equity on the path to uhc deliberate decisions for fair...

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

DRAFT:Notforattribution

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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


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


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.

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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.


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


16

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


17

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


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


19

(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.


20

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


21

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.


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


23

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,


24

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).


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


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


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.

References

Abelson,J.,Giacomini,M.,Lehoux,P.,andGauvin,F.P.2007.“Bringing‘thePublic’intoHealthTechnologyAssessmentandCoveragePolicyDecisions:FromPrinciplestoPractice.”HealthPolicy82:37-50.

AfricaHealthBudgetNetwork.2018.http://africahbn.info

AlkenbrackS,ChaitkinM,ZengW,CoutureT,SharmaS.DidequityofreproductiveandmaternalhealthservicecoverageincreaseduringtheMDGera?Ananalysisoftrendsanddeterminantsacross74low-andmiddle-incomecountries.PLoSOne2015;10:e134905.

Badano,G.,2018.”IfYou’reaRawlsian,HowComeYou’reSoClosetoUtilitarianismandIntuitionism?ACritiqueofDaniels’AccountabilityforReasonableness.”HealthCareAnalysis26(1):1-16.

Baltussen,R.,Jansen,M.P.,Bijlmakers,L.,Tromp,N.,Yamin,A.E.,andNorheim,O.F.2017.“ProgressiveRealisationofUniversalHealthCoverage:WhataretheRequiredProcessesandEvidence?”BMJGlobalHealth2(3),p.e000342.

Barros,F.C.,Victora,C.G.,Scherpbier,R.andGwatkin,D.,2010.Socioeconomicinequitiesinthehealthandnutritionofchildreninlow/middleincomecountries.RevistadeSaúdePública,44(1),pp.1-16.

Bastagli,F,Coady,D.,andGupta,M.S.2012.“IncomeInequalityandFiscalPolicy.”InternationalMonetaryFundStaffDiscussionNote12/08.

Bendavid,E.,2014.Changesinchildmortalityovertimeacrossthewealthgradientinless-developedcountries.Pediatrics,134:e1551–59.

Byskov,J.,Maluka,S.O.,Marchal,B.,Shayo,E.H.,Bukachi,S.,Zulu,J.M.,Blas,E.,Michelo,C.,Ndawi,B.,andHurtig,A.K.2017.“TheNeedforGlobalApplicationoftheAccountabilityforReasonablenessApproachtoSupportSustainableOutcomes:CommentonExpandedHTA:EnhancingFairnessandLegitimacy".InternationalJournalofHealthPolicyandManagement6(2):115.

Campbell,M.,Craig,P.,andEscobar,O.2017.“ParticipatoryBudgetingandHealthandWellbeing:ASystematicScopingReviewofEvaluationsandOutcomes.”TheLancet390:S30.

Cevik,S.andCorrea-Caro,C.2015.“Growing(Un)equal:FiscalPolicyandIncomeInequalityinChinaandBRIC.”IMFWorkingPaper15/68,Washington,DC.

Chaumont,C.,Hsi,J.,Bohne,C.,Mostaghim,S.andMoon,S.,2017.“ANewGoldenAge?ProposalforanInnovativeGlobalHealthFundingMechanismforMiddle-IncomeCountries.”GlobalChallenges1(7).

Chima,C.C.andFranzini,L.,2015.“SpilloverEffectofHIV-specificForeignAidonImmunizationServicesinNigeria.”InternationalHealth8(2):108-115.

Clements,B.,Gaspar,V.,andGupta,S.2015.“TheIMFandIncomeDistribution.”InequalityandFiscalPolicy,page21.

Daniels,N.2000.“AccountabilityforReasonableness.EstablishingaFairProcessforPrioritySettingisEasierthanAgreeingonPrinciples.”BritishMedicalJournal321:1300-1301.

Daniels,N.2008.“Justhealth:meetinghealthneedsfairly.”Cambridge:CambridgeUniversityPress.

Daniels,N.andSabin,J.E.,2008.“SettingLimitsFairly:LearningtoShareResourcesforHealth.”2ndedition.Oxford:OxfordUniversityPress.

Daniels,N.2011.“AgingandIntergenerationalEquity.”InGlobalPopulationAgeing:PerilorPromise,editedbyJ.R.Beard,S.Biggs,D.E.Bloom,L.P.Fried,P.Hogan,A.Kalache,andS.J.Olshansky.Geneva:WorldEconomicForum.

Daniels,N.2016.“AccountabilityforReasonablenessandPrioritySettinginHealth.InPrioritizationinMedicine,editedbyE.NagelandM.Lauerer.Springer,Cham.

EuropeanCommission.2013.“TheImpactoftheFinancialCrisisonUnmetneedsforHealthcare

Evans,T.,Whitehead,M.,Diderichsen,F.,Bhuiya,A.andWirthM.2001.ChallengesInequitiesinHealth:FromEthicstoAction.NewYork:TheRockefellerFoundation,NewYork:OxfordUniversityPress.

