Joseph Kutzin

Anything Goes on the Path to Universal Health Coverage? No

In its 2010 world health report,1 the World Health Organization noted that there is no single, best path for reforming health financing arrangements to move systems closer to universal health coverage, i.e. to improve access to needed, effective services while protecting users from financial ruin. However, this lack of a blueprint for health financing reforms was not meant to convey the message that “anything goes” on the path to universal health coverage. Indeed, concerns have been raised that some reforms, often implemented in the name of expanding coverage, may actually compromise equity.2 Theory and country experience yield important lessons on both promising directions and pitfalls to avoid. Interpretation of health financing reform experience requires getting beneath commonly used labels such as “tax-funded systems” or “social health insurance”, or simply even “health insurance”, which was used as the basis for a systematic review published in the September issue of the Bulletin.3 Such labels hide more than they illuminate, as shown by emerging evidence on reforms that increase access and financial protection but are funded predominantly from general tax revenues (e.g. Kyrgyzstan, Mexico, Rwanda, Thailand). Deriving meaningful lessons from innovative reform experiences requires a deeper understanding of how countries have altered their funding sources, pooling arrangements, purchasing methods, and policies on benefits and patient cost-sharing. All systems, regardless of what they are called, have to address these functions and policy choices.

Bismarck meets Beveridge on the Silk Road: coordinating funding sources to create a universal health financing system in Kyrgyzstan

Options for health financing reform are often portrayed as a choice between general taxation (known as the Beveridge model) and social health insurance (known as the Bismarck model). Ten years of health financing reform in Kyrgyzstan, since the introduction of its compulsory health insurance fund in 1997, provide an excellent example of why it is wrong to reduce health financing policy to a choice between the Beveridge and Bismarck models. Rather than fragment the system according to the insurance status of the population, as many other low- and middle-income countries have done, the Kyrgyz reforms were guided by the objective of having a single system for the entire population. Key features include the role and gradual development of the compulsory health insurance fund as the single purchaser of health-care services for the entire population using output-based payment methods, the complete restructuring of pooling arrangements from the former decentralized budgetary structure to a single national pool, and the establishment of an explicit benefit package. Central to the process was the transformation of the role of general budget revenues - the main source of public funding for health - from directly subsidizing the supply of services to subsidizing the purchase of services on behalf of the entire population by redirecting them into the health insurance fund. Through their approach to health financing policy, and pooling in particular, the Kyrgyz health reformers demonstrated that different sources of funds can be used in an explicitly complementary manner to enable the creation of a unified, universal system.

Health systems strengthening, universal health coverage, health security and resilience

Health system strengthening comprises the means (the policy instruments), while universal health coverage is a way of framing the objectives of policy. Without this distinction, there is a risk that instruments of reform become the objective, with the perception that “the problem” to be solved is the absence or presence of a particular policy instrument. When this occurs, policy dialogue shifts quickly away from where it needs to be – getting to consensus about the nature and causes of underperformance relative to universal health coverage goals – to what is often an ideologically polarized debate about the inherent merits or flaws of particular reform instruments. In health financing, for example, this has been observed in the debate on social or community-based health insurance, performance-based financing and user fees. Similarly, simply calling something a “universal health coverage reform” does not convey any meaning as to the actual content of what is being planned or implemented.

Lessons from health financing reform in central and eastern Europe and the former Soviet Union.

Policy makers in the so-called transition countries, as in all countries, face the challenge of improving the performance of their health systems. These countries share a unique historical experience – the period and collapse of communist rule – and all embarked on an unprecedented social, political and economic transition that began at the end of the 1980s. Despite this shared history, differences emerged (or became more apparent) in the early years of transition. Most obviously, there are large economic differences between the countries, with the richest country, Slovenia, having an estimated purchasing power parity-adjusted per capita gross national income in 2008 of

From scheme to system: social health insurance funds and the transformation of health financing in Kyrgyzstan and Moldova

26,910 compared with that of

Pay-for-Performance Debate: Not Seeing the Forest for the Trees

1860 in the poorest, Tajikistan (World Bank, 2009) (Table 1). The transition created particular challenges and opportunities for their health systems, in general, and for health financing systems, in particular. And indeed, most of the countries introduced either comprehensive or piecemeal reforms in a number of areas, including the introduction of compulsory health insurance (CHI) funds, changes in provider payment methods and changes in benefit packages and user charges. A recently completed edited volume (Kutzin et al., 2010) reviewed the experience of transition countries with two decades of health financing reform and synthesised lessons learnt to date, some of which may resonate for countries

