Unpacking the Implementation of the Universal Health Care Law: A Mixed-Methods Study on the Mediating Role of Nurses’ Readiness Between Awareness and Training Exposure

Unpacking the Implementation of the Universal Health Care Law: A Mixed-Methods Study on the Mediating Role of Nurses’ Readiness between Awareness and Training Exposure

Jemarlon L. Albinda, Brendon Jose B. Aureo, Warqueen M. Factor, Melissa Joy P. Quitoriano, Jessica L. Rodriguez, Robert John G. Tupas, Leonila M. Badilla, Genelyn R. Baluyos

Margosatubig Regional Hospital, Philippines

DOI: https://doi.org/10.51244/IJRSI.2025.1215000104P

Received: 03 July 2025; Accepted: 08 July 2025; Published: 06 August 2025

ABSTRACT

Readiness significantly enhances the effectiveness with which nurses implement the Universal Health Care (UHC) Law, with training exposure playing a crucial supporting role. This mixed-methods study investigated how nurses’ readiness mediates the relationship between their awareness of the UHC Law, their training experiences, and their ability to effectively implement the law. Using an explanatory sequential design, the study first gathered quantitative data from 290 nurses across different healthcare settings in the Philippines to measure their levels of awareness, training exposure, readiness, and actual implementation of the UHC Law. This was complemented by in-depth qualitative interviews with frontline healthcare providers to gain deeper insight into their day-to-day experiences with UHC implementation. The quantitative findings revealed that nurses demonstrated very high levels of awareness, readiness, and training exposure; however, the implementation of the UHC Law remained comparatively lower. Readiness and training exposure significantly predicted implementation, with readiness emerging as a key mediating factor between awareness, training, and actual practice. Nurses who feel more prepared are better able to apply UHC principles in practice. The qualitative results supported and enriched the statistical findings, revealing four key themes: Expanding Access through System Integration, Broadening Roles and Holistic Service Delivery, Implementation Gaps and Resource Constraints, and Strengthening the Frontline for Sustainable Universal Health Coverage (UHC). Participants described enhanced patient access and evolving nursing roles but also highlighted challenges such as inadequate resources, inconsistent training, and fragmented systems. Despite these challenges, nurses expressed a strong commitment to the goals of UHC. While nurses are equipped and motivated to implement the UHC Law, structural barriers hinder complete execution. Strengthening institutional support, enhancing training programs, and engaging nurses in policy development are essential to achieving equitable and sustainable healthcare delivery.

Keywords:  Health Policy Implementation, Mixed-Methods Study, Nurse Readiness, Training Exposure, Universal Health Care

INTRODUCTION

The enactment of Republic Act No. 11223, known as the Universal Health Care (UHC) Law, marks a pivotal transformation in the Philippine health system. Designed to provide equitable, accessible, and quality health services for all Filipinos, the law mandates automatic health insurance coverage. It aims to integrate fragmented health services into province-wide and city-wide health systems (DOH, 2021). Its goal is to create a healthcare model that provides a comprehensive set of quality and cost-effective services without causing financial hardship (Republic Act No. 11223, 2019). While its policy intentions are comprehensive and visionary, the successful implementation of UHC, particularly at the primary care level—remains complex and fraught with systemic challenges, including issues with workforce readiness, service delivery capacity, and coordination between national and local health systems (Ateneo de Manila University, 2025; Co et al., 2024). Among the frontline implementers of this reform are nurses, who form the largest and most geographically dispersed segment of the Philippine health workforce (Pepito et al., 2025). Their proximity to communities positions them as key agents in operationalizing the UHC Law, especially in underserved and remote areas.

However, nurses’ ability to carry out this obligation is dependent not just on their knowledge of the legislation but also on their willingness to accept increased tasks within the restructured health system.  In this context, readiness includes cognitive knowledge, emotional preparedness, and practical skills in implementing UHC-mandated service delivery adjustments.  Many new nursing graduates are deemed unprepared for the realities of public health work, often lacking a sufficient grasp of UHC principles due to a hospital-centric educational focus (Ateneo de Manila University, 2025; BusinessWorld Online, 2025). While there is increasing awareness among nurses about the goals and provisions of the UHC Law, awareness alone does not ensure effective implementation. Equally critical is their exposure to targeted training programs that equip them with skills in community health integration, interprofessional collaboration, and systems thinking. Yet, access to such capacity-building initiatives remains inconsistent, with significant challenges such as exorbitant training fees and a lack of onboarding programs to bridge the gap between education and public health practice (Pepito et al., 2025; Ateneo de Manila University, 2025).

The existing literature has a significant methodological gap in understanding the interaction between awareness, training exposure, and readiness.  Existing research frequently examines these variables separately, mostly using quantitative, cross-sectional, or descriptive methods that fail to capture the dynamic and mediating interactions between them. Furthermore, nurses’ voices, the very actors tasked with implementing UHC reforms, are usually underrepresented in scholarly discourse, particularly in qualitative investigations that provide contextual richness.   Poor working conditions and low pay were identified as workforce-related barriers to UHC implementation, underscoring the need for further research into healthcare workers’ lived experiences (Pepito et al., 2025). Insights into how institutional support, professional identity, and local reality influence preparedness remain untapped.   Without a nuanced understanding of these factors, there is a risk that implementation efforts will overlook the foundational role of workforce preparedness.

This study addresses this gap by examining the mediating role of nurses’ readiness in the relationship between their awareness of the UHC Law and their exposure to training programs. The Organizational Readiness for Change Theory guides it (Weiner, 2009), which posits that successful implementation of reform efforts depends on both the collective commitment and psychological preparedness (change efficacy) of the workforce. This theory’s relevance in the Philippine context is supported by local research indicating that self-efficacy is a key influencer of employee performance during organizational change in the health sector (Montes, 2025). Employing an explanatory mixed-methods design, the research integrates quantitative data from 290 nurses across various public and private healthcare institutions in Mindanao, Philippines, with qualitative insights drawn from in-depth interviews. This approach allows for a comprehensive analysis of both measurable relationships and lived experiences, offering a more holistic understanding of the conditions that enable or hinder effective policy implementation. By unpacking readiness as a mediating construct, the study provides critical insights for health policymakers, administrators, and training institutions aiming to strengthen UHC delivery through improved frontline preparedness. Ultimately, it contributes to the broader goal of realizing equitable and sustainable health system reform in the Philippines.

