The Chapter describes the status of health financing in low- and middle-income countries (L&MICs) and their health financing transition over the past two decades. Advancing Universal Health Coverage (UHC) requires an expansion of coverage over three dimensions: (i) health care benefits, (ii) population coverage, and (iii) cost coverage using prepaid/pooled funds. As national incomes rise, countries undergo a health financing transition, increasing total levels of health expenditure while increasing the publicly financed share of health spending and reducing the external- and OOP-financed share of spending. Two pro-poor paths are common for the expansion of health coverage. Many countries implement health insurance schemes for the poor. Others expand platforms of public providers that are mostly used by the poor, often focusing on community and primary care services. Countries choosing the pro-poor health insurance path develop targeting and enrolment instruments. Targeting tends to be stricter with social security purchasers, compared with ministerial purchasers. Fragmented systems, while suboptimal, can sometimes be more pro-poor than integrated systems.

BACKGROUND:In this paper, we review lessons learned about Universal Health Coverage (UHC) in middle-income countries, with specific reference to achievements and challenges observed during recent years in four middle-income to upper-middle-income countries - Mexico, Turkey, The Republic of Korea and Ukraine. Three of these countries - Mexico, the Republic of Korea, Turkey are members of the Organization for Economic Cooperation and Development (OECD). Ukraine has aspired to join Western institutions like the OECD since its independence in 1991.METHODS:The research included a combination of cross-sectional and longitudinal reviews of both statistical and contextual data, available from both published sources and available "grey literature" reports.RESULTS:Based on the research, we conclude the following. First, reaching UHC is achievable in middle-income and upper-middle-income countries. It is not an unattainable goal reserved for upper income countries. Second, successes and failures are evident both in the case of countries that pursue a contributory health insurance path to UHC and those that pursue a core government funding path. Third, the devil is often in the detail. De jure constitutional guarantees and national health legislation are often a necessary but do not constitute a guaranteed path to success without accompanying institutional measure to secure sustainability (political and economic) and supply and demand constraints in service provision and consumer/patient behavior. De facto, in most countries expansion in health insurance coverage does not happen "with the stroke of a pen" but require years of commitment and efforts to change the supply and demand after critical legislation has been enacted. Fourth, two major approaches dominate: incremental and "big bang" health system reforms.CONCLUSIONS:We caution against the pitfalls of over-attribution from drawing too strong conclusion from individual longitudinal country experiences ("over-determinism") and over-generalization from broad sweeping cross-sectional statistical analysis ("reductionism"). Every country is different and needs to find its own path towards UHC considering their contextual specificities, learning from the achievements and failures of others, but not try to copy their experiences.

1 Health Investment & Financing, New York, New York, USA 2 Palladium, Washington, D.C., USA 3 Graduate School of Public Health, Department of Health Policy and Management, Professor and Former Dean, Seoul National University, Seoul, South Korea 4 T.H. Chan School of Public Health, Department of Global Health and Population, Director of Global Health Systems Cluster/ Professor of Global Health Systems, Harvard University, Boston, Massachusetts, USA 5 Palladium, London, UK

