Equity on the Path to UHCDeliberate Decisions for Fair Financing

Background Report (Conference Version)

Greater Equity for Better Health and Financial ProtectionWashington, D.C. • April 19–20, 2018

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Thisisaforumpaper(conferenceversion)tothe“ThirdAnnualUHCFinancingForum:GreaterEquityforBetterHealthandFinancialProtection”.Thispapersetsthestageforthe

presentationsanddiscussionsattheForumandwaspreparedundertheguidanceoftheForumTechnicalWorkingGroup.Theinformationprovidedinthisdocumentdoesnotnecessarily

representtheviewsorpositionoftheorganizationsrepresentedontheTechnicalWorkingGroup

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Section1:Introduction

In2016,theWorldBankGroupandUSAIDestablishedtheAnnualUHCFinancingForum,whichtakes

placeattheWorldBankGroup/IMPSpringMeetings.Thesemeetingsarestrategicplatformswhere

thousandsoffinanceanddevelopmentleadersfrommembercountriesdiscuss,analyzeanddebate

goalsforendingextremepovertyandboostingsharedprosperity.

TheUHCFinancingForumisembeddedintheselargerdiscussionstodivedeeplyintotheprocessesfor

acceleratingcountryprogresstowardsustainablefinancingofUniversalHealthCoverage—whichis

integraltoreachingtheSpringMeetings’largergoals.

Thisyearmarksthethirdtimeinwhichover400policymakersandotherexpertshaveconvenedto

analyzeandcriticallydiscussthehealthfinancingrealitiesthatcountriesface.Inoneoftheonlyglobal

spacesforthesenecessarydiscussions,participantsusetheforumtohelpshapeacollectiveagendafor

tacklingkeyfinancingchallengesposedbysomeofthetrickiestproblems.

TheThirdAnnualUHCFinancingForumexaminesequityforbetterhealthandfinancialprotection.It

complementsandbuildsonthetopicsandpapersofthe1stand2

ndforum,whichfocusedonhowto

generaterevenuestomeetfinancingneedsforqualityhealthservicesandfinancialprotection,andhow

touseavailableresourcesinthemostefficientway.

Eachyearourdebatesareinformedbyabackgroundreportthatexamineswhatworksanddoesn’t

work,whiletakingstockofwhatiscontroversial,innovative,ofhighimpactorinneedofclarity.

Thisyear,wetakeadifferentapproachbyaskingpolicymakerstoconsiderequitymoredeliberatelyin

theirhealthfinancingchoices.Whenpolicy-makersaimtoredressinequitiesinfinancingoutcomes,

theycandrawuponawell-establishedbodyofliteraturethatevaluatesandoffersguidanceonhowbest

toapproachpolicychoices.Butwhenpolicy-makerspursuestrategiestoaccelerateprogresstoward

UHC,theyseematalosstofullyconsidertheequityimplicationsoftheirfinancingdecisions.Oratleast

thatiswhattoday’sdeepinequitiesinhealthfinancingsuggest.Wethinkthat,perhaps,equityasa

criterionfordecision-makingisfallingthroughthecracks.

Placingtheblameonpolicymakerswouldmissthemark.ThemainproblemisthatprogresstoUHC

doesnotnecessarilyleadtoimprovementsforallandtheworse-off.This,wethink,isbecausepolicy-makersgrapplewithhowbesttoreachtheequitableendpointofUHCwhilealsoworkingonhigher

priorityobjectives,likeimprovingefficiency,overallpopulationhealth,employmentoreconomic

growth.Littleguidanceisavailabletohelpmanagedifficulttrade-offsbetweencompetingneeds.

Thispaperandthisyear’sforumaimtoclosesomeoftheinformationandguidancegaps,andfacilitate

thechangesnecessarytomoveequityconsiderationstotheforefrontofhealthfinancingpolicy

development.Weseethisasathree-prongedprocesswithafocusoni)identifyingpolicydecisionsthat

aredeemed“unacceptable”;ii)establishingwhatwecall“fairnessofprocess”indecision-making;and

iii)monitoringtheoutcomestohelpidentifywherepoliciesneedtobeadjustedforequity.

Theproposedframeworkbuildsonalargebodyofworkthathasexploredthemeaningofequityand

fairnessinhealthfinancingandfiscalpolicy.(e.g.,Wagstaff&VanDoorslaer2000;Murrayetal.2003;

Xuetal.2007;O’Donnelletal.2008;VanDoorslaer&O’Donnell2011;Bastagli,Coady&Gupta2012;

Ottersen&Norheim2014;Clements,Gaspar&Gupta2015;Mulenga&Ataguba2017;Fleurbaey&

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Maniquet2017;Wooetal.2017;Evanetal,2001).Morerecently,thisworkhasbeenappliedtoUHC

(WHO2014).However,noconsensushasdefinedtheboundariesandcontentoftheterms“equity”and

“fairness”andwhetherandhowtheyaredifferent.So,followingontheWHOConsultativeGroupon

MakingFairChoicesonthePathtoUHC,weusethetermsinterchangeablyinthispaper.(WHO2014).

Thescopeofourframeworkisbrokendownintothefollowingsections.

InSection2,wedescribethechallengesthatcountriesfaceastheyprogresstowardsUHCwhilealsostrugglingwithvastinequitiesinservicecoverageandfinancialprotection.

Section3mapsoutwhyhealthfinancingandtheoutcomestheyproducematter,andhowandwhy

policiesthatmakeUHCagoal—evenifit’sfarfromareality—areworthwhile.

Section4isreallythemeatofthisreport.Itidentifiesunacceptablepolicychoices,mapsout

approachestoestablishfairprocesses,anddiscussesthevalueofandneedformonitoring.

Section5outlineswhatcountriescandotofundamentallychangethewaytheyincorporateequity

concernsintotheirhealthfinancingpoliciesandstrategies.

Section2:SettingtheStageforUHC

In1978,theAlmaAtaDeclarationarticulatedanambitiousextensiontotheWorldHealthOrganization’s

constitutionbydeclaringprimaryhealthcareasabasichumanright.InwhatisnowKazakhstan,world

leaderssignedontonewoperatingprinciples,declaringthatallpeoplehadarighttopersonalhealth

andpublichealth,withaccesstotraineddoctors,nurses,midwivesandtraditionalhealers,andto

sanitation,cleanwater,essentialdrugs,immunizationsandmore.Andtheyproclaimedthatthese

servicesmustbeavailable“ascloseaspossibletowherepeopleliveandwork.”

Signatoriesgavethemselvesuntiltheyear2000—22years—andimploredactiononthepromisethat

healthforallwouldalloweveryonetoleadsociallyandeconomicallyproductivelives.

Now,40yearslater,wenotonlymissedthemark,butwemisseditbyawidemargin.Thegoodnewsis

thatthefastestprogresseverinextendinghealthservicecoverageoccurredduringtheeraofthe

MillenniumDevelopmentGoals.Thebadnewsisthat,atthecloseoftheMDGin2015,onlyabouthalf

theworld’spopulationenjoyedthebasicbenefitsenvisionedforallinAlmaAta.

ThenewtargetdateoutlinedbytheSustainableDevelopmentGoalsandtheWHOConsultativeGroupis

toreachUniversalHealthCoverage—withaccesstoservicesaccordingtoneedandwithoutfinancialhardship—by2030.Ifwearetotakethisseriously,countriesneedtobeontherightpathandstay

there.

Wehave12yearstodoalotofwork.Oneofthebiggesthurdlesisreplacingout-of-pocketpayments,

whichlimitaccessibility,withotherformsofhealthfinancing.Onlymodestprogresshasbeenmadein

reducingthesepayments,andnocleartrendshowstheiroverallburdenislightening.Tothecontrary,

everyyearapproximately100millionpeoplefallintopovertybecauseofout-of-pocketpayments.

Thetragedyisthatwehavefailed,eventhoughthemeansexisttomakehugeleapstowardUHCby

2030,andeliminatethepaymentconditionsthatknockthese100millionpeopleannuallyintopoverty.

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Multipleglobalestimatesshowthatthecostofapackageofessentialhealthservicesshouldrunno

morethan$90perpersonperyear.Globaldomesticpublicspendingstoodat$3.9trillionin2015,

enoughtofinancetheseessentialpackagesformorethan40billionpeople,oroversixtimestheworld’scurrentpopulation.

Theproblemiswehavevastlyinequitableinvestmentsinhealthfinancing,coverageandaccessto

services.Inthewealthiest5percentofcountrieswiththehighestpublicinvestmentsinhealth,the

averagespentonhealthperpersonis$4,600.Andforthetop10percentofcountriestheaverageis

$4,100perperson.

Butinthepoorest5percentofcountries,theaveragespentperpersononhealthisjust$4.Andforthe

bottom10percent,theaverageis$5perperson.Evenwhenadjustingforcostofliving,thedisparitiesin

healthinvestmentsarestunning.

Thebiggestchallengenowistofigureouthowtoboosthealthfinancingacrosslow-andmiddle-income

countriesinwaysthatmakehealthcoverageapriorityandareconsistentwiththegoalsofUHC.

Thisreport,andthisyear’shealth-financingforum,asksallparticipantstoseethispointintimeas

pivotal—asamomentoftruth.Ifcountriescontinueattheslowrateofprogressthatwesawinthelast

40years,wewillfailtoevencomeclosetoourgoalsby2030.

CountriesmustaccelerateprogresstowardsUHCbysystematicallytacklingfundamentalshortcomings

inhealthfinancing.Thisreportandthisyear’sforumhoneinonprovenandleadingedgeapproaches,

whichincludegivingprioritytotheworse-off(thesickestandthepoorest);reducingandultimately

eliminatinginequalitiesinhealthinvestmentsacrosscountriesandwithincountries;protectingpeople

fromfinancialruinlinkedtoOOPsbyphasingoutOOPsasameansforhealthfinancing;increasing

prepaidandpooledfinancing;andincrementallyincreasingguaranteedpackagessothatcoverageof

services,andtheirquality,improveforeveryoneovertime.

CountriesmustmakefasterprogresstowardUHC.Theinequitiesthatweseeglobally,however,exist

alsowithincountries.Ascountriesaccelerateprogress,theyruntheriskofdeepeningtheseinequities.

Figure1:Incidenceandinequalityinskilledbirtha7endance,Threshold:10%oftotalconsump6on(n=120countries)Inequali)es,

Concentra6onindex

SOURCE:HEFPI2018Database

Notes:Basedonlatestavailablesurveyyear;circlesizeispropor)onaltototalpopula)on

Popula)onincidence,%30 40 60 80 10050 70 900 10 20

0.3

0.2

0.0

-0.1

-0.2

0.1

0.4

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Onthebenefits,side,thenatureofthegameisthatthehigherthecoverage,thelowertheinequities.

Likewise,thehighertheaveragecoverage,thelessthevariation.Forexample,lookingatSkilledBirth

Attendance(SBA),aservicecommonlyincludedinessentialservicepackages,countrieswithservice

coverageabove80percent,haveconcentrationindiceslowerthan0.1.Incontrast,countrieswith

averageinservicecoveragebetween30and50percent,haveconcentrationsindicesbetween0.1(e.g.,

Indonesia)tocloseto0.5(e.g.,Nigeria).Theconcentrationindexmeasuresinequalitiesbysocio-

economicstatus(SES).Theindexrangesfrom-1to1,withzeromeaningnoinequalitiesincoverage

acrossincomegroupsinthiscase,andinequalitiesincreasingastheindexapproaches1.Byconvention,

pro-richinequalitieshavepositiveindices,whilepro-poorinequalitiesshownegativeindices.

