Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress

Health Research Policy and Systems

Ayako Honda¹  Bhupinder K Aulakh²  Michael K Ranson²  Di McIntyre¹ 

[1] Health Economics Unit, Department of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa;Alliance for Health Policy and Systems Research, World Health Organization, Geneva 27 1211, Switzerland

关键词: Universal health coverage;    Revenue collection;    Purchasing;    Pooling;    Policy analysis;    Low- and middle-income countries;    Financial protection;   

Others  :  805173
DOI  :  10.1186/1478-4505-11-36

 received in 2013-06-19, accepted in 2013-06-19,  发布年份 2013

【 摘 要 】

Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.

These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.

The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.

This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC.

【 授权许可】

   
2013 World Health Organization; licensee BioMed Central Ltd.

【 参考文献 】

• [1]World Health Organisation: Health Systems Financing: The Path to Universal Coverage. World Health Report 2010. Geneva: WHO; 2010.
• [2]Kutzin J: A descriptive framework for country-level analysis of health care financing arrangements. Health Policy 2001, 56:171-204.
• [3]Walt G, Gilson L: Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan 1994, 9(4):353-370.
• [4]Zoidze A, Rukhadze N, Chkhatarashvili K, Gotsadze G: Promoting universal financial protection: health insurance for the poor in Georgia – A case study. In Health Res Policy Syst. In Press;
• [5]Devadasan N, Seshadri T, Trivedi M, Criel B: Promoting universal financial protection: evidence from the Rashtriya Swasthya Bima Yojana (RSBY) in Gujarat. Health Res Policy Syst 2013, 11:29. BioMed Central Full Text
• [6]Onoka C, Onwujekwe O, Uzochukwu B, Ezumah N: Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria. Health Res Policy Syst 2013, 11:20. BioMed Central Full Text
• [7]Borghi J, Maluka S, Kuwawenaruwa A, Makawia S, Tantau J, Mtei G, Ally M, Macha J: Promoting universal financial protection: a case study of new management of community health insurance in Tanzania. Health Res Policy Syst 2013, 11:21. BioMed Central Full Text
• [8]World Health Organisation: World Health Statistics, 2011. Geneva: World Health Organisation; 2011.
• [9]Chirwa M, Kazanga I, Faedo G, Thomas S: Promoting universal financial protection: contracting faith-based health facilities to expand access – Lessons learned from Malawi. Health Res Policy Syst 2013, 11:27. BioMed Central Full Text
• [10]Vargas J, Muiser J: Promoting universal financial protection: a policy analysis of introducing universal health coverage in Costa Rica (1940–2000). Health Res Policy Syst 2013, 11:11. BioMed Central Full Text
• [11]Tangcharoensathien V, Pitayarangsarit S, Patcharanarumol W, Prakongsai P, Sumalee H, Tosanguan J, Mills A: Promoting universal financial protection: how the Thai universal coverage scheme was designed to ensure equity. Health Res Policy Syst 2013, 11:25. BioMed Central Full Text
• [12]Mills A, Akazili J, Ataguba J, Borghi J, Garshong B, Makawia S, Mtei G, Harris B, Macha J, Meheus F, McIntyre D: Equity in financing and use of health care in Ghana, South Africa and Tanzania: implications for paths to universal coverage. Lancet 2012, 380:126-133.
• [13]Akazili J, Garshong B, Aikins M, Gyapong J, McIntyre D: Progressivity of health care financing and incidence of service benefits in Ghana. Health Policy Plan 2012, 27(Supplement 1):13-22.
• [14]Lagarde M, Palmer N: The impact of health financing strategies on access to health services in low- and middle-income countries (Protocol). Cochrane Database Syst Rev 2006., 3CD006092
• [15]Mkandawire T: Targeting and Universalism in poverty reduction. In Social Policy and Development Programme Paper Number 23. Geneva: United Nations Research Institute for Social Development; 2005.
• [16]Carrin G, James C: Reaching Universal Coverage via Social Health Insurance: Key Design Features in the Transition Period. Discussion Paper Number 2–2004. Geneva: World Health Organization; 2004.
• [17]Lindelow M, Hawkins L, Osornprasop S: Government spending and central-local relations in Thailand's health sector. In HNP Discussion Paper 75680. Washington, DC: World Bank; 2012.
• [18]Ensor T: Transition to Universal Coverage in Developing Countries: An Overview. York: Centre for Health Economics, University of York; 2001.
• [19]Agyepong I, Adjei S: Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health Policy Plan 2008, 23(2):150-160.