This mixed methods study investigated the mediating role of nurses’ readiness in the relationship between their awareness, training exposure, and implementation of the Universal Health Care (UHC) Law in selected Rural Health Units in the Province of Zamboanga Sibugay.

METHODS

Research Design.  This mixed-methods study employed an explanatory sequential design, beginning with a quantitative phase to determine significant relationships among key variables, followed by a qualitative phase to explore the underlying reasons behind these findings (Creswell, 2011). The qualitative component provided more profound insights into nurses’ awareness, readiness, training exposure, and implementation of the Universal Health Care (UHC) Law, thereby contextualizing the quantitative results.

The quantitative phase examined the significant relationship among nurses’ awareness, readiness, training exposure and their implementation of the UHC Law.  It also assessed the mediating role of readiness in the relationship between awareness, training exposure, and implementation. The qualitative phase further explored how nurses experience the implementation of the UHC Law, particularly among those with notable patterns in the quantitative data.

Setting.  The study was conducted in the Province of Zamboanga Sibugay, located in Region IX (Zamboanga Peninsula), Mindanao, Philippines. Zamboanga Sibugay is a third-class province comprising 16 municipalities, with Ipil serving as its provincial capital. The province features a mix of coastal and inland areas, including several geographically isolated and disadvantaged municipalities. Its health system comprises provincial and district hospitals, rural health units, and barangay health stations, operating within the framework of the Universal Health Care Law. The province’s diverse infrastructure and healthcare capacity provide a relevant context for examining the implementation of health policies at the local level.

Respondents.  For the quantitative component, 290 nurses deployed under the Nurse Deployment Program (NDP) of the Department of Health (DOH) were selected using stratified random sampling to ensure proportional representation across the 16 municipalities of Zamboanga Sibugay. Eligible respondents were registered nurses currently assigned to Rural Health Units (RHUs) and Barangay Health Stations (BHSs) and directly involved in the implementation of the Universal Health Care (UHC) Law at the grassroots level.

For the qualitative component, a purposive sample of 7 nurses was selected from the quantitative respondents based on key characteristics such as high or low levels of awareness, readiness, and implementation of the UHC Law. These participants provided in-depth perspectives on their lived experiences, challenges, and facilitators related to the implementation of UHC Law within their respective communities.

Instruments.  Five questionnaires were used in collecting data. The Nurses’ Level of Awareness of the Universal Health Care (UHC) Law Questionnaire is a researcher-developed instrument to assess nurses’ awareness of the key concepts, provisions, and implementation mechanisms of the UHC Law. The questionnaire consists of multiple statements rated on a 4-point Likert scale of agreement – Strongly Disagree (1), Disagree (2), Agree (3), and Strongly Agree (4), which encourages respondents to clearly express their level of agreement and understanding without a neutral option.  To ensure the instrument’s internal consistency, a reliability test was conducted. The results yielded a Cronbach’s alpha coefficient of 0.958, indicating excellent reliability and suggesting that the items in the scale are highly consistent in measuring the intended construct of awareness.

The Nurses’ Level of Readiness for the Universal Health Care (UHC) Law Questionnaire is a researcher-designed tool used to measure the extent to which nurses perceive themselves as prepared to implement the UHC Law in clinical and public health settings. The questionnaire includes items that evaluate various dimensions of readiness, such as knowledge application, confidence, institutional support, and willingness to engage in UHC-related initiatives.  Responses are measured using a 4-point Likert scale of agreement: 1 – Strongly Disagree, 2 – Disagree, 3 – Agree, 4 – Strongly Agree, which allows for precise and directional responses without a neutral midpoint.  To assess the internal consistency of the instrument, a reliability analysis was conducted. The questionnaire demonstrated good reliability, with a Cronbach’s alpha coefficient of 0.886, indicating a high level of internal consistency among the items used to measure readiness.

The Nurses’ Level of Training Exposure on the Universal Health Care (UHC) Law Questionnaire is a questionnaire developed to assess the extent of nurses’ participation in and exposure to training programs, seminars, workshops, and other capacity-building activities related to the UHC Law. The questionnaire items are designed to capture both the frequency and perceived adequacy of training experiences relevant to UHC implementation.  Responses are measured using a 4-point Likert scale of agreement: 1 – Strongly Disagree, 2 – Disagree, 3 – Agree, 4 – Strongly Agree.  This scale enables respondents to indicate their level of agreement regarding their training exposure without a neutral midpoint, thus encouraging more decisive responses.  A reliability test was conducted to determine the internal consistency of the instrument.  The questionnaire yielded a Cronbach’s alpha coefficient of 0.956, indicating excellent reliability and confirming that the items are highly consistent in measuring the construct of training exposure.

The Nurses’ Level of Implementation of the Universal Health Care (UHC) Law Questionnaire is also a researcher-designed instrument to assess the extent to which nurses apply and integrate the principles and provisions of the UHC Law in their clinical and administrative practice. The items cover various aspects of implementation, including policy adherence, service delivery practices, interprofessional collaboration, and patient education, all of which are aligned with UHC mandates.  Responses are recorded using a 4-point Likert scale of agreement: 1 – Strongly Disagree, 2 – Disagree, 3 – Agree, 4 – Strongly Agree, allowing respondents to express their level of engagement in UHC-related implementation activities without a neutral midpoint. To ensure internal consistency, a reliability test was conducted. The questionnaire achieved a Cronbach’s alpha coefficient of 0.934, indicating excellent reliability and confirming that the items consistently measure the construct of UHC Law implementation among nurses.