Whiletheconcentrationindexisanabstractconcept,theillustrationofcoveragebyincomequintile

providesabettersenseofthedepthoftheinequalities.Forexample,theconcentrationindexof0.47

forNigeriameansthatSBAcoveragewas87.5percentinthehighestincomequintile,butonly6.7

percentforthelowestincomequintile.

Figure2:Incidenceofskilledbirtha7endance:Nigeria(2014),%

6.7

18.8

41.6

64.1

87.5

0102030405060708090

Q1 Q2 Q4Q3 Q5

SOURCE:HEFPI2018Database

Incidence,%

Figure3:Incidenceandinequalityincatastrophicpayments,Threshold:10%oftotalconsump6on(n=136countries)

SOURCE:HEFPI2018DatabaseNotes:Basedonlatestavailablesurveyyear;circlesizeispropor)onaltototalpopula)on,n

Inequali)es,Concentra6onindex

0.6

0.4

0.0

-0.2

-0.4

Popula)onincidence,%5 10 20 30 4015 25 350

0.2

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Source:Urquieta-SalomonandVillarreal,2016

Ontheburdenside,thepictureislessclear.Dataareonlyavailableforasmallersetofcountries.

Multiplemeasuresoffinancialprotectionexist,producingdifferentpatterns.Moreover,patternsneed

tobecarefullyinterpretedagainstinformationonservicecoverage.Forexample,adeclineinservice

coveragemayresultinreductionsofOOPexpendituressotheindicesoffinancialprotectionmightseem

toimprove.Nevertheless,weseedeepinequalitiesinmanycountries.Forthepurposeofillustration,

weusecata10consumption.Inmostcountries,inequalitiestendtobeoverwhelminglyconcentrated

amongthepoor.

Likeonthebenefitsside,theillustrationoftheincidenceoffinancialcatastrophe(inthiscasemeasured

asout-of-pockethealthexpendituresexceeding10%oftotalexpenditures,calledcata-10)byincome

quintileprovidesabetterillustrationofthedepthoftheinequalities.

Forexample,theconcentrationindexof37.39forIndiameansthattheincidenceofcata10wasin15

percenthigheramongthelowestincomequintilecomparedtothehighestquintile.

InequalitiesinUHCoutcomesoftenreflectdifferencesinthelevelofinvestmentorotherhealth

financingoutcomesandfunctions.Forexample,attheturnofthecentury,servicecoveragevariedin

Mexicosignificantlybetweenpeoplewithandwithoutsocialhealthinsurance.

Table1:Coverageofeffectiveaccesstopreventivehealthinterventions

Uninsured Insured

Skilledbirthattendance 88.91% 94.78%

Basicvaccinationschedule 71.39% 73.18%

Adultsover20withhighbloodpressure

control

47.73% 67.72%

Figure4:Incidenceandinequalityincatastrophicpayments:RepublicofKorea(2011)Threshold:10%oftotalconsump6on

37.4

17.212.8

8.25.7

0

10

20

30

40 Q1 Q2 Q4Q3 Q5

SOURCE:HEFPI2018Database

Incidence,%

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Whilecoverageforessentialservicessuchasmaternalandchildhealthwashighindependentof

affiliation,starkdifferencesprevailedinthecoverageofservicesfornon-communicablediseases(table

1).Effectivecoveragewithhighbloodpressurecontrolwas20percentagepointshigheramongthe

insured.

Similarly,thelikelihoodofthosewithsocialhealthinsurancetosufferfromcatastrophichealth

expenditures(frominpatientvisits)overayearwasfourtimeslower(Knauletal,2006).These

differencesinUHCoutcomescorrespondedtothelevelsofgovernmentfinancialcontributions.For

peoplewithsocialhealthinsurance,itwasfivetosixtimeshighercomparedtothecontributionsfor

governmenthealthservicesusedbytheuninsured.

Section3:TheGoal

ThedefinitionofUHCholdsthatallpeopleshouldreceivepromotive,preventive,curative,rehabilitative

andpalliativehealthservicescovered,basedonhealthneeds.Thoseservicesshouldbeofsufficient

qualitytobeeffective,whilealsoensuringthatpeopleareprotectedfromfinancialhardshipswhen

usingtheservices(WHO2010).

ThegoalofUHCexpandsontheconceptofqualityhealthcareforallasabasichumanright,asoutlined

intheWHOconstitution,theAlmaAtaDeclarationonHealthforAllandanumberofhumanright’s

treaties,addingprotectionfromfinancialhardship.

ThefirstcriticalpartofUHCisaboutbenefits,ensuringpeoplearecoveredbasedonneed.Healthy

people—thebetter-off—needlessservicesfromthesystem.Andunhealthypeople—theworse-off—

needmorefromthesystem.Thespectrumofneedshoulddeterminethebenefits,settingupservicesto

berenderedinanunequal,butequitableway.Thiswecallverticalequity;thehighertheneedthe

greaterthebenefits.Butcoverageshouldalsotreatallpeoplewiththesamehealthneedsequally,so

thateveryonewithkidneyfailureinneedofhemodialysisreceivesit(iftheywant).Thiswecall

horizontalequity;acrossanygivenneed,everyoneiscovered.

Butwithinhorizontalequityistheaddeddimensionofqualityoreffectivenessoftheavailableservices.

Theeffectivenessofthoseservicesisequallyasimportant.Thatis,servicecoverageandquality

combinedresultineffectivecoverage,orthecapacitytoachievethedesiredresults.

ThesecondpartofUHCisaboutfinancialburdens,ensuringpeopleareprotectedfromseverefinancial

hardshipwhenpayingout-of-pocketforhealthservices.Thesekindsofhardshipshavetwowidely-

accepteddefinitions:out-of-pocketpayments(OOPs)thatpushpeopleintopovertyordeeperinto

poverty,andOOPsthatarenotimpoverishingbutnonethelessprovecatastrophicforthehousehold

becausetheyleadtoexcessiveborrowingorassetdepletion,orcuttingbackonessentialneedslike

education,clothing,housingandfood.UHCisclearthatnooneshouldsufferthesekindsoffinancial

hardshipsfromOOPs.

Equity in UHC outcomes matter

UHCisimportanttoimprovinghealthandreducingpoverty.Weseethiswherepeoplelackaccessto

healthservices.Theyoftentakelongertorecoverfromanillnessorinjury,orneverrecover,leadingto

lossofincome.Incountrieswithsocialsafetynets,thiscanendupcostingmoreinservicesthanthe

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originaltreatmentwouldhavecost(thepenny-wise,pound-foolishproblem).Wherenosocialsafety

netsexist,healthcostsareknowntotumblefamiliesintopovertyandholdthemthere.Forexample,the

compoundingeffectsofpovertyforcefamiliestoforegothecostofeducation,eitherbecausetheyhave

nomoneyforthefeesortheyneedtheirchildrentostayhomeandhelpearnincome.Wherethesick

areexpectedtopayforhealthservices,familiesmayendupborrowing,incurringdebtthatcanget

passeddownfromgenerationtogeneration.

Werecognizethatsocialdeterminantsalsoplayanimportantroleinhealth.Thatis,peoplewithperfect

healthcoverageataffordablecostswholiveinacommunitywithgunviolencearestillsusceptibleto

beingshot.Butwherethetwomeet,iswhereUHCmakeshealthcoveragereliableandaffordable.

Peoplehavemoremoneytopayforotherthings,likebettereducation,nutritionandlivingconditions

(tomoveawayfromthegunviolence).Andthatcanimprovehealthoutcomesandhelpliftpeoplefrom

poverty,oratleastnotexacerbateit.

WeseeUHCasleadingtooutcomesthatreachbeyondthepopulation’soverallphysicalhealth,because

theyplayaroleinreducingfinancialstresses.Theexplicitpovertyaversionaspectofthisholdsthe

potentialofpositivelyripplingout.Thatis,inadditiontogroundinghealthsystemsintheidealthat

healthisahumanright—asmuchasdecentlivingconditionsare—equitablefinancingthatprotects

peoplefromeconomichardshipensuresthatthehealthsectorplaysnopartinincreasingpoverty.

Wealsoseethatreducinginequalitiesinhealthoutcomeshelpsreduceincomeinequalities.Andbetter

healthtranslatesintohigherincome.Thisistrueofhealthservicesandsocialdeterminantsofhealth.So

wehavetwostrands.Financialprotectionimprovesincomeinequality,andhealthoutcomesreduce

incomeinequalitywhenoutcomesimprovethehealthofthepoor.Weknowreducedincomeinequality

promotesgrowth,andthatincomeinequalityhasa“negativeandstatisticallysignificantimpacton

subsequentgrowth.”(Cinganro,F.,2014)

Importantlessonscanalsobelearnedfromseveralhigh-incomecountriesthattodayfacegrowing

inequitiesinhealthoutcomesandincreasingratesofpoverty,andthathavecorrespondingerosionof

socialcohesion,advancedpoliticalpolarization,andslowereconomicgrowth.(IMFFiscalMonitor,

October2017)Closingthesegapsshouldbethegoalofallcountries,andhealth-financingchoicescan

help.

Dramaticglobalhealthsecuritylessonsalsocanbelearnedfromlower-incomecountriesthathavebeen

unableorunwillingtoworkequitablytowardUHC,orotherwisestrengthentheirentirehealthsystems.

Intheseplaces,infectiousdiseasesspreadmorerapidlyinareaswithweakcorepublichealthfunctions,

sometimesindramaticwaysthatputimmensefinancialandpoliticalstressontheentireglobalhealth

system.The2014EbolaoutbreakinWestAfricaservesasoneofthemostrecentacuteexamples.We

canbegintohead-offthesekindsofoutbreaksbybringingequitytohealthfinancingsothathealth

systemsare,attheveryleast,abletodeliverbasicdiagnosticanddiseasesurveillancetoolseverywhere.

Journeying to UHC

AchievingUHCisthegoal.Butnocountryisallthewaythere,withcompletecoverageofhighquality

servicesthatareaccessibleandaffordableforall.Somewealthycountriescomeclosewithrelatively

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largeguaranteedcoveragepackagesthatincludeabroadrangeofhealthservicesavailableforloworno

out-of-pocketpayments.

Formanycountries,however,UHCisinthedistantfuture.Toofewcanaffordthesuiteofhealth

interventionsthatareknowntoprolongandimprovelife,whilealsoensuringfinancialprotectionforall

users.ThegoalforthemistoseeUHCasajourney,tostartwithatleastasmallerguaranteedpackage

withabaselineofessentialservicesthatareavailabletoall,ofequalqualityforallandaffordable.Then,

overtime,thesizeandscopeofthepackagesshouldexpand—allthewhilekeepingasagoal

improvementsinequitability,availabilityandaffordabilityofservices.Bystartingoutsmall,these

countriesarestrategicallyandtacticallysetuptocontinuethejourneytoUHC.

Signposts show the way

CountriesthathavesetUHCasatargetandmadetheobligationtoprogressivelystayonthejourney,

however,areunabletolooktotheUHCgoalsforguidanceonmakingpolicychoicestohelpkeepthem

oncourse.Indeed,assomecountriesmadeprogressonservicecoverageoverall,inequitieswidened.

Andduringtimesofcrisis,servicecoveragedroppedandfailedtoprotectthepoor.