With respect to the welfare of children and mothers, the transition from the Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs) is sometimes perceived as risky. The relevant MDGs had a focus on interventions to address maternal and child health, while the focus of the SDGs is expanded to “ensure healthy lives and promote wellbeing for all at all ages”.1UN General AssemblyTransforming our world: the 2030 agenda for sustainable development. Resolution adopted by the General Assembly on Sept 25, 2015.http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=EGoogle Scholar This transition raises two concerns: a broader set of priorities might dilute the attention on maternal and child health, and the broader priorities of the SDGs require the use of more complex implementation instruments than those used in the past. A Countdown to 2015 case study in Peru by Luis Huicho and colleagues2Huicho L Segura ER Huayanay-Espinoza CA et al.Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar published in The Lancet Global Health might provide findings that help countries transition to the SDGs. Peru had huge success improving health outcomes during the Countdown years to 2015. Peru was ranked first globally among 75 low-income and middle-income countries in the reduction in neonatal mortality and second in the reduction of under-5 mortality; stunting prevalence was cut in half; and equity in health-care use and in health outcomes improved significantly. Huicho and colleagues2Huicho L Segura ER Huayanay-Espinoza CA et al.Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar carefully examined the determinants of this success in their study, concluding that many stars were aligned: Peru enjoyed a period of unusually rapid economic growth which coincided with a transition from authoritarianism to democracy, and with the modernisation of the anti-poverty programmes; long-term trends in the education level of mothers, total fertility rate, and urbanisation were also favourable. All of this led to a striking reduction in poverty which fell from 55% of the population in 2001 to 23% by 2014 and provided a fertile ground for the stellar improvement in health outcomes. In the 2000s, health-sector policies in Peru anticipated the shift towards the SDGs by moving away from an exclusive emphasis on maternal and child health and from the use of vertical programmes. In the mid-1990s, Peru had relied on vertical programmes to earmark money, staff, information systems, and efforts to ensure that the statements of MDG priorities translated into high levels of coverage for the MDG interventions. Around the turn of the 21st century, Peru integrated the narrow vertical programmes into a broader programme for primary health care. A few years later, the challenge of steering this new primary care programme was made greater by a process of decentralisation that left the Peruvian Ministry of Health with few instruments to influence the implementation of health policy by the newly autonomous regions. Peru used three types of tool to influence the behaviour of health-care providers in the new context. First, in the early 2000s it created a public insurance scheme to enrol poor mothers and their children, and to reimburse providers for services given to its beneficiaries. After a few years, during which the skills required to pay providers and enrol targeted beneficiaries were refined, the scheme was widened into the Integrated Health Insurance scheme (SIS); expanding its benefit package beyond maternal and child health, and expanding its coverage to include poor and vulnerable populations of all ages. This expansion was made possible by the use of methods of personal identification and of targeting that had been developed outside the health sector.3Francke P Peru's comprehensive health insurance and new challenges for universal coverage. UNICO Studies Series; number 11. World Bank, Washington, DC2013https://openknowledge.worldbank.org/handle/10986/13293Google Scholar Second, management contracts were used to facilitate a dialogue about results between the national Ministry of Health and the new regional authorities, with numerical targets prioritising maternal and child interventions. Managerial efforts were also launched to facilitate a dialogue between the local managers of health, social protection programmes directed towards mothers and children, and local authorities. These efforts were built on a new consensus that the fight against poverty was an essential element of development, that the effectiveness of programmes should be measured, and that the ultimate measure of success of antipoverty programmes should be the reduction of child mortality and of stunting.4Cotlear D Making accountability work: lessons from RECURSO. En breve, number 135. World Bank, Washington, DC2008https://openknowledge.worldbank.org/handle/10986/10270Google Scholar Third, the Ministry of Finance created a new, centrally managed so-called budget for results. The health sector was used to test the new budget; former staff from the Ministry of Health were hired by the Minister of Finance to implement the information system, based on their experience managing the vertical programmes during the 1990s. The government then recentralised a substantial portion of the health-sector budget, placing decision making for the budget with the Ministry of Finance and assigning responsibilities for implementation of the budget to deconcentrated budget units. Which of these instruments should other countries consider for the transition from MDGs to SDGs? The first, SIS, eliminates copayments for their beneficiaries and provides price signals and financial incentives to managers of clinics and hospitals. The second (management contracts) aims to influence the priorities of regional authorities, and the third (a centrally managed budget) to direct the operation of district level budget operators. It is difficult to disentangle the specific influence of the three instruments. However, significant tension exists between the health-sector authorities who implement SIS and the management contracts, and the managers of the budget for results who see the other side as obstacles and competitors, rather than as complements. Assessment studies for the effect of these instruments only exist for SIS. Findings from the most recent study5Neelsen S O'Donnell O Progressive universalism? The impact of targeted coverage on healthcare access and expenditures in Peru. Tinbergen Institute 16-019/V.http://dx.doi.org/10.2139/ssrn.2753122Date: 2016Google Scholar corroborated those from previous studies linking SIS with improved access for the poor, and finding that the introduction of SIS increased the probability that a poor person was treated by a formal health-care provider when sick by over 40% and the use of diagnostic testing by poor people by a third.5Neelsen S O'Donnell O Progressive universalism? The impact of targeted coverage on healthcare access and expenditures in Peru. Tinbergen Institute 16-019/V.http://dx.doi.org/10.2139/ssrn.2753122Date: 2016Google Scholar These findings are consistent with a review of 42 impact evaluations6Giedion U, Alfonso EA, Diaz Y. The impact of universal coverage schemes in the developing world : a review of the existing evidence. Universal Health Coverage (UNICO) studies series, number 25, 2013. Washington, DC: World Bank.Google Scholar showing that around the world, the main beneficiaries of inclusive health insurance programmes are poor people.6Giedion U, Alfonso EA, Diaz Y. The impact of universal coverage schemes in the developing world : a review of the existing evidence. Universal Health Coverage (UNICO) studies series, number 25, 2013. Washington, DC: World Bank.Google Scholar We have found no rigorous third-party impact evaluation studies for the central budget for results. Countries looking for instruments that could be rapidly adapted to their circumstances might also wish to focus on programmes similar to SIS. Findings from a recent study of low-income and middle-income countries implementing pro-poor universal health coverage policies showed that 18 of the 24 countries studied used systems similar to SIS—designed to eliminate user fees and to reimburse providers for services delivered to poor and vulnerable people.7Cotlear D Nagpal S Smith OK Tandon A Cortez RA Going universal: how 24 developing countries are implementing universal health coverage reforms from the bottom up. World Bank Group, Washington, DC2015http://documents.worldbank.org/curated/en/2015/09/25018544/going-universal-24-developing-countries-implementing-universal-health-coverage-reforms-bottom-upCrossref Google Scholar By contrast, none of these countries used a budget for results like the one used in Peru. Countries considering the transition from MDGs to SDGs and looking to Peru for lessons will find plenty of useful information in Huicho and colleagues' Peru Countdown to 2015 case study.2Huicho L Segura ER Huayanay-Espinoza CA et al.Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar They might also wish for more research attempting to disentangle the effects of the many stars that were aligned during Peru's Countdown to 2015. I declare no competing interests. This Comment is the personal work of DC and CV and does not express the views of the World Bank. Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case studyPeru has made substantial progress in reducing neonatal and under-5 mortality, and child stunting. This country is a good example of how a combination of political will, economic growth, broad societal participation, strategies focused on poor people, and increased spending in health and related sectors can achieve significant progress in reproductive, maternal, neonatal, and child health. The remaining challenges include continuing to address inequalities in wealth distribution, poverty, and access to basic services, especially in the Amazon and Andean rural areas. Full-Text PDF Open Access