Interview Guide. The interview guide was thoughtfully developed to understand how healthcare providers personally experience the implementation of the Universal Health Care (UHC) Law. It aimed to capture their everyday realities, including how their work has changed, the challenges they face, and how they perceive the law’s impact on the quality of care and patient access. It also invited them to share practical suggestions for improving the implementation of the UHC Law in their workplace. Adapted from similar tools used to gather feedback in educational settings, the guide was tailored to reflect the unique voices and insights of those on the front lines of healthcare.

Data Collection. Upon receiving approval from the Graduate School, data collection commenced in accordance with the research objectives. The study utilized an online survey developed through Google Forms. The instrument consisted of five parts: an informed consent form, followed by four structured questionnaires that assessed nurses’ awareness, readiness, training exposure, and implementation of the Universal Health Care (UHC) Law.

The target respondents under the Nurse Deployment Program (NDP) of the Department of Health (DOH) in Zamboanga Sibugay. Stratified random sampling was used to assure proportional representation across the province’s 16 municipalities. Local health officials managed the distribution of survey links through official means. Ethical criteria, including secrecy and voluntary participation, were strictly adhered to.

To enrich the findings, a qualitative component was also conducted. Seven nurses were purposively selected for face-to-face semi-structured interviews based on their active involvement in implementing the Universal Health Coverage (UHC) Law. Interviews lasted 30 to 45 minutes, were audio-recorded with consent, and held in private settings. The transcripts were analyzed using thematic analysis, allowing the study to identify key patterns and insights related to frontline experiences with UHC implementation.

This mixed-methods approach provided both broad and in-depth perspectives on the challenges and readiness of nurses in implementing the UHC Law at the community level.

Ethical Considerations. This study adheres to the highest standards of ethical conduct in research, particularly given its mixed-methods design, which involves both qualitative interviews and quantitative surveys with licensed nurses.  All participants were informed of the study’s aim, voluntary participation, and the right to withdraw at any moment without penalty. Written consent was obtained for the interviews, and participation in the survey indicated consent. Confidentiality and anonymity were strictly maintained by using pseudonyms and securing all data in password-protected files. The study posed no danger, but participants could skip questions or discontinue participation if they were uncomfortable. Respect for nurses’ professional responsibilities was prioritized by scheduling participation around their schedules and ensuring it did not interfere with their work. The data was thoroughly analyzed, and processes such as triangulation and reflexivity were employed to ensure that the conclusions were reliable. Instruments were designed with cultural sensitivity and contextual relevance to respect the diversity of nursing experiences across healthcare settings.

Data Analysis. The data were analyzed with Jamovi software, which is capable of conducting mediation analysis. The analysis consisted of various phases, beginning with descriptive statistics (mean and standard deviation) that summarized the respondents’ feedback regarding nurses’ preparedness, awareness, training exposure, and implementation of the Universal Health Care Law. The Pearson product-moment correlation coefficient was then computed to explore the relationships between and among the variables: nurses’ readiness, awareness, training exposure, and the implementation of the Universal Health Care Law. Generalized Linear Model mediation analysis was used to assess whether nurses’ readiness mediated the relationship between nurses’ awareness, training exposure, and the implementation of the Universal Health Care Law. Path analysis was employed as a specialized kind of multiple regression analysis to investigate the multiple predictors and outcomes, including the direct and indirect links among a set of observed variables. It can be considered a precursor to Structural Equation Modelling (SEM) and offers a method for evaluating proposed causal models.

Qualitative data from student interviews were analyzed using Hyper Research software. Thematic analysis (Braun & Clarke, 2013) was employed, beginning with familiarization and data coding, followed by theme identification, refinement, and definition. The final themes were presented in a cohesive narrative supported by excerpts from student responses.

RESULT AND DISCUSSION

Level of Nurses’ Awareness of Universal Health Care Law

Table 1 presents the level of nurses’ awareness of the Universal Health Care (UHC) Law. The results indicate that nurses exhibit a very high level of awareness across all constructs. Specifically, the highest mean was observed in Knowledge of the UHC Law (M = 3.46, SD = 0.434), followed by Awareness of Policy Change and Impact (M = 3.37, SD = 0.475) and Awareness of Stakeholders and Roles in Implementation (M = 3.37, SD = 0.502). The overall mean score for awareness was 3.40 (SD = 0.435), classified as very high based on the given scale.

The results suggest that Filipino nurses are well-informed about the core provisions, policy changes, and implementation roles associated with the UHC Law. This high level of awareness may enhance the quality of health service delivery, facilitate smoother implementation of UHC policies, and strengthen inter-professional collaboration. Nursing administrators and policymakers can leverage this level of awareness to actively engage nurses in advocacy, education, and leadership roles within the UHC framework.

The findings underscore a very high level of awareness among nurses regarding the Universal Health Care Law, consistent with recent studies emphasizing the importance of healthcare workers’ policy literacy in achieving successful health reforms (Nisperos et al., 2022; Domingo et at., 2023). The high mean scores in all constructs suggest that ongoing institutional training and information dissemination campaigns may have been effective in familiarizing nurses with the UHC Law.

In particular, the elevated awareness of stakeholders and their roles aligns with the recommendations of the World Health Organization (2022), which emphasize that intersectoral engagement is essential for the equitable delivery of UHC. Nurses’ strong understanding of policy changes and impacts further supports their readiness to adapt to evolving healthcare structures and practices, which is vital in a post-pandemic recovery era (Lee et al., 2023).

Moreover, this heightened awareness positions nurses as key implementers and educators in the health system, supporting prior assertions that informed health workers are more likely to engage in policy advocacy and reform (Tomanan et al., 2022). As such, these findings advocate for continued education and inclusion of nurses in decision-making processes, particularly in policy implementation and evaluation.