SoUHCshowstheobjectiveofthejourney,nothowtogetthere.Weattempttofillsomeofthosegaps

inguidancebyofferingpolicy-makerswhatwecallsignposts.Theyaredesignedtoprovidenecessary

directionsforstayingoncourse.

Onthebenefitsside,UHCrequiresdistributionofhealthservicesaccordingtoneed.Ontheburden

side,financingsystemsthereforecannotputupfinancialbarriertoaccessthebenefits.Andthatis

wherehealthfinancingofUHCextendsbeyondfinancialprotectiontoprovidingservicesregardlessof

theabilitytopay.Sothesetwocomponentshavetobeseparated.

Wecallitdecoupling.Policy-makersforUHCmustdevelopauniversalguaranteedcoveragepackage

accordingtotheircountry’sfinancingcapacities.Whatisincludedinthepackagewillbebasedon

Inequali)es,Concentra6onindex

Figure5:Servicecoveragevs.inequality,Concentra6onindex(-1=skewtopoorto1=skewtorich)

0.3

0.2

0.1

0.0

-0.1 30 40 50 60 70

Servicecoverage,%

SOURCE:WorldBankHEFPI2017

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whatevercountryfinancingwillallow,startingwithacoresetofhealthservicesandexpandingitover

time.

Onaseparatetrackpolicy-makersmustraisethefinancing.Butthismustbedoneinawaythatremoves

thefinancialburdenforpeoplewhoareunabletopay.Theonlywaytodothisisthroughprepaidand

pooledfinancing.Inpractice,thismeanspublicfinancing--taxesandcontributionstosocialhealth

insurance.Tosubsidizethepoor,andthosewithlargehealthneeds,publicfundsshouldingeneralbe

raisedbasedontheabilitytopaywithsomedegreeofprogressivity,thatis,therichercontributea

highershareoftheirincome.

Socountriesestablishaguaranteedpackagewithhealthservicesthatareavailabletoallatan

affordableprice(UHC).Whoutilizestheservicesisseparatedfromwhopaysforthem.Utilizationis

basedonhealthserviceneed.Payingintoprepaidandpooledsystemsisbasedontheabilitytopaywith

OOPsminimized.

ThisprovidestwoguidepostswhendevelopingpoliciestowardUHC:healthservicesaccordingtoneed

andcontributionstoprepaidandpooledfinancingbasedonabilitytopay.Twotrackswithseparate

directionsforstayingonthepathtoUHC.

OnthejourneytoUHCcomefurtherconsiderationswithinthesetracks.Thereisbroadconsensusthat

someprioritymustbegiventotheworse-off.Onthebenefitsside,thismeansgivingprioritytothe

sickestandthosewiththelowestservicecoverage;ontheburdenside,thismeansgivingprioritytothe

poor.1Inthisway,UHCdirectspolicy-makerstopayspecialattentiontothemostdisadvantaged

segmentsoftheirpopulations,andmakedecisionsdesignedtoreachthem.

Incountrieswithlittlepotentialforraisingenoughprepaid,pooledfundstocoverabroadsuiteof

healthservices,effortshavefocusedonidentifyingpackagesofsufficientserviceswithguaranteed

accessandfinancialprotectionwithinthelimitationsofavailablepublicfinancingandservicedelivery

capacities.ThesepackagesconstitutethestartingpointfortheprogressiverealizationofUHC.Decision-

makersthenfacethechallengeofdefiningwhatis“sufficient”inabasicpackage,andwhatshouldbe

addedasthepackageexpandsovertime.

ThechallengescountriesfacestayingonthepathtoUHCaremany.Thefollowingarefourinterrelated

butdistinguishablechoicesthatmakepolicydecisionsdifficult.

First,theprinciplesofbenefitsandburdenarenotabsolute.Forinstance,withrespecttobenefits,

shouldcountriesgiveprioritytoexpandingtherangeofservicesavailabletoall,basedonneed,or

shouldtheyfocusonimprovingthequalityofexistingservices?Likewise,ontheburdenside,shouldthe

principleofabilitytopaybeinterpretedastherichpaymorethanthepoororthattherichpayahigher

proportionoftheirincomesthanthepoor?Eveniffaircontributionsareunderstoodasthelatter,i.e.

progressivecontributionswheretherichpayahigherproportionoftheirincome,policymakersmust

stilldeterminehowmuchmoretherichshouldpay.

1

Oneformalizationofthisapproachisinherentintheidealsofprogressiveuniversalism,whichdictatethatateverystageon

thepathtoUHC,topoor—whoasagroupareinthemostneedofhealthservicesandfinancialprotection—shouldbenefitat

leastasmuchastherich.

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Second,decisionsoftenpitbenefitsagainstburden.Often,decision-makershavetodecidebetweenthe

twocompetinginterests:expandingandimprovinghealthservicesontheonehand,andextending

financialprotectionontheother.Shouldcountriesprioritizetheexpansionofeffectiveservicesfor

thosewiththegreatesthealth-serviceneeds,ortheextensionoffinancialprotectiontothosewiththe

leastabilitytopay?Moreover,ifcountriesdecidetofocusonamixofhealthserviceexpansionand

financialprotection,howmuchweightshouldbegiventoeachcomponent?And,ofcourse,theyhaveto

figureouthowtopayforeverything—whichcirclesbacktothefirstdifficulty.

Third,prioritizingtheworse-offrequiresdata,whicharescarce.Whilemanycountriesaresettingup

systemstoidentifytheworseoff,lackofsufficientsurveydatahasmadeidentifyingthosewithgreater

healthcoverageneedsandlowestactualcoveragedifficult.Oneansweristofocusfirstonuniversal

coveragetocastawidenetthatcoversabasicsetofservicesthatreacheveryone,includingtheworse-

offandpoorestpeople.Thisensuresthatthepoorgainatleastasmuchasthebetter-offduringservice

coverageexpansions,onthewaytoUHC.

Thefourthdifficultyweseeis,perhaps,thetrickiest.Thisiswhenpolice-makersmustdecidebetween

improvingequityinhealthfinancingandreachingothersocialgoals—suchasstimulatingeconomic

growthorraisingadditionalrevenuerapidly.Thisisthefocusofthenextsection.

Section4

ChartinganequitablepathforwardinfinancingUHCincludesthreepolicyanglesthatthispaperdefines

andofferssuggestionsfor.Thefirstisidentifyingunacceptablepolicychoicesthatshouldbeavoided.Thesecondisestablishingcriteriaforfairprocessesthatwillengagethepublicandkeeppolicydecisionsoncourse.Andthethirdismonitoringimpactsbyusingavailabledatatohelpinformpolicy

choicesandleadtoequitableoutcomes—notexacerbateexistinginequitiesorleadtonewones.

UnacceptablePolicyChoicesinFinancingUHC

Decisionsthatdeepeninequitiesinhealthfinancingneedtobeidentifiedandavoidedascountries

moverclosertoUHConaggregate.Broadlyspeaking,an“unacceptablepolicychoice”isonethatcreates

orexacerbatesanexistingunfairinequalityandcannotbejustifiedbytrade-offsagainstotherpolicy

objectives.Herewearetalkingaboutincrementalpolicychoiceswithinthethreehealthfinancing

functions:revenuegeneration,poolingandpurchasing.

WearrivedattheseunacceptablepolicychoicesbybuildingonthelogicoftheWHOConsultativeGroup

onEquityandUniversalHealthCoverage,whichfocusedonfairchoicesintheprioritizationofservicesin

theprogressiverealizationofUHC.Here,welookmorebroadlyatfinancingUHC.

WhileexaminingoptionsforimprovingUHCoutcomes(everyonegetsthehealthservicestheyneed,of

goodquality,andwithfinancialprotection),weidentifiedpotentialinequalitiesamongindividualsand

groups(differingbyincome,gender,geographicregion,ethnicorigin,affiliationwithpooling

arrangements,legalstatusofresidency,andhealthordiseaserelatedproblem).Wethendrilleddown

tounderstandtheinequalitiesacrossthethreehealthfinancingfunctionsthatcontributetoinequalities

inhealthoutcomes.

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Fromthereweestablishedprinciplesoffairnessinthedistributionofbenefitsandburdens,basedon

thevaluesinherentinUHCandthemorewidelyacceptedprinciplesoffairnessandequity.Wethen

scrutinizedtheinequalitiesinUHCoutcomesandthoserelatedtoeachhealthfinancingfunction;

measuredthoseinequalitiesagainsttheprinciplesoffairness;determinedwhethertheywere

inequitable(i.e.inequalitiesthatareinherentlyunfair);identifiedpolicychoiceslikelytodeepen

inequities,andconcludedthatsuchchoices—unlessjustifiedbytheneedtopursueotherpolicy

objectives—are“unacceptable”.

Thepolicychoicesthatwedeem“unacceptable”inallthreefinancingfunctions,basedontheapproachdescribedabove,meettwocriteria:

1) TheydeepeninequalitiesidentifiedasunfairintheUHCprinciplesforbenefitsandburden.

2) Theycannotbejustifiedbytheneedtopursueotherpolicyobjectives.Examplesinclude

stimulatingemployment,maximizingrevenues,controllinginflation,orstimulatingeconomic

growth.

Bothcriteriainvolvevaluejudgmentsthatreasonablepeoplecandebate.Whatwefocusonispolicy

decisionsthatincreaseinequity,butthatcannotbejustifiedbyotherpolicyobjectivesthatoffer

counterbalancingtrade-offs.

TenUnacceptableChoices

Thefollowingareten“unacceptable”choices,byhealthfinancingfunction(revenuegeneration,pooling

orpurchasing)outlinedintable1ofAnnex1

Thefirstthreeunacceptablechoicesrelatetorevenuegeneration,whichisdefinedasraisingfinancialresourcesneededtodevelopandrunahealthsystem.

Broadconsensusisthatguaranteedservicesmustbefinancedlargelywithcompulsoryprepaid

resourcesandnotout-of-pocketpayments.Thisprovidesbetterfinancialprotectionandpreventsthat

tumbling-into-povertyeffectthatOOPstoooftencause.Wearguethattheequitabilityofhowthese

prepaidfundsareraisedmattersonlytotheextentthatthechoicesaffectthefairnessoftheentire

publicfinancingsystem,includingbothcontributionsandexpenditures.Soweseehealthfinancingasa

partofpublicfinancing—fromindividualtaxrevenuestofirmsthatpaydedicatedtaxesordirectlyfund

employeehealthservices.Howrevenuesareraisedandspent,onthewhole,iswhatmattersmost.

UnacceptablechoiceNo.1:Raiseadditionalrevenuesforhealththatmakecontributionstothepublic

financingsystemlessprogressivewithoutcompensatorymeasuresthatensurethatthepost-tax,post-

transferdisposableincomedistributionisnotlessequal.

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15

Atfirstglance,thePhilippines’2012decisiontoraiseamajorityofrevenuesforthenationalinsurance

programthroughtaxesontobaccoandalcoholmighthavebeenseenasanunacceptedpolicydecision

becausesintaxesareknowntoberegressive.2However,thegovernmentusedaportionofthetaxesto

payhealthinsurancepremiumsforthebottom40percentofthepopulation(Kaiseretal,2016).From

2012to2014,theprogramexpandedhealthinsurancecoverageamongthepoorto14.71million

households,upfrom4.61million—a300percentincreaseinjusttwoyears.

Datahasyettobecomeavailabletoconfirmthattheexpansioncounter-balancedtheregressivityofthe

taxmeasure.Butresultsfromothercountriesthathavemadesimilarchoicesareencouraging.For

example,Indonesiareliesheavilyonregressivetaxestoraiserevenue,butthenetfiscalincidenceis

progressivethroughmostlyin-kindtransfersforhealthandeducationforthepoor(Jellemaetal,2017).