In its report Global Health 2035, the Commission on Investing in Health proposed that health investments can reduce mortality in nearly all low- and middle-income countries to very low levels, thereby averting 10 million deaths per year from 2035 onward. Many of these gains could be achieved through scale-up of existing technologies and health services. A key instrument to close this gap is policy and implementation research (PIR) that aims to produce generalizable evidence on what works to implement successful interventions at scale. Rigorously designed PIR promotes global learning and local accountability. Much greater national and global investments in PIR capacity will be required to enable the scaling of effective approaches and to prevent the recycling of failed ideas. Sample questions for the PIR research agenda include how to close the gap in the delivery of essential services to the poor, which population interventions for non-communicable diseases are most applicable in different contexts, and how to engage non-state actors in equitable provision of health services in the context of universal health coverage.

Efforts to mitigate health inequity are at the heart of health policy in Israel and in many developing countries seeking to advance toward universal health coverage. This commentary uses the conceptual framework and the description of health policy interventions presented in a recent IJHPR article to compare policies implemented by Israel’s Ministry of Health during 2011–2014 with policies under implementation in 24 developing countries, and identifies key differences and similarities. It also identifies three areas of policy where Israel seems to have strong capacities that are in high demand in developing countries. Identifying these areas of policy could help design a menu for Israeli technical assistance in health policy.

The last few years have seen a growing commitment worldwide to universal health coverage (UHC). Yet there is a lack of clarity on how to measure progress towards UHC. We propose a 'mashup' index that captures both aspects of UHC: that everyone-irrespective of their ability-to-pay-gets the health services they need; and that nobody suffers undue financial hardship as a result of receiving care. We break service coverage into prevention and treatment, and financial protection into impoverishment and catastrophic spending; we use nationally representative household survey data to adjust population averages to capture inequalities between the poor and better off; we allow non-linear trade-offs between and within the two dimensions of the UHC index; and we express all indicators such that scores run from 0 to 100, and higher scores are better. In a sample of 24 countries for which we have detailed information on UHC-inspired reforms, we find a cluster of high-performing countries with UHC scores of between 79 and 84 (Brazil, Colombia, Costa Rica, Mexico, and South Africa) and a cluster of low-performing countries with UHC scores in the range 35-57 (Ethiopia, Guatemala, India, Indonesia, and Vietnam). We find that countries have mostly improved their UHC scores between the earliest and latest years for which we have data-by about 5 points on average. However, the improvement has come from increases in receipt of key health interventions, not from reductions in the incidence of out-of-pocket payments on welfare.