Assessing Fiscal Space for Health in the SDG Era: A Different Story

OBJECTIVE The aim of the paper is to bring evidence and lessons from two low- and middle-income countries (LMIs) of the former USSR into the global debate on health financing in poor countries. In particular, we analyze the introduction of social health insurance (SHI) in Kyrgyzstan and Moldova. To some extent, the intent of SHI introduction in these countries was similar to that in LMIs elsewhere: increase prepaid revenues for health and incorporate the entire population into the new system. But the approach taken to universality was different. In particular, the SHI fund in each country was used as the key instrument in a comprehensive reform of the health financing system, with the new revenues from payroll taxation used in an explicitly complementary manner to general budget revenues. From a functional perspective, the reforms in these countries involved not only the introduction of a new source of funds, but also the centralization of pooling, a shift from input- to output-based provider payment methods, specification of a benefit package, and greater autonomy for public sector health care providers. Hence, their reforms were not simply the introduction of an SHI scheme, but rather the use of an SHI fund as an instrument to transform the entire system of health financing. METHODOLOGY/APPROACH The study uses administrative and household data to demonstrate the impact of the reforms on regional inequality and household financial burden. FINDINGS The approach used in these two countries led to improved equity in the geographic distribution of government health spending, improved financial protection, and reduced informal payments. IMPLICATIONS FOR POLICY The comprehensive approach taken to reform in these two countries, and particularly the redirection of general budget revenues to the new SHI funds, explain much of the success that was achieved. This experience offers potentially useful lessons for LMIs elsewhere in the world, and for shifting the global debate away from what we see as a false dichotomy between SHI and general revenue-funded systems. By demonstrating that sources are not systems, these cases illustrate how, in particular by careful design of pooling and coverage arrangements, the introduction of SHI in an LMI context can avoid the fragmentation problem often associated with this reform instrument.

From silos to sustainability: transition through a UHC lens

The Potential Health System Benefits of P4P Concerns Around the Current P4P Debate Moving Forward References Over the past 10 to 15 years, results-based financing (RBF) has gained increased prominence in global health. Though the term RBF encompasses a variety of demandand supplyside incentives to increase output or enhance access and quality, the focus of this special issue and our commentary is on incentives that target service providers. In high-income countries including the UK, France, and the United States these types of incentives are typically referred to as pay-for-performance (P4P), defined as financial incentives to hospitals, physicians, and other health care providers “aimed at improving the quality, efficiency, and overall value of health care.” The term performance-based financing (PBF) has acquired a wider use in lowand middle-income countries (LMICs) and refers to supply-side financial incentives where payment depends explicitly on quantity of services delivered and “on the degree to which services are of approved quality, as specified by protocols for processes and outcomes.” PBF may not only target health facilities but also include ministries of health, local governments, provincial and district health teams, and central medical stores. Though terminologies may differ, at their core, PBF or P4P is a provider payment mechanism, which uses information on provider activities and the health needs of the population they serve to drive resource allocation in order to maximize societal objectives. For purposes of this commentary, we will use the term P4P to refer to this mechanism. In this commentary, we argue that it is crucial to pay greater attention to the “forest”—that is, overall health system reforms and how provider payment arrangements interact with these to influence health outcomes, as opposed to looking almost solely and more narrowly at the “trees”—that is, the details and impact of a P4P mechanism divorced from the underlying health system. P4P is a category of strategic purchasing, the effectiveness of which depends critically on its connections with the wider environment of purchaser– provider relations. In the following paragraphs, we unpack the potential health system benefits of P4P. Next, we briefly Received 28 January 2017; revised 1 March 2017; accepted 2 March 2017. *Correspondence to: Elina Dale; Email: dalee@who.int 2017 World Health Organization. Published by Taylor & Francis. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 IGO License, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. This article shall not be used or reproduced in association with the promotion of commercial products, services or any entity. There should be no suggestion that the World Health Organization (WHO) endorses any specific organization, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.