Thecountryhassinceseenadeclineinincomeinequities,asmeasuredbyadropintheGINIcoefficient

from0.394to0.370(whichmeasureschangesonscalefrom0to1,with0indicatingperfectequality

and1beingperfectinequality.

UnacceptablechoiceNo.2:Increaseout-of-pocketpaymentsforuniversallyguaranteedpersonalhealth

serviceswithoutanexemptionsystem3orcompensatingmechanisms.

Debatesoverout-of-pocketpaymentsariseintwocategoriesofcountries:thepoorestandthosein

crisissituations.Extremelypoorcountrieswithlimitedresourcesfacethemostdifficulttrade-offs.Their

limitedoptionsforraisingfinancescanhemthemintouserfees,iftheyseenootherpathtofinancing

government-sponsoredhealthservices.Doministriesofhealthrelyonuserfeesorletservicedelivery

falter(withnomedicinespurchasedtorestockshelves,nonewhealthworkerstofillshortages,andno

capitaltorepaircrumblinghealth-relatedinfrastructure)?Withlittleevidencethatexemptionsystems

work,mostlookforalternativefinancingmechanisms.

Eveninhigher-incomeOECDcountries,whenfacedwiththe2008financialcrisis,one-thirdofthem

(includingGreeceandIreland)introducedorincreaseduserfeestoshoreuphealthfinancingshortfalls.

Greeceoffersaparticularlyvividexampleofwhatcanhappenwithoutexemptionsforthepoor.There,

userfeeswereincreasedforoutpatientcare.Buteventhoughsomevulnerablegroupswereexempted

fromthecharges,unforced4unmetneedforhealthservicesincreasedfrom7.5percentto11.7percent

forthepoorestpeople(OECD,2015andEuropeanCommission,2013).

2Tobaccotaxesareregressiveintheburdenspacesincesmokingprevalenceisconsistentlyfoundtobehigher

amongthepoor,theycontributeadisproportionallyhigherproportionoftheirincomestothesetaxesthanthe

rich.Ontheotherhand,theimpactofthesetaxesisprogressiveinthebenefitsspace–thepoorgain

disproportionallymorethantherichintermsofsubsequenthealthbenefits(Summers,2018).

3

Giventhelimitedevidence-baseinsupportofsuchpolicies,proofthatthesesystemsandmechanismsiscritical4

Unforcedunmeetreferstotheproportionofpeoplewhoreportanunmetneedforhealthcareduetothree

reasons:(i)affordability,(ii)waitinglist,and(iii)distancetohealthfacility/nomeansoftransport

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UnacceptablechoiceNo.3:Raiseadditionalrevenuesforuniversallyguaranteedpersonalhealthservicesthroughvoluntary,prepaidandpooledfinancingarrangementsbasedlargelyonhealthstatus,

includingpre-existingconditionsandriskfactors.

Countrieswithnoorlimitedgovernment-sponsoredservicepackagesrelyonprivatehealthinsurance,

whichhavebeenknowntosetpremiumsbasedonvariablessuchasage,genderandpre-existinghealth

conditions.Thesepremiumschedulesmakeinsuranceunaffordableforthosewhoarepoorandsick.

Peopledon’tgetcareaccordingtoneed.Yet,somecountriesencouragesuchcoveragethroughtax

exemptions.

Thenextthreeunacceptablechoicesrelatetopoolingresources,whichmeansspreadingcontributions

acrossindividualsandgroupsinawaythatreducesthefinancialriskassociatedwithmedicalexpenses.

Healthsystemstendtobehighlyfragmentedintopoolsoffundsforhealthfinancingschemes,

administrativeterritorialunits,orhealthprograms.Healthfinancingschemesarethefinancing

arrangementsthroughwhichhealthservicesarepaidforandobtainedbypeople.Examplesinclude

nationalhealthservices,socialhealthinsuranceandvoluntaryinsurance,includingcommunity-based

healthinsurance.Administrativeterritorialunitswithinhealthfinancingschemesmayconstitute

separatepools,wherelowerlevelsofgovernmentareresponsibleforservicedeliveryandreceive

transfersfromhigherlevelsofgovernmentandsometimesalsoraiselocaltaxesandotherrevenues.

Financingsystemsmaybefurtherfragmentedintoprogramsthattargetcertainpopulationsand

diseases,withring-fencedfundinginlessdevelopedcountries,oftenco-financedfromDAH,whether

passingthroughgovernmentbudgetsoradministeredseparately.

Theproblemsweseearelargelyassociatedwithallocatingpublicmoniesinawaythatmakesexisting

inequitiesintheavailabilityoffundsperpersonacrosspoolsworse,thatis,inequalitiesinthe

availabilityoffundsunlesstheyarejustifiedbydifferentneeds.Inequities,though,mayalsoarisefrom

exclusionbecausepeopleareineligibleorfaceotherbarrierstotheirparticipationinpools.

UnacceptablechoiceNo.4:Changepercapitaallocationsoftaxrevenue5ordonorfundsacrossprepaidandpooledfinancingschemesinwaysthatexacerbateinequities,unlessjustifiedbydifferencesinneed

ortheavailabilityoffundsfromothersources.

Priorto2003,Mexicohadthreemajorfinancingschemes,twoofthemsocialhealthinsuranceschemes

paidforbyemployeeandemployercontributions.Andthethird,paidforthroughgeneralgovernment

revenues,servedtheuninsured.Thetwosocialhealthinsuranceschemesspentnearlyfivetosixtimes

morepercapitaonbeneficiariesthanthegovernment-fundedprogram.(WorldBank,2012).

5

Taxrevenueexcludessocialhealthinsurancecontributions

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Whenthetwoemployment-relatedschemesfacedshortfalls,theyreceivedbailoutmoneywithno

increasesinallocationtothethirdscheme.So,ineffect,thetwoplansservicingwealthierpeoplewith

broaderpackagesweregivenadditionalresourcesfromthesamepotofmoneythatunderfundedand

providedfewerservicestothegeneralpopulation.Theseallocationsdeepenedinequitiesandwerenot

justifiedbyanyotherpolicyobjectives.

MexicorectifiedtheentirefundinglevelsbylaunchingtheSocialProtectionSysteminHealth(SPSS),

widelyreferredtoasSeguroPopular.Thisprogramdirectsfederalandstatecontributionstoincrease

financingforthenationalhealthscheme,sothatthepercapitaspendingisnowmoreeven.

UnacceptablechoiceNo.5:Withinfinancingschemes,changepercapitaallocationsfromhigherto

loweradministrativelevelsinwaysthatexacerbateinequities,unlessjustifiedbydifferencesinneedor

theavailabilityoffundsfromothersources.

Infederalsystems,centralgovernmentstypicallytransferblockgrantstosubnationalentities.InNigeria,

thesizeoftheseblockgrantsislargelydeterminedbywhatiscalled“principleofequality,”whichmeans

allstatesreceiveanequalshareoftherevenues(WorldBank,forthcoming).Population,size,levelof

socialdevelopment,andfiscalcapacityplayonlyminorrolesindeterminingeachstate’sshare.6This

formulaforresourceallocationalsofailstoaccountforthelargevariationsinrevenuegeneratedbythe

states.7

Undertheassumptionthatallstatesgivethesameprioritytohealth,disparitiesinavailablerevenues

leadtosignificantinequalityinpercapitaallocationsforhealth.Moreover,poorerstateswithsmaller

overallbudgetsoftentendtogivelowerprioritytohealthdespitehigherneeds,furtherexacerbating

inequalities.

Toaddressthisproblem,thegovernmentproposedtheBasicHealthCareProvisionFund(BHCPF),which

seekstorectifythedifferencesbyofferingadditionalfinancingtostatesproportionaltotheir

populations.Thefundsarechanneleddirectlytofrontlineserviceswiththeaimtoexpandcoveragewith

theBasicMinimumPackageofHealthServices.

Thenextfourunacceptablechoicesrelatetopurchasing,whichisconcernedwithdecisionsmadeon

whatandhowtopayfor,includingservicesandinputs(coveringhumanresources,equipment,supplies

andinfrastructure).

Herewemakethreeprincipledistinctions.First,wedifferbetweenpersonalhealthservices(suchas

treatment,rehabilitation,palliationaswellaspreventionandpromotionatthepersonallevel)andnon-

6

Forinstance,populationestimatesonlyaccountfor25.6%oftheformula.7

StategeneratedrevenuesrangefromNRA1000percapitainNigerstatetoNRA25000percapitainLagos

DRAFT:Notforattribution

18

personalhealthservices(suchasessentialpublichealthfunctions,includingpopulation-based

preventionandpromotionaswellassystemgovernance).

Amongpersonalhealthservices,wedistinguishbetweenentitlementsandtheservicesthataredefacto

available.Ontheentitlementside,forexample,socialhealthinsuranceservicepackagestypically

guaranteefortheformalsectorabroaderrangeofservicesthanthoseguaranteedbygovernment

fundingorinsuranceschemesdesignedspecificallyfortheinformalsectororthepoor.Onthe

availabilityside,guaranteedhealthbenefitspackagesareinprincipleavailabletoeverypoolmember,

but,inreality,contractingandpaymentsystemsmaynotmaketheseservicesavailableforeveryone.

Finally,forservicesthatareactuallyavailable,wemustlookatkeyinputs(humanresources,medicines,

othersupplies,equipmentandinfrastructure)Thedefactoavailabilityofserviceshingesontheactual

availabilityoftheseinputs,whichoftendiffersinqualityandrangeacrossurbanandruralareas.

UnacceptablechoiceNo.6:Withinschemesorpools,changeallocationsoffundsacrossdiseasesin

waysthatexacerbateinequities,unlessjustifiedbydifferencesinneedortheavailabilityoffundsfrom

othersources.

Acommonexampleiswheregovernmentsincreasefundingforparticulardiseaseprogramsthatare

alreadywell-fundedthroughexternaldonorfinancing,perhapsaspartofcounterpartfunding

requirements,leavingotherdiseasesprogramsaddressingpriorityhealthproblemswithseverefunding

shortages.

UnacceptablechoiceNo.7:Introducehigh-cost,low-benefitinterventionstoauniversallyguaranteedservicepackagebeforeachievingclosetofullcoveragewithlow-cost,high-benefitservices.

Inmanycountries,publicsectorresourcesaredirectedtowardshospitalizationbenefitsbeforefull

coverageofbasichealthserviceisachieved.Forexample,in2008,IndialaunchedtheRashtriya

SwasthyaBimaYojana(RSBY)toprovideinsurancecoveragetohouseholdslivingbelowthepovertyline.

RSBYismeanttoaddressthehighincidenceofOOPsamongthepoor.Theschemeoffershospitalization

benefitswithcompletecoverageinbothprivateandpublichospitals,whichwouldpreviouslyhavebeen

inaccessibletothepoor.Theprogramhasenrolledover36millionhouseholdslivingunderthepoverty

line(RSBY,2018).

WhileRSBYsignificantlyimprovedfinancialprotectionfromhospitalizationamongthepoorest,itdidnot

addresstheneedforlow-costinterventionslikeprimaryandpreventivecare.Toaddressthisgap,the

governmentsimultaneouslyexpandedsignificantresourcesdirectedtowardstheNationalRuralHealth

Mission(NRHM)throughConditionalCashTransfers(CCTs)andcommunityhealthvolunteers.Andin

February2018,thegovernmentalsoannouncedtherolloutoftheNationalHealthProtectionScheme

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(NHPS),whichwillincludeinpatientandoutpatientcare,andbuild150,000newhealthandwellness

centerstoincreaseaccesstocareinunderservedareas.