Table 1 Level of Nurses’ Awareness of Universal Health Care Law (N=290)

Constructs	M	SD	Remarks
Knowledge of UHC Law	3.46	0.434	Very High
Awareness of Policy Change and Impact	3.37	0.475	Very High
Awareness of Stakeholders and Roles in Implementation	3.37	0.502	Very High
Overall Level of Nurses’ Awareness of Universal Health Care Law	3.40	0.435	Very High

Scale:  3.26-4.00 (Very High); 2.26-3.25 (High); 1.26- 2.25(Low); 1.00-1.25 (Very Low)

Level of Nurses’ Preparedness of Universal Health Care Law

The table 2 shows the degree of nurses’ readiness to execute the Universal Health Care (UHC) Law, organized from highest to lowest according to the average scores of various constructs. The top score is observed in Attitude toward Change, with an average of 3.56 (SD = 0.431), categorized as Very High. This shows that nurses are very open and responsive to policy changes and health care reforms, reflecting deep personal dedication and flexibility. Next is the Overall Preparedness score, which has an average of 3.27 (SD = 0.352), likewise classified as Very High. This indicates the overall preparedness of nurses when evaluating all assessed factors, demonstrating that although there are some shortcomings in particular domains, nurses uphold a generally strong level of readiness for UHC implementation (Ozkalay& Karaca, 2021).

‎The subsequent highest score is in Professional Preparedness, with an average of 3.18 (SD = 0.463), which is categorized as High. This aspect evaluates nurses’ self-assessed ability regarding their knowledge, training, and skills to fulfill the duties linked to the UHC Law. Even though the score is elevated, it falls short of the attitude score, indicating a need for ongoing professional growth and skill enhancement. Finally, Organizational Support and Resources obtained the lowest rating among the constructs, achieving a mean of 3.06 (SD = 0.466), which is also categorized as High. This indicates nurses’ views on the sufficiency and accessibility of organizational support systems, staffing levels, and logistics. Though remaining in the elevated range, this reduced score reveals current deficiencies in the organizational setting that could obstruct the effective implementation of UHC policies (Ozkalay& Karaca, 2021).

In general, although nurses show a highly positive attitude toward change, organizational investments in training, facilities, and workforce assistance are essential for closing the gap between preparedness and actual execution (Zheng et al., 2024).

Table 2 Level of Nurses’ Preparedness of Universal Health Care Law

Constructs	M	SD	Remarks
Professional Preparedness	3.18	0.463	High
Organizational Support and Resources	3.06	0.466	High
Attitude toward Change	3.56	0.431	Very High
Overall Level of Nurses’ Preparedness of Universal Health Care Law	3.27	0.352	Very High

Scale:  3.26-4.00 (Very High); 2.26-3.25 (High); 1.26- 2.25(Low); 1.00-1.25 (Very Low)

Level of Nurses’ Training Exposure of Universal Health Care Law

The findings in Table 3 illustrate a very high level of nurses’ training exposure to the Universal Health Care

(UHC) Law, as reflected in the overall mean score of 3.32 (SD = 0.405). This indicates that nurses have been extensively involved in training programs aligned with UHC principles, in keeping with the Department of Health’s mandate to strengthen health workforce readiness during the law’s implementation phase (Department of Health [DOH], 2020).

Training Exposure and Relevance of Training Content both scored a mean of 3.30, revealing that nurses not only participated in these programs but also found the content relevant to their practice. This is especially significant as the UHC Law calls for a transition from hospital-based models to primary care and preventive approaches (Republic Act No. 11223, 2019). Yet despite this engagement, many nurses reportedly continue to feel ill-equipped for these evolving roles, often due to the historic orientation of nursing education towards hospital-centered care (Ateneo de Manila University, 2025).

The highest mean was observed for Mode of Delivery of Trainings (M = 3.36, SD = 0.481), suggesting high satisfaction with training formats, potentially due to the increased use of blended learning and online platforms like Nurse LEAD, which have expanded training accessibility and enhanced public health competencies (University of the Philippines Manila, 2021). These innovations are particularly valuable in reaching nurses in geographically isolated and disadvantaged areas (GIDAs), where traditional training delivery may be less feasible.

Overall, these results affirm the strength of ongoing training efforts while also pointing to the need for continuous assessment to ensure contextual relevance and practical application, particularly through mentorship, interdisciplinary learning, and community-based immersion strategies.

Table 3 Level of Nurses’ Training Exposure of Universal Health Care Law

Constructs	M	SD	Remarks
Training Exposure	3.30	0.405	Very High
Relevant of Training Content	3.30	0.433	Very High
Mode of Delivery of Trainings	3.36	0.481	Very High
Overall Level of nurses’ training exposure of Universal Health Care Law	3.32	0.405	Very High

Scale:  3.26-4.00 (Very High); 2.26-3.25 (High); 1.26- 2.25(Low); 1.00-1.25 (Very Low)

Level of Nurses’ Implementation of Universal Health Care Law

The results of Table 4 highlight a high level of implementation of the Universal Health Care (UHC) Law among nurses, with an overall mean of 2.95 (SD = 0.501). This finding reflects nurses’ positive engagement with UHC principles, though it falls slightly short of a “very high” rating. The construct on adherence to UHC policies scored a mean of 2.82 (SD = 0.633), indicating moderate consistency in aligning nursing practices with policy directives. This may be influenced by the decentralized nature of the Philippine health system and evolving policy dissemination processes, which create disparities in understanding and implementation, especially in rural areas (Department of Health [DOH], 2020; Think Well, 2021).

Collaboration and coordination in healthcare delivery received a mean of 2.94 (SD = 0.580), which implies active nurse involvement in interprofessional care networks—an approach reinforced by the UHC Law’s vision for an integrated health system (Republic Act No. 11223, 2019). However, challenges such as fragmented referrals and unclear role definitions persist (Ateneo de Manila University, 2025). Notably, the highest score emerged in patient education and advocacy (M = 3.09, SD = 0.412), which reflects nurses’ strong commitment to promoting health literacy and empowering patients—practices that are central to the UHC’s people-centered model (Domingo et al., 2023).