Applies the criteria of the World Bank's World Development Report of 2004 to explain accountability as a relationship between actors that has the five features of delegation, finance, performance, information about performance, and enforceability. The 26 universal health coverage (UHC) programs across the 24 case study countries aim to fundamentally change the way stakeholders interact, alongside the objective of strengthening accountability. Four groups of policies emerge from the study of the 26 programs, three of which focus on the relationship between politicians and policy makers on one hand and providers on the other, while the last one, empowerment, addresses the interaction between the population with politicians and policy makers (as citizen voice) and with providers (as client power). The case studies provide examples of steps for enhanced social accountability, such as the right to health constitutional mandates in Latin America, patient rights legislation, greater patient choice of provider, and explicit benefit packages.

Appendix A lists the titles and authors of 27 studies from the Universal Health Coverage Studies Series (UNICO). Appendix B summarizes key attributes of countries in UNICO, providing country context and comparisons with non-UNICO developing countries and with high-income countries. Appendix C reviews the literature on the impact of universal health coverage (UHC) programs on access, financial protection, and health status, synthesizing key findings and identifying gaps in knowledge for further research. Appendix D provides the online link to the Unico Questionnaire and Universal Health Coverage Study Series.

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens—with defined and enlarged benefits packages—and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

Stresses the importance of a well-organized supply system, describes five areas of intervention commonly pursued alongside the universal health coverage (UHC) programs in Universal Health Coverage Studies Series (UNICO) countries to expand health care services provision, and draws policy implications. Many of the case study countries use retention incentives and community health workers (CHWs) to address distribution issues, and most aim to improve the supply response of public providers by increasing managerial flexibility in public clinics and hospitals. Many UNICO programs contract with private providers to deliver care, and many UNICO countries are using their UHC programs to develop processes aiming to improve quality more broadly in the health system, including accrediting health facilities. The UNICO countries increasingly recognize the need for integration across the health system, aiming to give the population access to a coherent, optimally functioning network of health care providers, along the continuum of health promotion, disease prevention, diagnosis, treatment, management, rehabilitation, and palliative care.

Considers experiences of the 24 countries in the Universal Health Coverage Studies Series (UNICO) study to demonstrate the spectrum of services that universal health coverage (UHC) should address to achieve effectiveness. The 24 case study countries are adding services and going beyond the millennium development goals (MDGs); trending toward explicit benefit packages; using complex mechanisms in setting priorities for these packages; adopting de facto benefit packages smaller than promised; and generally shifting to closed-ended provider-payment mechanisms with improved linkages to performance. The UNICO countries define their increasingly explicit benefit packages with implicit rationing; implicit rationing combined with systematic priority setting processes and other strategies; or with explicit benefit packages using positive lists. All but three UNICO programs use explicit benefit packages to move from the implicit rationing often inherent in the broad promises in their implicit benefit packages; most explicitly define their benefit packages with positive lists or a combination of positive and negative lists.

This book is based on systematic data collection among 26 universal health coverage (UHC) programs across 24 countries in the UHC studies. The main objective of this report is to document and analyze the experiences of 24 countries based on a systematic data collection that sought to capture in great detail how they are doing so. Thus the book aims to extend, on number of countries covered and detail of information collected the large number of case studies that have already enriched the global knowledge base on UHC. The UHC cube raises the real-world dilemma of which dimension to prioritize, given the inevitable trade-offs. The recent Lancet Global Commission 2035 analyzed alternative pathways to progressive universalism, and espoused support for two options. The first will make coverage available to the whole population but target the poor by prioritizing health interventions for diseases that disproportionately affect that group. The second will provide a larger package of interventions to the full population but with some patient copayment, from which poor people will be exempt.

Identifies key trends, highlights good practices, and summarizes policy implications for financing universal health coverage (UHC) expansion in the 24 Universal Health Coverage Studies Series (UNICO) countries. Health financing can be classified across five broad subcategories of UHC, including supply-side programs (SSPs); poor and vulnerable programs (PVPs); informal sector programs (ISPs); social health insurance programs (SHI+); and social health insurance programs with de facto mandatory enrollment for the non-poor informal sector (SHI++). Some issues of financing UHC programs include levels of financing; sources and contribution methods; cost-sharing modalities; and risk pooling and resource allocation. The analysis confirms the importance of government financing in expanding coverage for the poor: some 70 percent of revenues across all UHC programs come from general government revenues. Coverage for the poor, whether targeted or part of a universal program, was noncontributory in all UNICO UHC programs; half the case study countries had diverse forms of earmarked taxes to co-finance coverage expansions.