UnacceptablechoiceNo.8:Increasetheavailabilityandqualityofpersonalhealthservicesthatareuniversallyguaranteedinwaysthatexacerbateexistinginequalitiesunlessjustifiedbydifferencesin

need.

Governmentstendtoprioritizeinvestmentsinhospitalinfrastructuretoensureaminimumaccessto

life-savingservicesaswellastotraintheirfuturehealthworkers.Thesehospitalstendtobe

concentratedinurbanareas,whilepeopleinruralareasoftenlackaccesstothemostbasicservices.

UnacceptablechoiceNo.9:Increasetheavailabilityandqualityofcorepublichealthfunctionsinwaysthatexacerbateexistinginequalitiesunlessjustifiedbydifferencesinneed.

Priorto2013,Brazilhadhugedifferencesinthedensityofskilledhealthprofessionals.Thiswaslargely

becausethedecentralizedsystemthatallowedsub-nationalentitiestosettheirownsalariesfor

physicianshadinadvertentlycreateddisincentivesfordoctorstoworkinareaswheresalarieswere

lower.WealthierstatesandcitiesinBrazilthatpaidhigherwagesendedupwithahighernumberof

physicians,whileotherpartsofthecountryexperiencedsignificantshortages.

Acrossthecountrymorethan20percentofmunicipalitieshadashortageofphysiciansinpublicsector

facilities,whilemorethan10percentofmunicipalitieshadnodoctorsatall.ThepooreststatesofBrazil

hadthehighestshortageofhealthworkers,forcingpatientstorelyonnurse-associatesandcommunity

healthworkerswithrelativelylowerlevelsofhealthtraining.(Ref:MonitoringInequalitiesintheHealth

Workforce:TheCaseStudyofBrazil1991-2005,PLOS1,2012).

Then,in2013,Brazillaunchedthemaismedicosprogram,whichofferedfinancialandcareer

advancementincentivesfordoctorstoacceptpostsinunderservedlocations.Thisnewpolicyaddressed

significantdisparitiesinthedistributionofphysiciansinthecountryandmadethecountry’sallocations

forstaffacceptable.

UnacceptablechoiceNo.10:Increasetheavailabilityandqualityofcorepublichealthfunctionsinwaysthatexacerbateexistinginequalities,unlessjustifiedbydifferencesinneed.

DRAFT:Notforattribution

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Failurestopreventtherapidspreadofthe2014Ebolaoutbreakgrewoutofseveralweaknessesin

Liberia’shealthsystem.Thecountry’slimitedsurveillancecapacitytoidentifyandreportanoutbreak

wasconcentratedinurbanareas,andalmostnon-existentinruralareas,whereEbolawasspreading

fast.ThispostponeddetectionofthediseaseuntilitwasfinallydiagnosedforthefirsttimeinMonrovia.

Skewingresourcestocitiesallowedadeadlyvirustokillpeoplebeforeitwasfinallydetected.

Sincethen,Liberiahasmadesignificantinvestmentsinstrengtheningcorepublichealthfunctions,while

addressingexistinginequalitiesincommunity-levelsurveillanceanddiseasereporting.Theresultshave

alreadybeenfelt.Duringthe2018Lassafeveroutbreakthere,CommunityBasedEventSurveillance

reportingshowedmarkedimprovementswithcompletenessandtimelinessofreporting.Healthofficials

estimatedthatnearlyallLassacaseswerereported.

Fairnessofprocessandaccountability:Aframeworkformakingdecisions

Certainprocessesmustbeestablishedtoclaimfairnessandaccountabilityinpolicymaking.Thisisas

trueinhealthpolicyasitisinanyotherareaofsocialpolicy.Werecognizethatcompleteagreementon

the“fairness”oftheoutcomesofpolicydecisionsisunachievablebecausepeople’sperceptionsofsocial

justicevary.Butwecanagreeonafairprocessformakingthosedecisionsthatthepublicseesas

legitimate.Sopublicparticipationandsomelevelofaccountabilityarenecessary,becausetheyhelp

leadtodecisionsthatcreateageneralsenseoffairnessintheprocess,eventhoughsomepeoplemay

disliketheoutcome.

Hereweteaseoutdifferentstrandsofhealth-financing-relateddecisionsastheyrelatetopublic

involvementandaccountabilityforreasonableness.

Thesefirsttworefertopublicinvolvementandpurchasingdecisions(whattobuy):

• Publicinvolvementinmakingone-offdecisionssuchaswheretolocateanewhealthcenter

oftentakestheshapeofopendiscussionsordebateinconsensusconferences,townmeetings,

orcitizenjuriesorpanels.(Rowe&Frewer2005;Abelsonetal.2008;Mittonetal.2009;WHO

2014).

• Publicinputstolonger-termdecision-makinghave,insomecountries,beenformalizedthrough

representationonbodiessuchashospitalboards,localgovernmenthealthauthorities,priority-

settingcommitteesandinstitutions,ortheboardsofhealthinsurancefunds(Sabik&Lie2008;

Glassman&Chalkidou2008;Stewartetal.2016;Byskovetal.2017;Giedion&Guzman2017;

Simonet2017).

Thesenexttworefertopublicinvolvementandallocationdecisions(howtospend):

• Furtherupstreaminfinancingfunctions,citizenshavebeeninvitedtoparticipateinformal

decisionsonhowtoallocategovernmentbudgetsacrosscompetingneeds.Thishashappened

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inplacesasdiverseasBrazil,Cameroon,Europe,Peru,SriLankaandNewYorkCity(WHO2014;

Kasdan&Markman2017).

• Lessdirecteffortsbycivilsocietyorganizationsinclude,forexample,theAfricanHealthBudget

Network.Thisnetworkofgroupshasinfluencedgovernmentallocationstohealththrough

advocacyandbyencouragingAfricangovernmentstoadheretotheagreementmadeinAbuja

Declarationof2001toallocate15%oftheirbudgetstohealth(AfricaHealthBudgetNetwork

2018).

Thesekindsofcitizenengagementcaninfluencedecisions,thoughtheyareonarelativelylimitedscale.

Forexample,withformaldecisions,citizeninvolvementinbudgetinghasbeengenerallylimitedtolower

levelsofgovernment–e.g.municipalities–andusuallyrestrictedtoarelativelysmallproportionofthe

budget(Shapiro&Talmon2017).Withone-offdecisions,limitedevidencesuggeststhatthingslike

townmeetingsandjuriesinfluencethepublic’ssenseofinclusion,eitherwithrespecttothequalityof

publicdebateortheresultingdecisions.Andthoseonhospitalboardsorcitizenpanelstendtobewell

educatedandmaybelimitedintheirabilitytoreflecttheviewsofthebroadercommunity(Campbell,

Craig&Escobar2017).

Thesefinalpointsrefertotheneedforaccountability(transparencywithfairprocess):

Answerabilityandenforceabilityarefundamentaltoaccountability.Sodecisionsthataffectthe

population’swellbeingmustbetransparentandjustified.Andindividualsandinstitutionsengagedin

fraudorothermisconductmustfacecensureorsanctions,perhapsbackedbythejudiciary(Schedler

1999;WHO2014,Gruskin&Daniels2008;Rumboldetal.2017;Yamin2017).

Acommonmotivationforestablishingaccountabilitycomesfromthehumanrightsframework,which

seestheStateasactingonbehalfofitscitizens(Yamin2000;Farmer2003).Informedpublicscrutiny,in

turn,requiresareliablemonitoringsystem,meaningfulpublicparticipationinprocesses,and

transparencyandaccesstoinformation(Yamin2008).

Agrowingbodyofliteraturepointstotheadvantageofinfusingdecisionswithaccountabilityand

transparency.ForemostistheAccountabilityforReasonablenessframeworkappliedtotherationalefor

purchasingservicesinpooledfunds(Daniels2000;Daniels2008;DanielsandSabin2008;Daniels2016;

WHO2014;Petricca&Bekele2017).Thisframeworkestablishesfourconditions:

1. Publicity:Detailsofdecisionsmadeneedtobereadilyavailabletothepublic,alongwiththe

justificationforthosedecisions;

2. Relevance:Theorganizationorauthoritymakingthedecisionmustprovideareasonable

explanationofthecriteriaitusestomakedecisions;

3. Revisionandappeals:Mechanismsforchallengeandappealneedtobeavailablewith

opportunitiestomodifydecisionsovertime,forexample,whennewevidencebecomes

available(whichrequiresadequatedatacollection,discussedinthenextsection);

4. Regulation:Formalrulesareneededtoensurethefirstthreeconditionsarefulfilled.

DRAFT:Notforattribution

22

Whilemostoftheseconditionsarerelativelystraightforward,therelevanceconditioncanbetricky.On

thewholeitsimplymeansthatfair-mindedpeoplecanandshouldagreeondecision-makingcriteria

thatareclearandeasytounderstand—andbeaccessibletothepublic.Thisapproachisincreasingly

usedfordecisionsonbudgetallocationsduringscarcityandforotherdifficultdecision-makingareas,

likepolicyresponsestoclimatechange.Butnoteveryonewillagreeonwhatconstitutesreasonable

criteria.Andevenwhenthecriteriaareacceptedasreasonable,decision-makersmayreasonably

disagreeonhowtoweighthedifferentcriteria.Forexample,“valueformoney”(orbangforthebuck)

asacriterionforallocatingscarceresourcesmightshortchangeequityconsiderations.Inthiscase,

additionalcriteria(cost-effectivenessversusequity)areneededtofullyinformrationingdecisions(e.g.

WHO2014;Baltussenetal.2017;Badano2018).

But,onthewhole,havingdecision-makingbodiesexplainthecriteriafortheirdecisionsfeedsintothis

greatersenseoffairnessinprocess.Box1and2offergoodexamples.

Box1:ParticipatoryBudgetinginBrazil

AprocesspioneeredinPortoAlegrein1989,called“participatorybudgeting”(WHO2014-Makingfair

choices),invitedthepublicintothedecision-makingprocessandexplicitlyprioritizedimprovinghealth

servicesinpoorercommunities.Civilsocietyorganizationshaddemandedgreaterrepresentationin

thesedecisionstobringbalancetowhattheyperceivedasacorruptpoliticalestablishment.Within10

yearsofitsimplementation,publicparticipationinthemunicipality’sbudgetprocessesforthingslike

howtousebondsforcapitalimprovementsincludedover40,000peopleeachyear.[Bhatnagar,Prof.

Deepti;Rathore,Animesh;Torres,MagüiMoreno;Kanungo,Parameeta(2003),ParticipatoryBudgeting

inBrazil(PDF),Ahmedabad;Washington,DC:IndianInstitutesofManagement;WorldBank.]Andthe

shareofthetotalbudgetdedicatedtohealthandeducationtripledto40percentby1996,upfrom13

percentin1985.(RebeccaAbers,“FromClientelismtoCooperation:LocalGovernment,Participatory

Policy,andCivicOrganizinginPortoAlegre,Brazil,”Politics&Society26(1998),pp.511–538.)