Collectively, these findings suggest that while nurses are implementing UHC with meaningful intent, system-level barriers such as inadequate inter-agency coordination, limited access to continuing education, and a lack of digital infrastructure continue to impede optimal outcomes. Addressing these issues through supportive policies, feedback mechanisms, and targeted capacity-building could accelerate progress toward full realization of the UHC vision.

Table 4 Level of Nurses’ Implementation of Universal Health Care Law

Constructs	M	SD	Remarks
Adherence to UHC Policies and Guidelines	2.82	0.633	High
Collaboration and Coordination in Healthcare Delivery	2.94	0.580	High
Patient Education and Advocacy	3.09	0.412	High
Overall Level of nurses’ implementation of Universal Health Care Law	2.95	0.501	High

Scale:  3.26-4.00 (Very High); 2.26-3.25 (High); 1.26- 2.25(Low); 1.00-1.25 (Very Low)

Significant Relationship Between Level of Nurses’ Awareness and Implementation of Universal Health Care Law

Table 5 presents the results of the correlation analysis examining the relationship between nurses’ level of awareness and their implementation of the Universal Health Care (UHC) Law. The findings reveal that all components of awareness are positively and significantly correlated with implementation at the p < .001 level, indicating highly significant relationships.

Specifically, knowledge of the UHC Law demonstrated a moderate positive correlation with implementation (r = 0.438, p < .001), suggesting that nurses who possess greater knowledge about the UHC Law are more likely to implement it in clinical practice. This finding is consistent with the book of The WHO (2022) highlighted that education is a pivotal field for enhancing the health workforce’s involvement in Universal Health Coverage (UHC).

Awareness of policy changes and their impact was also significantly correlated with implementation (r = 0.343, p < .001), supporting the idea that) Policy discussions on health issues at national, regional, and global levels must be guided by excellent and  precise data that is varied, recent, and internationally comparable; nurses require new cohorts of ‘data literacy’ (Rumsey et al., 2022).. A clear understanding of evolving policies strengthens alignment between policy intent and healthcare delivery.

Furthermore, awareness of stakeholders and their roles showed a significant association with implementation (r = 0.382, p < .001). This suggests that nurses who understand the collaborative roles of various institutions and establishing confidence within the populace via openness in metrics and budgets, robust accountability mechanisms, knowledge of local cultural sensitivities, education on the UHC concept, and community engagement will be crucial for a multisectoral implementation of UHC (Ifeagwu et al., 2024).

The overall level of nurses’ awareness of the UHC Law was also significantly associated with its implementation (r = 0.418, p < .001), indicating that awareness plays a crucial role in operationalizing policy reforms. This supports the work of Aziz (2023), who found that continuous education and training are essential for improving nurse performance, hence boosting healthcare quality and facilitating the adoption of best practices among nurses.

Healthcare workers’ awareness of UHC concepts is crucial for cultivating trust and transparency within communities, which is necessary for effective implementation (Ifeagwu et al., 2024). Efficient knowledge dissemination among healthcare professionals is essential for adapting to and maintaining policy modifications in Universal Health Coverage (Hashiguchi et al., 2024).Nurses, as frontline implementers of health policy, must be equipped with timely information and a comprehensive understanding of both the content and context of the UHC Law to drive successful implementation.

Table 5 Significant Relationship Between Level of Nurses’ Awareness and Implementation of Universal Health Care Law

Variables	r-value	p-value	Decision
Level of Nurses’ Implementation of UHC Law
Knowledge of UHC Law	0.438	<.001**	Highly Significant
Awareness of Policy Changes and Impact	0.343	<.001**	Highly Significant
Awareness of Stakeholders and Roles in Implementation Overall Level of Nurses’ Awareness of UHC Law	0.382   0.418	<.001**   <.001**	Highly Significant   Highly Significant

Note: **p < 0.01 (Highly Significant); *p < 0.05 (Significant); p > 0.05 (Not Significant)

Significant Relationship Between Level of Nurses’ Readiness and Implementation of Universal Health Care Law

Table 6 presents the correlation between the level of nurses’ readiness and their implementation of the Universal Health Care (UHC) Law. The results demonstrate that all readiness indicators —professional preparedness, organizational support and resources, and attitude toward change are positively and significantly related to the implementation of UHC, with all p-values less than 0.001, indicating highly significant relationships.

Professional preparedness showed a strong positive correlation (r = 0.672, p < .001) with UHC implementation, suggesting that nurses who feel professionally equipped in terms of knowledge, skills, and training are more likely to carry out UHC-related responsibilities effectively. This aligns with the findings of Dela Cruz and Gutierrez (2023), who emphasized that competency-based readiness enhances nurses’ capacity to fulfill their roles in health policy reforms.

Organizational support and resources had the highest correlation (r = 0.755, p < .001), indicating that systemic support, such as access to tools, staffing, and institutional backing, plays a crucial role in empowering nurses to implement Universal Health Coverage (UHC) guidelines. Similar findings were reported by Debie et al. (2021), who noted that modern healthcare facilities and a sufficient quantity of healthcare professionals are crucial for attaining Universal Health Coverage (UHC).

Attitude toward change, while showing a smaller effect size, still had a significant positive correlation with UHC implementation (r = 0.224, p < .001). This suggests that nurses with a more favourable attitude toward health system reforms are more receptive and participatory in the implementation process (Anders, 2021). This is supported by the book of the World Health Organization (2022), the way that health professionals’ behavior during practice has an impact on their safety, healthcare quality, and ability to build trust.

The overall readiness score (r = 0.720, p < .001) further affirms that a high level of preparedness across individual and organizational domains significantly influences nurses’ ability to implement UHC initiatives effectively. Strong health systems and health professionals who are trained and equipped to deliver the medical care that communities seek are essential to the advancement of universal health coverage (UHC) (WHO, 2022).

In summary, these findings affirm that nurse readiness, particularly in terms of institutional support and professional competence, is a strong predictor of successful UHC implementation. Strategic investment in these readiness dimensions is essential to achieving the UHC goals in the Philippine context and beyond.

