in a national health insurance (NHI) pilot district (universal coverage in Tanzania and South Africa). Policies aimed at achieving UHC were tracked from 2011-2015 to understand why there are varying UHC policy implementation states and outcomes among facilities in the same district? # Results Lessons learned in the process include: i) to adopt or adapt policy is a process – actors at the front-line seem to engage with policy, carry out a policy-context audit, try to engage with superiors if there are discrepancies between policy and context and eventually take a decision to adopt or adapt policy; ii) local facility contexts matter and vary – decision to implement policy is influenced by the conditions on the ground, hence implementation states can vary from one facility to the other despite being in the same district; iii) implementation states range from full policy adoption and implementation, policy adaptation and partial implementation, delayed implementation to non-implementation; iv) a resource audit before policy is implemented could go a long way in reducing policy-practice gaps; and v) Policy implementation states are dynamic subject to change – for example, when equipment breaks down and is not replaced immediately. # Conclusion There seems to be inherent respect among implementing actors, for the department of health and people above them. They are however concerned with the fact that they are removed from the ground, could have lost touch with realities on the ground, hence the policy directives sent from the top, are often not congruent with ground conditions. Actors revealed how they engage with the policy, assess what they are being asked to do and compare that with the existing resources. To adopt or adapt policy in a UHC context: there seems to be a series of steps actors take.