Sincethen,participatorybudgetinghasspreadtoBrazil’spublichealthsystem,calledSistemaÚnicode

Saúde(SUS).HalfofthehealthcouncilssetupinnearlyallBrazilianmunicipalitiesareregularcitizens

whoareusersofSUS(mainlypatients).Theremainderincludeshealthworkers,administrators,and

managers.Thesecouncilsareresponsibleforoversightfunctionsthatincludestrategicplanning,

approvingtheannualhealthbudget,andmonitoringthedisbursementoffunds.(MartinezMG&Kohler,

JC.Civilsocietyparticipationinthehealthsystem:thecaseofBrazil'sHealthCouncils.Globalizationand

Health2016.)Thisdrovechangeandpeople’spreferencesarenowreflected.

Absentfromthisframeworkisthequestionofoversight.

Thatis,doesanorganizationorbodyneedtobecreatedtoensurefairnessinthedecision-making

process?Forexample,theWHOConsultativeGrouparguedthatoneoptionwouldbetoestablisha

“standingnationalcommitteeonprioritysettingtohandleparticularlydifficultcases”(WHO2014).

Thesekindsofbodiescanensurepublicdebateandinvolvementwhencombinedwiththeprinciples

behindtheAccountabilityforReasonablenesscriteria.

Publicinvolvementandaccountabilityforreasonablenesscouldbeappliedtoanyofthekeyhealth

financingdecisionsaroundrevenuegeneration,poolingorpurchasing.Thiswouldincludeinvolvingthe

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publicindecisionmaking;makingpublicallinformationaboutthedecisionsandmotivationsbehind

them;creatingappealandreviewprocesses;andsettingclearcriteriathatlayoutwhatfactorsshould

influencedecisionoutcomes.Criteriaforreasonableness,however,woulddifferdependingonthe

question.Forexample,decisionsoncontracting(whichhealthservicesorinputsshouldbepurchased

andatwhatprice)aredrivenbyfactorssuchasefficiency,thecostsofadministrationandenforcement,

incentivesforquality,andtheriskoffraud.Theextenttowhichthepubliccouldfeasiblybeengagedin

eachtypeofdecisionwouldneedtobedeterminedonacase-by-casebasis.Butbroadpublicdebate

wouldbewarranted.

Thequestionofoveralltaxpolicy—decisionsabouthowmuchtoraise,whoshouldcontributeand

when—isevenmorecomplicatedandrequiresdeeperconsideration.Thesedecisionsareusuallymade

inparliament,byelectedrepresentativeswhotheoreticallyactonbehalfofcitizens.Changestotax

policyusuallygeneratewidepublicreaction.Anddecisionsmadeusuallyfollowwidelypublicized

debatesamongmembersofparliaments.Buttheoutcomes—thewaythevotestally—donot

necessarilyrepresentpublicsentiment.Viewsvaryonwhetherthisissufficienttoensureaccountability

andfairnessinprocesses.Forexample,addinganadditionallayerofcomplexitytore-enforceprocess

fairnessmaynotbejustifiedwhenthepurposeofaparliamentistorepresentthepeople.However,

manycountrieshaveelectedofficialswhoarerelativelywealthyandwhorepresentwealthy

constituencies.Theywilloftenhaveaconflictofinterestwhenitcomestoraisingmoretaxesormaking

ataxsystemmoreequal.Sootherwaysofinfluencingthesedecisionsneedtobefound.

Box2:SocialAccountabilityinEthiopia

Ethiopiaisnowinitsthirdphaseofalongprocessthatisbringingthepublicintogovernmentdecisions

onhealth,education,agriculture,ruralroadprojects,andwaterandsanitation.Since2011,theEthiopia

SocialAccountabilityProgramhashelpedsetupSocialAccountabilityCommittees(SACs)in223ofthe

country’s770localdistricts,calledworedas.

Thecommitteesaremadeupinequalpartsoflocallyelectedcouncilmembers,locallyappointed

administratorsandcivilsocietyorganizations.Theirmainpurposeistoensurethatlocaladministrative

unitsaretransparentandheldaccountabletocitizens.

TheseSACshelpbuildstrongsystemsforevidence-basedserviceperformancemeasures,usingfive

socialaccountabilitytools:CommunityScoreCards(CSCs)thatusefocusgroupsforself-assessments;

CitizenReportCards(CRCs)thatsurveyhouseholdstoassesthelevelofservicestheyarereceiving;

ParticipatoryPlanningandBudgeting(PPB)andGenderResponsiveBudgeting(GRB)forcitizen

engagementinbudgetplanning;andthePublicExpenditureTrackingSurvey(PETS)forassessmentof

budgetexecution.

Oneexampleofawell-functioningSACisinMalgaWoreda,insouthwesternEthiopia.TheSACthere

startedbyusinghouseholdsurveysandmeasuredaninsufficientnumberofhealthworkerstoservethe

community.Thatputpressureonthelocalgovernmenttoallocatemoreresources.And,asaresult,

healthcentersrecruitedandtrainedadditionalmidwives,healthofficers,andrecordofficers.Through

purchasing,clinicsreceivedneededmedicalequipmentandmedicines.Andinfrastructuremoneywas

allocatedtobuildroadstohealthcentersinTenkaroandHaro,andcreateanewwatersourcein

Manichotown.

TheseSACs,aswithparticipatorybudgetinginBrazil,createinclusionandbringfairnesstotheprocess,

DRAFT:Notforattribution

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whichmakethelocalgovernmentsaccountabletothecitizenstheyrepresent.

Monitoring

TrackingProgressisaMust

Countriesmustgetmoreseriousaboutdatacollection,orthequestforequitywillbemeaningless.This,

ofcourse,requirestrackingUHCoutcomes.Butitalsorequirestrackinginequitiesinthethree

componentsofhealthfinancing(revenuegeneration,poolingandpurchasing)thatcanaffectUHC

outcomes.

Decisionmakerscannotadjusttheirpoliciesovertimeunlessknowledgeisavailableonwherehealth-

relatedoutcomesaregettingbetterand,moreimportantly,wheretheyaregettingworse.Thisrequires

trackingthosewhoarecovered,thequalityofhealthservicestheyarereceiving,andtheextentto

whichtheyareprotectedfromfinancialhardship.Withouttheseaggregateddata,policymakersare

unabletofocusonthemostdisadvantaged—whichtheymustdotoremaininkeepingwiththegoalsof

UHC.

Ataminimum,policymakersneedregularlycollecteddatadisaggregatedbygender,income(orwealth),

andgeographicallocation(forexample,ruralorurban).Countriesshouldaddonotherdeterminants

thatapplytotheiruniquepopulations,like,forexample,ethnicity,age,familystructure,typeofhealth

problem,andcapacitytodeliver.Theimportantpointhereisthatdisaggregateddatawillallowthe

healthfinancing-relatedinequitiestobemeasuredandtrackedovertime,whichissocriticalto

producingequityduringpolicyadjustments,andkeepinghealthfinancingdecisionsontrackforUHC.

Forexample,onrevenuegeneration,dataneedstobecollectedtounderstandwhoissufferingsevere

financialhardshipfromout-of-pocketpaymentsforwhichtypeofservice,andwhetheradjustmentsto

policiesarereducingtheburden.Onpooling,dataisneededtotrackhowdomesticrevenuesare

allocatedtofinancingschemestoensuretaxmoneyisusedequitablyandnottosubsidizealreadywell-

endowedpools.Andonpurchasing,inequitiesinthedistributionofhealthworkersandotherinputs

suchasessentialmedicinesneedtobemonitored,becausethisfunctiondetermineswhetherthe

servicespeopleneedareavailable,closetothem,andofgoodquality.

Tosupportfairnessofprocess,thesedatathenmustbeanalyzedaccuratelyandpresentedtopolicy

makersinaneasy-to-understandformat(seeHosseinpooretal2018).Theotherhalfofsupporting

fairnessofprocessistoalsoensurethatdataaresharedwiththepublicandotherstakeholdersinaway

theycandigest.

Thismeansmanycountrieswillhavetochangethewaytheymonitor,shareandevaluateprogressin

theirhealthsystems.Neededarerecordsofpatientattendanceandtreatmentathealthfacilities.These

canbecollectedthroughhouseholdsurveys,butareroutinelyavailableiftheyaresystematicallyand

accuratelycollectedatthetimeofserviceandquicklyaggregatedandreported.Theserecordsmaybe

supplementedbyothersources,suchascancerregistries.Buttheyvaryacrosscountriesinnumberand

qualityandgenerallyfailtoprovideinformationonqualityofservices,levelsoffinancialprotection,and

abaseline(whoneedsservices).

DRAFT:Notforattribution

25

Apushisbeingmadenowtouseelectronicmedicalrecordsandspecificallyinputsystems,which

capturecomprehensiveinformationonpatientcare,includingsymptoms,diagnoses,etiologies,

proceduresandoutcomes.(“Towardgreaterintegrationofcareandimprovedefficiency:Acritical

reviewofEHIF’spaymentsystem,WorldBank2017,page46.)

Othermethodsforundertakingtherequiredanalysisincludetrackingoutcomesofadult,maternaland

childmortality(e.g.Marmotetal1991;Mackenbacketal.1997;Gwatkin2000;Victora2003;Moseret

al.2005;Barrosetal.2010;Bendavid2014;Wagstaff,Bredenkamp&Buisman2014;Gwatkin2017).

Theyalsoincludemeasuringprogressinincreasingoverallcoverageandreducinginequalitiesin

coveragewithcorehealthinterventions,largelyfocusedontargeteddiseasesoftheMDGs(e.g.Raoet

al.2014;Alkenbracketal.2015;Restrepo-Méndezetal.2016;Hoganetal.2017;WHO&WorldBank

2017;Wongetal.2017;Victoraetal.2017).

AnumberofdifferentmethodshavebeenusedtodocumentOOPs-relatedfinancialcatastropheand

impoverishment,whichhashelpedpolicymakersunderstandwhoissufferingthemost(e.g.Xuetal.

2003&2006;Wagstaff&Lindelow2014;Bredenkamp&Buisman2016;Khan,Ahmed&Evans2017;

Wagstaffetal.2017aandb;Ghimireetal.2018).Disagreementoverwhichonesworkbesthaveledto

studiesthatincluderesultsfromtwoormoreofthesemethods(forexample,WHOandWorldBank

2017).

AshortcomingintheoverallapproachtotrackingprogresstowardsUHC,asitrelatestoservice

coverageandfinancialprotection,isthatthemethodsdevelopedfailtodrilldowndeepenoughto

unearthalltheinequalitiesassociatedwithhealth-financingfunctions(e.g.Boermaetal.2014;WHO

andWorldBank2017).Improvementsthathavebeenmaderelateto:

• examiningwhetherfiscalpolicyispro-poor,whiletakingintoaccountthenetimpactofwhat

theypayinandwhattheyreceiveincashorin-kindbenefits(e.g.Lustig2016&2017;Jellemaet

al.2017;Lustig2018).

• inequalitiesintheavailabilityofservicesandinkeyinputs,suchashealthworkers(e.g.O’Neillet

al.2013;WHO2015;Speybroecketal.2012).

Toolstohelpcountryanalystsundertakethisworkarenowbeingdeveloped.Theyaredesignedtogive

guidanceon1)estimatingtheabsenceoffinancialprotectionandinequalitiesinthehealthfinancing

functions(Wagstaffetal.2007;Wagstaff2008;Saksena,Hsu&Evans2014;Wagstaff&Eozenou2014;

WorldBank2018a),and2)analyzinginequalitiesinhealthoutcomesandhealthservicecoverage

(Hosseinpoor2016&2018;WorldBank2018).