Table 6 Significant Relationship Between Level of Nurses’ Readiness and Implementation of Universal Health Care Law

Variables	r-value	p-value	Decision
Level of Nurses’ Readiness of UHC Law
Professional Preparedness	0.672	<.001**	Highly Significant
Organizational Support and Resources	0.755	<.001**	Highly Significant
Attitude toward Change	0.224	<.001**	Highly Significant
Overall Level of Nurses’ Readiness in UHC Law	0.720	<.001**	Highly Significant

Note: **p < 0.01 (Highly Significant); *p < 0.05 (Significant); p > 0.05 (Not Significant)

Significant Relationship Between Nurses’ Training Exposure and Implementation of Universal Health Care Law

The findings of this study indicate a highly significant and positive relationship between nurses’ training exposure and their implementation of the Universal Health Care (UHC) Law. As shown in Table 7 below, all aspects of training exposure demonstrated statistically highly significant correlations with implementation, with p-values less than .001, indicating strong evidence of association.

Specifically, general training exposure showed the strongest positive correlation (r = 0.533, p < .001), suggesting that the more frequently nurses are exposed to UHF-related training, the more likely they are to implement UHC principles in their practice. This confirms the Department of Health’s (2020) recommendation that regular training serves as a critical strategy in strengthening the UHC roll-out at the front line level.

The overall training exposure also demonstrated a moderate positive correlation (r = 0.488, p < .001), reinforcing the idea that training plays a crucial role in ope-rationalizing health reforms. This supports Reyes et al. (2021), who emphasized that continuous professional development significantly contributes to the successful implementation of health policies among nurses.

Furthermore, the results also revealed that the relevance of training content (r = 0.386, p < .001) and the method of training delivery (r = 0.437, p < .001) had significant positive correlations with the implementation of the UHC Law. This indicates that when training is designed to be practical, aligned with real-world responsibilities, and delivered through flexible formatssuch as blended learning or simulations—it can more effectively support the application of knowledge and skills in clinical settings. To successfully implement universal health care in the Philippines, leadership training programs must be customized to address the unique challenges of the local health system, equipping nurses not only with technical expertise but also with the leadership skills necessary to drive health reforms at the community level (Tomanan et al., 2022).

Table 7 Significant Relationship Between Nurses’ Training Exposure and Implementation of Universal Health Care Law

Variables	r-value	p-value	Decision
Level of Nurses’ Training Exposure in UHC Law
Training Exposure	0.533	<.001**	Highly Significant
Relevant of Training Content	0.386	<.001**	Highly Significant
Mode of Delivery of Trainings	0.437	<.001**	Highly Significant
Overall Level of Nurses’ Training Exposure in UHC Law	0.488	<.001**	Highly Significant

Note: **p < 0.01 (Highly Significant); *p < 0.05 (Significant); p > 0.05 (Not Significant)

Predictors of Level of Nurses’ Implementation of Universal Health Care Law

Table 8 presents the results of the multiple linear regression analysis, identifying significant predictors of nurses’ implementation of the Universal Health Care (UHC) Law. The model yielded an adjusted R² of 0.526, indicating that nurses’ readiness and training exposure can explain 52.6% of the variance in UHC implementation. This finding highlights a moderately strong model fit, underscoring the predictive value of these two variables in shaping successful implementation outcomes.

Readiness to implement the UHC Law emerged as the strongest and most statistically significant predictor (β = 0.9804, SE = 0.0756, t = 12.98, p < .001). This suggests that nurses who feel adequately prepared professionally, organizationally, and attitudinally are significantly more likely to implement Universal Health Coverage (UHC) policies effectively. This finding is consistent with the work of Ifeagwu, S. C et al.(2024), who emphasized that frontline workers’ readiness has a significant influence on the rollout of national health reforms in both urban and rural settings. Likewise, Ifeagwu, S. C. et al. (2024) reported that nurses with high levels of perceived readiness were more confident in managing policy transitions under the Universal Health Coverage (UHC) mandate.

Training exposure was also found to be a significant predictor (β = 0.1633, SE = 0.0775, t = 2.11, p 0.036), although its effect size was smaller than readiness. This supports the notion that professional development enhances policy comprehension and compliance with policies. As stated byHaruta, J., & Goto, R. (2024) ongoing, relevant, and skill-oriented training boosts the confidence of healthcare professionals and aligns their practices with evolving national health frameworks. Moreover, Zhao, R., Wang, (2024) found that frequent and context-specific UHC training correlates with higher implementation fidelity, particularly in primary care settings.

The significance of both readiness and training exposure affirms global and national policy directions. The World Health Organization (2021) and the Philippine Department of Health (2022) have emphasized the importance of investing in health workforce education and system readiness to achieve the goals of Universal Health Coverage (UHC). Without these, reforms risk being inconsistently applied, especially in underserved areas. The findings of this study echo this call, revealing that readiness, more than any other factor, drives the operational success of UHC at the grassroots level.

Taken together, the results underscore the need for robust, sustained investments in both nurse training and organizational capacity development. Empowering nurses through structured readiness programs and continuous training is crucial to ensuring the long-term success of Universal Health Coverage (UHC) in the Philippines and similar contexts.

