Adaptive Alignment Thresholds in Universal Health Coverage: Health system transformation in Burundi (2020–2025)

“Adaptive Alignment Thresholds in Universal Health Coverage: Health System Transformation in Burundi (2020–2025)” is a theory-building and empirical study that introduces the Universal Health Coverage Adaptive Alignment Threshold Theory (UHC-AATT) to explain why similar health-system reforms may produce different outcomes depending on the degree of structural alignment within the system. Using Burundi as an empirical case over the 2020–2025 period, the study conceptualizes health-system transformation through the interaction of four structural pillars: institutional coherence, financial harmonization, incentive alignment, and regulatory stability. It operationalizes these relationships through the Mean Alignment Score (St) and the Adaptive Alignment Threshold (AATt), which incorporates both the level and dispersion of alignment across the system. The study examines whether health-system performance exhibits non-linear and threshold-dependent dynamics, whereby reforms may become more effective as structural alignment improves. It also explores the role of digital technologies and artificial intelligence as conditional amplifiers whose contribution depends on the underlying alignment of the health system. Rather than presenting Burundi as a completed transformation model, the study uses the country as a theory-generating empirical case to develop a framework that can subsequently be tested through prospective longitudinal and multi-country research. The UHC-AATT therefore offers a theoretically grounded and empirically testable approach for understanding how coordinated structural conditions may influence the transition from fragmented reforms toward more coherent and adaptive UHC transformation.