Forcountrieswithresourcestodohouseholdexpendituresurveys,theWorldBankhasestablishedthe

ADePTResourceCenterwithsoftwarethatallowsanalyststouploadtheirsurveydataandproduce

indicatorsofinequalitiesandunsustainablehealth-relatedfinancialburdens.(WorldBank2018a).

Approachestorapidserviceavailabilityandreadiness,whichcanbeusedtotrackgeographic

inequalities,havealsobeendeveloped,includingtheServiceAvailabilityandReadinessTool(WHO

2018b).

Butforcountrieslackingtheresourcesfortheseexpensive,time-consumingandlabor-intensive

householdsurveys,theWorldBankhasdevelopedtheSwiftSurveyapproach.Thisisalowcost,rapid

DRAFT:Notforattribution

26

wayofmeasuringincomesandtrackingprogressinthereductionofpoverty(WorldBank2018b).This

approachoffershopeoflower-costandtimelywaysofobtainingthenecessarydataforUHCtracking.

Themainmessagehereisthattoolsareavailabletohelpcountries.Butwerecognizethatfindingfunds

topayformonitoringischallenging,especiallyinlow-incomecountries.Thisareaofhealthsystemsis

generallyunderfunded.MostOECDcountriesinvestlessthan4percentoftotalhealthexpendituresin

informationsystems,andlow-andmiddle-incomecountriesinvestlessthan1percent.(WHO,OECD,

WorldBank,2018)

Robustinformationsonecessarytomonitoring,whichprovidespolicymakersandthepublicwith

neededdatatohelpestablishfairprocessesandassesswhetheradecisionisunacceptable,mustbea

priority.

Section5:SeeingtheWayForward

ThisexerciseinmappingoutwhatequityinfinancingUHCmeansistoshowtheneedforafundamental

shiftinpolicymaking.Weknowthatmany,manycountrieshavecommittedtoUHC.Wearestillseeing

deepinequitiesinservicecoverageandfinancialprotectionthatareassociatedwithequityinfinancing.

Thistellsusthatsomethingisgoingwrongindecision-makingprocesses.Webelievethattakingamore

mindfulapproach—applyingthethreeprongsoutlinedinthispaper—willmakeadifference.Thereward

willbemoreequitableUHCoutcomesandgreatersocietalandeconomicbenefits.

Countriesmustchartawayforward.Whetheralreadyontherightpathortryingtoafindawaythere,

theapproachmappedoutinthisreportshouldhelp.Itisdesignedtofillsomegapsinguidanceforthose

whohavecommittedtoUHC.Andwhilemosttechnicaldetailsofwhatcanandshouldbedonehaveto

bedomesticallydetermined,weknowhealthassistanceplaysarole.Theprincipleslaidoutherealso

applytodevelopmentassistance;theyshowthatequitableoutcomesmustbetheultimategoal.

Soforcountryministriesandpolicymakers,thestartingpointistoestablishorexpandbasicguaranteed

packages,withprogressiverealization(expandingthereachovertimetoincludemoreandbetter

services).BasedonanextensionofthelogicofUHC,everycountryshouldstartwithsomelevelof

guaranteedcoveragewithsomeprioritygivetotheworse-off,financedbyprepaidandpooledsystems,

accordingtoabilitytopay.OncecommittedtothisUHCpolicy-makingpath,webelievethethree-

prongedapproachmappedoutinthisreportwillbringclaritytodifficultdecisions.

Onlycountriescanknowwhatneedstobedone,andinwhatorder—identifyingandavoiding

unacceptabledecisions,invitingincivilsocietyandestablishprocessesthatcommunitiescanagreeare

fair,orsettingupdatacollectionprocessesforbettermonitoring.

Thesethreeprongsareintrinsicallylinked.Whenthepublicparticipatesindecisionsandfeelsthat

processesarefair,alldecisionsmovingforwardcarrythatimportantquality.Decisions,ofcourse,are

bestmadebasedonevidence,whichrequiresdatacollectionandmonitoring.Butpolicy-makersneedto

moveforwardwithpublicinvolvementasameansforestablishingprocessfairness,regardlessofwhere

theyareindatacollection.Slowprogressononeshouldnotleadtoslowprogressontheother.

Likewise,countriescangothroughthisprocessandlookforward—andmaybeaddtothelistof10

unacceptableoutcomeswe’veidentifiedthusfar—regardlessofwheretheyareinsettinguppublic

DRAFT:Notforattribution

27

involvementordatacollectionandmonitoring.Theseothertwoprongswilleventuallypropupthe

abilitytoidentifyunacceptabledecisionssotheymaybecorrected,andwillhelpavoidmakingfuture

decisionsthatleadtoinequities.

Theglobalcommunityshouldhelpfacilitatethisshiftusingaparallelthree-prongedapproach.

Aswithcountrydecisions,developmentpartnersshouldsystematicallyintroduceequityconsiderations

intoallengagementsonhealthfinancingpolicies,andassesstheequityimplicationsoftheirfinancial

support.Thegoalhereisthesame:toseewhetherhealthsectorfinancialsupportisleadingcountriesto

makeunacceptablechoices.Developmentpartnersalsoshouldusetheirfinancialandtechnicalsupport

toincreasinglybuildcountrycapacitiesandinstitutionsthatproduceandsupportprocessestoteaseout

unacceptablechoices,establishfairnessinprocess,andcreatebetterdatacollectionandmonitoring.

And,finally,developmentpartnersshoulddevelopthetools,methodsandapproachesessentialto

carryingouttheseworkstreams—asglobalpublicgoods.

AN

NEX

1

Tabl

e 1:

Ineq

ualit

ies

and

Ineq

uitie

s in

UH

C O

utco

mes

and

UH

C F

inan

cing

, Inc

ludi

ng U

nacc

epta

ble

UH

C F

inan

cing

Pol

icy

Cho

ices

UHC

Outc

omes

Outc

omes

In

equa

lities

In

equi

ties

Effec

tive C

over

age w

ith

Need

ed H

ealth

Ser

vices

Diffe

renc

es ac

ross

peop

le or

grou

ps in

eff

ectiv

e cov

erag

e with

healt

h ser

vices

(p

erso

nal h

ealth

servi

ces,

publi

c hea

lth

(inclu

ding n

on-p

erso

nal h

ealth

servi

ces)

and

gove

rnan

ce fu

nctio

ns

Diffe

renc

es in

the e

ffecti

ve co

vera

ge of

he

alth s

ervic

es (in

cludin

g non

-per

sona

l he

alth s

ervic

es) a

nd go

vern

ance

func

tions

un

less j

ustifi

ed by

diffe

renc

es in

healt

h ne

eds1

No

diffe

renc

es in

effec

tive c

over

age o

f he

alth s

ervic

es w

hen t

here

are d

iffere

nces

in

healt

h nee

ds2

Cove

rage

with

Fina

ncial

Pr

otecti

on

Some

peop

le or

grou

ps ar

e pus

hed i

nto

pove

rty or

furth

er in

to po

verty

due t

o out-

of-po

cket

paym

ents

(OOP

s) for

healt

h ser

vices

Some

peop

le or

grou

ps ar

e pus

hed i

nto

pove

rty, o

r dee

per in

to po

verty

due t

o OOP

s be

caus

e of la

ck of

acce

ss or

in us

ing qu

ality

servi

ces g

uara

nteed

by co

mpuls

ory p

repa

id an

d poo

led fin

ancin

g arra

ngem

ents

Diffe

renc

es ac

ross

peop

le or

grou

ps in

the

incide

nce o

r exte

nt of

catas

troph

ic OO

Ps fo

r he

alth s

ervic

es

Diffe

renc

es ac

ross

peop

le an

d gro

ups i

n the

inc

idenc

e or e

xtent

of ca

tastro

phic

OOPs

be

caus

e of la

ck of

acce

ss or

in us

ing qu

ality

servi

ces g

uara

nteed

by co

mpuls

ory p

repa

id an

d poo

led fin

ancin

g arra

ngem

ents

1 Hor

izonta

l equ

ity

2 Ver

tical

equit

y

Healt

h Fi

nanc

ing

Func

tions

In

equa

lities

3 In

equi

ties4

Un

acce

ptab

le Fi

nanc

ing

Polic

y Cho

ices5

Reve

nue G

ener

atio

n

Di

ffere

nces

acro

ss pe

ople

and g

roup

s in n

et co

ntribu

tions

to th

e pub

lic fin

ance

syste

m (in

cludin

g, bu

t not

limite

d to h

ealth

) 6

Reve

nue g

ener

ation

syste

ms w

ith

differ

ence

s acro

ss pe

ople

and g

roup

s in n

et co

ntribu

tions

to th

e pub

lic fin

ance

syste

m (in

cludin

g, bu

t not

limite

d to h

ealth

) whic

h ma

ke th

e pos

t-tax

, pos

t-tra

nsfer

disp

osab

le inc

ome d

istrib

ution

less

equa

l than

the p

re-

tax di

stribu

tion

1. Ra

ise ad

dition

al re

venu

es fo

r hea

lth th

at ma

ke co

ntribu

tions

to th

e pub

lic fin

ancin

g sy

stem

less p

rogr

essiv

e with

out

comp

ensa

tory m

easu

res t

hat e

nsur

e tha

t the

post-

tax, p

ost-t

rans

fer di

spos

able

incom

e dist

ributi

on is

not le

ss eq

ual.

Di

ffere

nces

acro

ss pe

ople

and g

roup

s in t

he

incide

nce o

f OOP

s for

healt

h ser

vices

Some

peop

le or

grou

ps ar

e pus

hed i

nto

pove

rty, o

r dee

per in

to po

verty

due t

o OOP

s be

caus

e of la

ck of

acce

ss or

in us

ing qu

ality

servi

ces g

uara

nteed

by co

mpuls

ory p

repa

id an

d poo

led fin

ancin

g arra

ngem

ents

Diffe

renc

es ac

ross

peop

le an

d gro

ups i

n the

inc

idenc

e or e

xtent

of ca

tastro

phic

OOPs

be

caus

e of la

ck o

f acc

ess o

r in us

ing qu

ality

servi

ces g

uara

nteed

by co

mpuls

ory p

repa

id an

d poo

led fin

ancin

g arra

ngem

ents

Diffe

renc

es ac

ross

peop

le an

d gro

ups i

n the

inc

idenc

e of O

OPs t

hat d

eter t

hem

from

using

quali

ty se

rvice

s gua

rante

ed by

co

mpuls

ory p

repa

id an

d poo

led fin

ancin

g ar

rang

emen

ts

2. Inc

reas

e out-

of-po

cket

paym

ents

for

unive

rsally

guar

antee

d per

sona

l hea

lth

servi

ces w

ithou

t an e

xemp

tion s

ystem

7 or

co

mpen

satin

g mec

hanis

ms.