Table 8 Predictors of Level of Nurses’ Implementation of Universal Health Care Law

Predictors	Coef (β)	SE Coef	t- value	p-value
(Constant)	-0.4783	0.2037	-2.35	0.020
Readiness of UHC Law	0.9804	0.0756	12.98	<.001
Training Exposure of UHC Law	0.1633	0.0775	2.11	0.036
Adjusted r2 = 0.526
Statistical Proficiency = 52.6%

Mediation Analysis of Nurses’ Readiness on the Relationship Between Awareness, Training Exposure, and Implementation of the Universal Health Care Law

The results of the mediation analysis provide clear evidence that both awareness and training exposure related to the Universal Health Care (UHC) Law influence nurses’ level of implementation primarily through their readiness. Table 9 reveals that both awareness (a₁ = .252, p < .001) and training exposure (a₂ = .327, p < .001) significantly enhance nurses’ readiness, which in turn strongly predicts implementation of the UHC Law (b = .980, p < .001). Notably, the direct effect of awareness on implementation is non-significant (c₁ = –.092, p = .190), while training maintains a modest yet significant direct influence (c₂ = .163, p = .034). Mediation analysis confirms that readiness fully mediates the relationship between awareness and implementation (indirect effect: .247, p < .001), whereas it partially mediates training’s impact (indirect effect: .321, p < .001). The total effect of training (.484, p < .001) substantially exceeds that of awareness (.155, p = .071), underlining the dual importance of training—both in promoting readiness and directly enhancing implementation.

These patterns align with broader literature that emphasizes readiness as a pivotal mediator in health policy uptake. For example, a global systematic review found that readiness for practice hinges on individual competence, educational experience, and workplace context—factors echoed in our strong b coefficient (Wynne et al., 2024). In the Philippine UHC context, Partial and Locsin (2024) identify the necessity of advanced nursing competencies—like decision making and community-centered care—as fundamental to implementation success. Moreover, broader implementation science highlights the need for facilitation, context-aware adaptation, and participatory training strategies to convert readiness into action (Harrison et al., 2021). Collectively, these findings suggest that raising awareness is necessary but insufficient—without accompanying readiness, built through comprehensive training and supportive systems, implementation of UHC by nurses remains constrained.

Table 9 Mediation Analysis of Nurses’ Readiness on the Relationship Between Awareness, Training Exposure, and Implementation of the Universal Health Care Law

Pathway	Label	Estimate	SE	95% Confidence Interval (Lower – Upper)	Z	p
Awareness → Readiness	a1	0.2523	0.0531	0.1482–0.3565	4.75	<.001
Training Exposure → Readiness	a2	0.3269	0.0571	0.2150–0.4387	5.73	<.001
Readiness → Implementation	b	0.9804	0.0750	0.8334–1.1275	13.07	<.001
Awareness → Implementation (Direct)	c1	-0.0924	0.0705	-0.2306–0.0457	-1.31	.190
Training Exposure → Implementation (Direct)	c2	0.1633	0.0769	0.0126–0.3141	2.12	.034
Awareness → Readiness → Implementation (Indirect)	a1 × b	0.2474	0.0554	0.1388–0.3560	4.46	<.001
Training Exposure → Readiness → Implementation (Indirect)	a2 × b	0.3205	0.0611	0.2008–0.4402	5.25	<.001
Awareness → Implementation (Total)	c1 + a1×b	0.1550	0.0857	-0.0130–0.3230	1.81	.071
Training Exposure → Implementation (Total)	c2 + a2×b	0.4838	0.0921	0.3034–0.6643	5.26	<.001

The model showed excellent fit indices (e.g., CFI > .95, RMSEA < .06), supporting the hypothesized relationships. Awareness (β = 0.31, p < .001) and training exposure (β = 0.38, p < .001) were both significant predictors of readiness, which in turn strongly predicted implementation (β = 0.69, p < .001). These findings align with recent literature emphasizing that health systems reforms, such as UHC, require more than policy dissemination—they demand a prepared, confident, and skilled nursing workforce (Parial& Locsin, 2024).

The results support the mediational pathway, where readiness significantly transmits the influence of awareness and training on implementation, mirroring implementation science frameworks that highlight the importance of internal capacity and contextual adaptation (Escoffery et al., 2023). In particular, readiness is increasingly recognized not merely as an outcome of training, but as a translational mechanism that operationalizes knowledge and motivation into practice (Wynne et al., 2024). The diminished direct effects of awareness and training when readiness was introduced into the SEM model reinforce this role, consistent with evidence from global UHC initiatives showing that policy knowledge alone rarely predicts successful frontline implementation without concurrent investments in workforce readiness (World Health Organization, 2020). Hence, the SEM framework presented in Figure 1 not only validates the statistical mediation of readiness but also reflects a broader shift in health systems thinking—positioning frontline readiness as a strategic lever in the effective rollout of UHC policies.

Figure 1 presents a Structural Equation Modeling (SEM) analysis that examined the mediating role of nurses’ readiness in linking awareness and training exposure to the implementation of the Universal Health Care (UHC) Law.

Experiences of Healthcare Providers with the Implementation of the Universal Health Care (UHC) Law

This study explored the lived experiences of healthcare providers in the Philippines in relation to the implementation of the Universal Health Care (UHC) Law.  Thematic analysis of the interview transcripts revealed four major themes: Expanding Access through System Integration, Broadening Roles and Holistic Service Delivery, Implementation Gaps and Resource Constraints, and Strengthening the Frontline for Sustainable Universal Health Coverage (UHC). Each theme is supported by participants’ narratives and situated within the broader context of recent literature.

Expanding Access through System Integration

Participants consistently acknowledged that the Universal Health Care (UHC) Law has improved access to essential services, particularly for underserved populations.

“Because of UHC Law, the patient in our community can avail the services free of charge… our Super Health Center now offers a range of essential health services.”(P1)

“Patients are now more aware that they can avail of services regardless of their financial capacity.”(P5)

These narratives reflect the UHC Act’s emphasis on integrated service delivery networks and automatic enrollment in the National Health Insurance Program (Republic Act No. 11223, 2019). The Department of Health (DOH) has also highlighted the importance of province-wide and city-wide health systems to ensure continuity of care and reduce fragmentation (DOH, 2020). However, as emphasized by Cagurangan (2025), integration remains uneven, with some LGUs advancing faster than others.

Broadening Roles and Holistic Service Delivery

The UHC Law has expanded the scope of nursing practice beyond clinical care to include health promotion, referral coordination, and patient education.