A descriptive framework for country-level analysis of health care financing arrangements

Abstract—Initially defined for overall public purposes, the concept of fiscal space was subsequently developed and adapted for the health sector. In this context, it has been applied in research and policy in over 50 low- and middle-income countries over the past ten years. Building on this vast experience and against the backdrop of shifts in the global health financing landscape in the Sustainable Development Goals (SDG) era, the commentary highlights key lessons and challenges in the approach to assessing potential fiscal space for health. In looking forward, the authors recommend that future fiscal space for health analyses primarily focus on domestic sources, with specific attention to potential expansion from the improved use and performance of public resources. Embedding assessments in national health planning and budgeting processes, with due consideration of the political economy dynamics, will provide a way to inform and impact allocative decisions more effectively.

Health for some? The effects of user fees in the Volta Region of Ghana

The transition to higher-income status is a positive step forward for countries, but this transition brings with it the prospect of declining external assistance, both in general and in particular for health. Most health donor agencies rely at least in part on an income threshold to establish eligibility for support. Such a donor transition implies that government is increasingly responsible for the financing of a health programme and its supported interventions. However, focusing attention only on replacing external assistance with domestic revenues for the programmes concerned is problematic in two ways: firstly, this approach limits the sustainability question to revenues, and secondly, it limits the scope for action to the specific health programme that was receiving external support. The commitment countries have made to universal health coverage (UHC) is an opportunity to reframe the transition agenda towards sustaining coverage results rather than externally funded programmes per se. This perspective has implications for the overall approach to transition taken at both national and global levels. UHC embeds the goals of equity in service use, quality, and financial protection at the level of the entire health system and population. The way external resources are often channelled, as a legacy of the Millennium Development Goals era, creates or reinforces vertical struc tures focused on specific dis eases or interventions. In many countries, these subsystems operate independently of the rest of the health system, with separate plans, budgets, funding, procurement, supply chains, and information systems. When viewed through a UHC lens (ie, across the health system, within which programmes are embedded), it is apparent that these separate subsystems duplicate responsibilities, compromising efficiency in resource use and sometimes effective case management—eg, when service use data on a pregnant woman who has HIV is managed separately by the HIV programme and the maternal health programme. Consolidating underlying sub systems can help sustain progress. External assistance should support such real system-building actions. Purely financial solutions to the challenges posed by donor transi tion, such as blended financing arrangements, should not mask the need to address these efficiency challenges that are at the core of putting national health systems on more sustainable trajectories. There is no need to wait for transition; the time to initiate such change is now. The economic growth that triggers donor transition also provides an opportunity for a health financing transition—ie, reforms which, if effective, result in an increase in health spending per person and a decrease in the share of that spending that is paid out of pocket. Realising this in practice requires targeted policy measures. As with efficiency considerations, financing actions should be add ressed at the system rather than the programme level. Specifically, government-wide efforts to strengthen taxation capacity and increase priority for the health sector in public budgets are key. Within the health sector, actions are needed to reduce fragmentation in the way that funds are pooled, and to then allocate these funds strategically to improve health and drive efficiency gains. For example, the inclusion of currently programme-supported individual health services (eg, immunisation and HIV and tuberculosis treatment) within integrated benefit packages, pay ment systems, and service delivery arrange ments can be considered as part of building a more sustainable system. Finally, citizens and taxpayers (ie, those driving domestic funding) need to move this effort through collective action, as part of national health assemblies and parliamentary debates. Looking at transition through a UHC lens implies three shifts: building consensus that what is to be sustained is increased effective coverage of priority health interventions; that sustainability requires acting on both revenue and expenditure issues; and that such actions must be done system-wide rather than programme by programme. A UHC lens means looking at these challenges from the perspectives of the health and finance ministers rather than simply those of each programme manager. A minister’s perspective puts financing issues within the frame of funding for the entire sector, leading to an emphasis on strengthening overall taxation capacity and improving equity and efficiency, which are core principles for any health financing system, regard less of transition. It also means going beyond financing to carefully address inefficiencies through reforms and investments that might require donor support, to streamline the underlying administrative machinery of the entire health system. Focusing on UHC goals to drive consensus and the system-wide unit of analysis to frame actions better enables policy responses to build stronger health systems that address programmatic priorities, regardless of the source of funding.