3 Link

ed to

UHC

outco

mes

4 Link

ed to

UHC

outco

mes

5 Una

ccep

table

as th

ey ex

acer

bate

inequ

ities i

n UHC

outco

mes

6 Net

contr

ibutio

ns ar

e gro

ss co

ntribu

tions

minu

s tra

nsfer

s rec

eived

in ca

sh or

kind

7 G

iven t

he lim

ited e

viden

ce-b

ase i

n sup

port

of su

ch po

licies

, pro

of tha

t thes

e sys

tems a

nd m

echa

nisms

is cr

itical

Healt

h Fi

nanc

ing

Func

tions

In

equa

lities

3 In

equi

ties4

Un

acce

ptab

le Fi

nanc

ing

Polic

y Cho

ices5

Di

ffere

nces

acro

ss fir

ms in

their

net

contr

ibutio

ns to

the p

ublic

finan

ce sy

stem8

Reve

nue g

ener

ation

syste

ms w

ith

differ

ence

s acro

ss fir

ms in

their

net

contr

ibutio

ns to

the p

ublic

finan

ce sy

stems

tha

t can

not b

e jus

tified

by so

me

comp

ensa

ting b

enefi

t for t

he ec

onom

y

Di

ffere

nces

acro

ss in

dividu

als or

grou

ps in

co

ntribu

tions

to vo

luntar

y pre

paid

and

poole

d fina

ncing

arra

ngem

ents

Diffe

renc

es ac

ross

indiv

idual

or gr

oups

in

contr

ibutio

ns to

volun

tary p

repa

id an

d po

oled f

inanc

ing ar

rang

emen

ts ba

sed

large

ly on

healt

h stat

us, in

cludin

g pre

-ex

isting

cond

itions

and r

isk fa

ctors

3. Ra

ise ad

dition

al re

venu

es fo

r univ

ersa

lly

guar

antee

d per

sona

l hea

lth se

rvice

s thr

ough

volun

tary,

prep

aid an

d poo

led

finan

cing a

rrang

emen

ts ba

sed l

arge

ly on

he

alth s

tatus

, inclu

ding p

re-e

xistin

g co

nditio

ns an

d risk

facto

rs.

Pool

ing

Func

tion

Ine

ligibi

lity ac

ross

peop

le an

d gro

ups t

o pa

rticipa

te in

any p

ool o

r diffe

renc

es in

eli

gibilit

y acro

ss pe

ople

and g

roup

s to

partic

ipate

in po

ols

Inelig

ibility

of pe

ople

and g

roup

s to

partic

ipate

in an

y poo

l or d

iffere

nces

in

eligib

ility a

cross

peop

le an

d gro

ups t

o pa

rticipa

te in

pools

unles

s jus

tified

by

differ

ence

s in n

eed9

,10

Diffe

renc

es ac

ross

peop

le an

d gro

ups i

n en

rolm

ent w

ith pr

ivate

healt

h ins

uran

ce

includ

ing in

sura

nce f

or se

rvice

s not

guar

antee

d by c

ompu

lsory

prep

aid an

d po

oled f

inanc

ing ar

rang

emen

ts

Diffe

renc

es ac

ross

peop

le an

d gro

ups i

n en

rolm

ent w

ith pr

ivate

healt

h ins

uran

ce

includ

ing in

sura

nce f

or se

rvice

s not

guar

antee

d by c

ompu

lsory

prep

aid an

d po

oled f

inanc

ing ar

rang

emen

ts un

less

justifi

ed by

diffe

renc

es in

need

8 For

exam

ple, ta

x holi

days

, exe

mptio

ns fr

om so

cial c

ontrib

ution

s, pr

ofit s

hiftin

g, etc

.) 9 D

iffere

nces

in ne

ed in

clude

both

healt

h and

inco

me. T

hose

with

lowe

r hea

lth ne

ed m

ore h

ealth

servi

ces,

and t

hose

that

are p

oor a

re le

ss ab

le to

pay f

or ne

eded

healt

h ser

vices

. 10

It is

acce

ptable

whe

n elig

ibility

is re

strict

ed to

the w

orse

off (

sicke

r and

poor

er),

but n

ot the

bette

r off (

healt

hier a

nd ric

her).

Healt

h Fi

nanc

ing

Func

tions

In

equa

lities

3 In

equi

ties4

Un

acce

ptab

le Fi

nanc

ing

Polic

y Cho

ices5

Diffe

renc

es in

per

capit

a allo

catio

ns (o

f do

mesti

c gen

eral

gove

rnme

nt re

venu

e or

dono

r fun

ds) t

o pre

paid

and p

ooled

healt

h fin

ancin

g sch

emes

(inclu

ding p

ublic

ly fun

ded h

ealth

servi

ces,

socia

l hea

lth

insur

ance

, volu

ntary

insur

ance

)11

Diffe

renc

es in

per c

apita

alloc

ation

s (of

dome

stic g

ener

al go

vern

ment

reve

nue o

r do

nor f

unds

) acro

ss pr

epaid

and p

ooled

sc

heme

s unit

s unle

ss ju

stifie

d by d

iffere

nces

in

need

or th

e ava

ilabil

ity of

fund

s fro

m oth

er

sour

ces

4. Ch

ange

per c

apita

alloc

ation

s of t

ax

reve

nue1

2 or

dono

r fun

ds ac

ross

prep

aid

and p

ooled

finan

cing s

chem

es in

way

s tha

t exa

cerb

ate in

equit

ies, u

nless

justi

fied

by di

ffere

nces

in ne

ed or

the a

vaila

bility

of

funds

from

othe

r sou

rces.

W

ithin

finan

cing s

chem

es, d

iffere

nces

in pe

r ca

pita a

lloca

tions

from

high

er to

lowe

r au

tonom

ous,

admi

nistra

tive u

nits

With

in fin

ancin

g sch

emes

, diffe

renc

es in

per

capit

a allo

catio

ns fr

om hi

gher

to lo

wer

auton

omou

s, ad

minis

trativ

e unit

s unle

ss

justifi

ed by

diffe

renc

es in

need

or th

e av

ailab

ility o

f fund

s fro

m oth

er so

urce

s

5. W

ithin

finan

cing s

chem

es, c

hang

e per

ca

pita a

lloca

tions

from

high

er to

lowe

r ad

minis

trativ

e lev

els in

way

s tha

t ex

acer

bate

inequ

ities,

unles

s jus

tified

by

differ

ence

s in n

eed o

r the

avail

abilit

y of

funds

from

othe

r sou

rces.

W

ithin

sche

mes o

r poo

ls, di

ffere

nces

in

alloc

ation

s of fu

nds a

cross

dise

ases

With

in sc

heme

s or p

ools,

diffe

renc

es in

all

ocati

ons o

f fund

s acro

ss di

seas

es th

at ar

e no

t justi

fied b

y diffe

renc

es in

need

or th

e av

ailab

ility o

f fund

s fro

m oth

er so

urce

s

6. W

ithin

sche

mes o

r poo

ls, ch

ange

all

ocati

ons o

f fund

s acro

ss di

seas

es in

wa

ys th

at ex

acer

bate

inequ

ities,

unles

s jus

tified

by di

ffere

nces

in ne

ed or

the

avail

abilit

y of fu

nds f

rom

other

sour

ces.

Purc

hasin

g Fu

nctio

n

Di

ffere

nces

in en

titlem

ents

of gu

aran

teed

servi

ce pa

ckag

es, im

plicit

or ex

plicit

, acro

ss

peop

le an

d gro

ups1

3

Diffe

renc

es in

entitl

emen

ts of

guar

antee

d se

rvice

pack

ages

acro

ss pe

ople

and g

roup

s un

less j

ustifi

ed by

diffe

renc

es in

need

9

7. Int

rodu

ce hi

gh-co

st, lo

w-be

nefit

inter

venti

ons t

o a un

iversa

lly gu

aran

teed

servi

ce pa

ckag

e befo

re ac

hievin

g clos

e to

full c

over

age w

ith lo

w-co

st, hi

gh-b

enefi

t se

rvice

s.

11 H

ealth

care

finan

cing s

chem

es ar

e the

main

type

s of fi

nanc

ing ar

rang

emen

ts thr

ough

whic

h hea

lth se

rvice

s are

paid

for an

d obta

ined b

y peo

ple. H

ere w

e refe

r to p

ooled

sche

mes r

ather

than

to

OOPs

, inclu

ding n

ation

al or

sub-

natio

nal h

ealth

servi

ces f

unde

d fro

m go

vern

ment

reve

nues

(som

etime

s with

dono

r fun

ds as

well

), so

cial h

ealth

insu

ranc

e, vo

luntar

y ins

uran

ce (O

ECD

2011

).

12 T

ax re

venu

e exc

ludes

socia

l hea

lth in

sura

nce c

ontrib

ution

s 13

Enti

tleme

nts re

flect

the se

rvice

s and

leve

ls of

finan

cial p

rotec

tion t

o whic

h peo

ple ar

e enti

tled

de ju

re. W

hethe

r peo

ple re

ceive

thes

e enti

tleme

nts de

facto

is a

matte

r for

purch

asing

.

Healt

h Fi

nanc

ing

Func

tions

In

equa

lities

3 In

equi

ties4

Un

acce

ptab

le Fi

nanc

ing

Polic

y Cho

ices5

Di

ffere

nces

acro

ss pe

ople

or gr

oups

in th

e av

ailab

ility a

nd qu

ality

of pe

rsona

l hea

lth

servi

ces1

4

Diffe

renc

es ac

ross

peop

les an

d gro

ups i

n the

avail

abilit

y and

quali

ty of

unive

rsally

gu

aran

teed p

erso

nal h

ealth

servi

ces u

nless

jus

tified

by di

ffere

nces

in ne

ed15

8. Inc

reas

e the

avail

abilit

y and

quali

ty of

perso

nal h

ealth

servi

ces t

hat a

re

unive

rsally

guar

antee

d in w

ays t

hat

exac

erba

te ex

isting

ineq

ualiti

es un

less

justifi

ed by

diffe

renc

es in

need

.

Di

ffere

nces

acro

ss pe

ople

or gr

oups

in th

e av

ailab

ility o

f key

servi

ces i

nputs

16

Diffe

renc

es ac

ross

peop

le or

grou

ps in

the

avail

abilit

y of k

ey in

puts

to pr

oduc

e a

unive

rsally

guar

antee

d set

of pe

rsona

l he

alth s

ervic

es un

less j

ustifi

ed by

dif

feren

ces i

n nee

d

9. Inc

reas

e the

avail

abilit

y and

quali

ty of

core

publi

c hea

lth fu

nctio

ns in

way

s tha

t ex

acer

bate

exist

ing in

equa

lities

unles

s jus

tified

by di

ffere

nces

in ne

ed.

Di

ffere

nces

acro

ss pe

ople

and g

roup

s in t

he

avail

abilit

y and

quali

ty of

core

publi

c hea

lth

functi

ons1

7

Diffe

renc

es ac

ross

peop

le an

d gro

ups i

n the

av

ailab

ility a

nd qu

ality

of co

re pu

blic h

ealth

fun

ction

s unle

ss ju

stifie

d by n

eed

10.

Incre

ase t

he av

ailab

ility a

nd qu

ality

of co

re pu

blic h

ealth

func

tions

in w

ays t

hat

exac

erba

te ex

isting

ineq

ualiti

es un

less

justifi

ed by

diffe

renc

es in

need

.

14 A

vaila

bility

mea

ns th

at se

rvice

s exis

t and

peop

le ca

n use

them

. 15

As f

or he

alth s

ervic

es, th

is inc

ludes

both

horiz

onal

and v

ertic

al eq

uity c

onsid

erati

ons –

e.g.

wher

e nee

ds di

ffer,

the av

ailab

ility a

nd qu

ality

of a s

et of

servi

ces s

hould

diffe

r.

16 F

or ex

ample

, hea

lth w

orke

rs, eq

uipme

nt, m

edici

nes,

and i

nfras

tructu

re et

c. 17

For

exam

ple, p

opula

tion-

base

d hea

lth pr

omoti

on, s

urve

illanc

e, ou

tbrea

k con

trol e

tc.

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