“We’re now expected to integrate services across facilities and coordinate care more efficiently… We also spend more time educating patients on their entitlements.”(P6)

“There is a stronger emphasis on providing comprehensive and accessible healthcare services… ensuring not only treatment but also prevention, health promotion, and early intervention.”(P7)

This shift aligns with the UHC Act’s prioritization of primary care and people-centered service delivery (DOH, 2020). It also reflects global best practices that advocate for holistic, community-based care models to improve health outcomes and reduce system inefficiencies (Asian Development Bank [ADB], 2023).

Implementation Gaps and Resource Constraints

Despite these gains, participants identified persistent barriers to effective implementation.

“It is challenging in the implementation part, specifically to far-flung areas with poor road conditions and limited resources.”(P1)

“The actual operational processes—like integrating electronic medical records, coordinating between LGU and DOH health units… are not yet fully streamlined.”(P4)

These concerns mirror national findings that underscore the need for stronger infrastructure, digital health systems, and equitable resource distribution (ADB, 2023; Yap, 2022). The shortage of trained personnel and logistical support in GIDA barangays continues to hinder the full realization of UHC goals (Domingo et al., 2023).

Strengthening the Frontline for Sustainable UHC

Participants offered grounded recommendations to enhance UHC sustainability. Policymakers to:

“Support health workers—give fair pay, training, and incentives… and prioritize poor communities.”(P1)

“Actively involve frontliners in the planning and evaluation of UHC policies… we see the gaps and solutions firsthand.”(P5)

“Policymakers should invest in systems strengthening—technology, manpower, and continuous education.” (P6)

These insights reinforce the UHC Act’s call for continuous capacity-building and participatory governance (Republic Act No. 11223, 2019). As emphasized by Villaverde et al. (2022), empowering frontline workers through training, feedback mechanisms, and inclusive decision-making is essential to sustaining reforms and ensuring equitable health outcomes.

The experiences of healthcare providers reveal both the strengths and limitations of Universal Health Care (UHC) implementation in the Philippines. While the policy has expanded access and fostered a more integrated approach to health care, systemic challenges remain. Addressing gaps in training, infrastructure, and workforce development, particularly in underserved areas, is crucial for achieving the goals of Universal Health Coverage (UHC). As echoed by participants, empowering frontline providers and fostering collaboration among all stakeholders are crucial steps toward a more equitable and resilient health system.

FINDINGS

Healthcare providers in the Philippines overwhelmingly perceive the Universal Health Care (UHC) Law as a positive step toward equitable access, as reflected in both statistical data and lived experiences. Quantitative results show that nurses report very high levels of awareness and training exposure, as well as a strong sense of readiness, particularly in their attitudes toward change. These findings align with providers’ narratives, which describe how UHC improved access to services in rural communities through system integration and expanded PhilHealth coverage. However, while nurses showed a high overall level of implementation, it remains slightly lower than their readiness and awareness, highlighting a gap between policy understanding and actual practice. Correlational and regression analyses confirmed that readiness and training exposure significantly predict implementation success. Moreover, mediation analysis revealed that nurses’ readiness plays a crucial role in translating awareness and training into practical implementation, suggesting that equipping nurses both emotionally and professionally is critical to achieving Universal Health Coverage (UHC) success.

Qualitative insights deepen this picture by highlighting real-world challenges and opportunities. Providers described taking on broader roles under UHC, ranging from clinical care to patient education and community health coordination, which mirrored the high scores in attitude and training relevance. Yet they also voiced concerns about limited resources, uneven implementation across regions, and a need for more consistent, hands-on training. These concerns align with the quantitative findings, which show weaker implementation scores in areas such as adherence to policy and care coordination. Despite these barriers, providers expressed a strong commitment to sustaining UHC’s gains, calling for greater investment in technology, workforce support, and participatory planning. Ultimately, both sets of findings emphasize that successful UHC implementation depends not only on awareness and training but also on empowering frontline workers, strengthening systems, and ensuring that those who implement the law are continuously heard and supported.

CONCLUSION

Based on the convergence of both quantitative data and qualitative insights, it is evident that the implementation of the Universal Health Care (UHC) Law in the Philippines has made meaningful strides in expanding access to essential health services, particularly in underserved areas.  Nurses and healthcare providers demonstrated very high levels of awareness and training exposure, indicating a strong readiness to adapt to their evolving roles under a Universal Health Coverage (UHC) framework. Their preparedness, especially in terms of attitude and professional competence, emerged as a key driver of successful implementation, mediating the relationship between what they know and the services they can deliver. However, while the policy framework has laid a solid foundation, the reality on the ground reveals lingering disparities in resource allocation, coordination, and infrastructure, which temper the full realization of UHC goals.

Healthcare providers’ narratives add critical depth to these findings, revealing how they have evolved into broader, more holistic roles while also navigating the weight of systemic limitations. Their voices reflect the urgency of addressing implementation gaps, such as the need for stronger referral systems, digital integration, and sustained capacity-building. Importantly, their commitment to the vision of UHC is unwavering, signaling a deep well of potential if properly supported. For UHC to achieve its promise of equitable, patient-centered care, the insights and lived experiences of frontline workers must not only inform future policies but also shape investments in healthcare systems. Empowering providers through inclusive planning, adequate resourcing, and continuous training is not just a recommendation; it is a necessity. It is a prerequisite for sustaining the gains of universal health reform.

RECOMMENDATION

In light of the findings and conclusion, it is recommended that the Philippine health system prioritize a more inclusive and systems-based approach to strengthen the implementation of the Universal Health Care (UHC) Law.  This includes sustained investment in workforce development through regular, face-to-face capacity-building programs, improved coordination mechanisms between national and local health units, and the upgrading of digital and physical infrastructure, particularly in geographically isolated and disadvantaged areas. Frontline healthcare providers, especially nurses, must be actively engaged in policy planning, evaluation, and decision-making processes, as their on-the-ground experience offers invaluable insights into both the challenges and solutions in UHC implementation. By reinforcing support for health workers and bridging systemic gaps, the country can accelerate the shift toward a more equitable, resilient, and truly universal healthcare system.

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