Farmer,P.2004.“PathologiesofPower:Health,HumanRights,andtheNewWaronthePoor.”Volume4.Berkeley:UniversityofCaliforniaPress.

Fleurbaey,M.andManiquet,F.2017.“OptimalIncomeTaxationTheoryandPrinciplesofFairness.”CentreforOperationalResearchandEconometricsDiscussionPaper,UniversitéCatholiquedeLouvain.https://uclouvain.be/en/research-institutes/immaq/core/discussion-papers.html

Ghimire,M.,Ayer,R.andKondo,M.,2018.Cumulativeincidence,distribution,anddeterminantsof catastrophic health expenditure in Nepal: results from the living standards survey.Internationaljournalforequityinhealth,17(1),p.23.

Giedion,U.andGuzman,J.2017.“DefiningtheRulesoftheGame:GoodGovernancePrinciplesfortheDesignandRevisionoftheHealthBenefitsPackage,”inWhat'sIn,What'sOut:DesigningBenefitsforUniversalHealthCoverage,editedbyA.Glassman,U.Giedion,andP.C.Smith.Washington,DC:BrookingsInstitutionPress.

Glassman,A.andChalkidou,K.2012.“Priority-settinginHealth:BuildingInstitutionsforSmarterPublicSpending.”Washington,DC:CenterforGlobalDevelopment.

Gruskin,S.andDaniels,N.2008.“JusticeandHumanRights:PrioritySettingandFair,DeliberativeProcess.”AmericanJournalofPublicHealth98:1573-7.

Gwatkin,D.R.,2000.Healthinequalitiesandthehealthofthepoor:Whatdoweknow?Whatcanwedo?.Bulletinoftheworldhealthorganization,78(1),pp.3-18.

Gwatkin,D.R.,2017.Trendsinhealthinequalitiesindevelopingcountries.TheLancetGlobalHealth,5(4),pp.e371-e372.

Hogan,D.R.,Stevens,G.A.,Hosseinpoor,A.R.andBoerma,T.,2017.MonitoringuniversalhealthcoveragewithintheSustainableDevelopmentGoals:developmentandbaselinedataforanindexofessentialhealthservices.TheLancetGlobalHealth.

Hosseinpoor,A.R.,Bergen,N.,Barros,A.J.,Wong,K.L.,Boerma,T.andVictora,C.G.,2016.Monitoringsubnationalregionalinequalitiesinhealth:measurementapproachesandchallenges.Internationaljournalforequityinhealth,15(1),p.18.DHS,comparemethods

Hosseinpoor,A.R.,Bergen,N.,Schlotheuber,A.andBoerma,T.,2018.Nationalhealthinequalitymonitoring:currentchallengesandopportunities.Globalhealthaction,11(sup1),p.1392216.

International MonetaryFund (IMF).2017. FiscalMonitor: Tackling Inequality.WashingtonDC.October2017

Jellema, J., Wai-Poi, M. and Afkar, R., 2017. The Distributional Impact of Fiscal Policy inIndonesia. The Distributional Impact of Taxes and Transfers, p.149. CEQ Commitment toEquity,TulaneUniversity,WorkingPaper40.

Kaiser,K.,Bredenkamp,C.,andIglesias,R.2016.SinTaxReforminthePhilippines:TransformingPublicFinance,Health,andGovernanceforMoreInclusiveDevelopment.DirectionsinDevelopment.Washington,DC:WorldBank.doi:10.1596

Kasdan, A. andMarkman, E., 2017. “Participatory Budgeting and Community-Based Research:Principles,Practices,andImplicationsforImpactValidity.”NewPoliticalScience,39(1):143-155.

Khan, J.A.,Ahmed,S.andEvans,T.G.,2017.“Catastrophichealthcareexpenditureandpovertyrelatedtoout-of-pocketpaymentsforhealthcareinBangladesh—anestimationoffinancialrisk protection of universal health coverage.”Health policy and planning. 32(8), pp.1102-1110.

Knaul,F.M.,Wong,R.,Arreola-Ornelas,H.,Méndez,O.,Bitran,R.,Campino,A.C.,FlórezNieto,C.E.,Giedion,U.,Maceira,D.,Rathe,M.,andValdivia,M.2011.“HouseholdCatastrophicHealthExpenditures:AComparativeAnalysisof12LatinAmericanandCaribbeanCountries.SaludPúblicadeMéxico53:s85-s95.

Knaul,F.M.,Arreola-Ornelas,H.,Mendez-Carniado,O.,Bryson-Cahn,C.,Barofsky,J.,Maguire,R.,Miranda,M.andSesma,S.2006.“Evidenceisgoodforyourhealthsystem:policyreformtoremedycatastrophicandimpoverishinghealthspendinginMexico.”TheLancet,368:1828-41

Kotlikoff,L.J.2018.“MeasuringIntergenerationalJustice.”IntergenerationalJusticeReview11(2).

Lu,J.F.R.,Leung,G.M.,Kwon,S.,Tin,K.Y.,vanDoorslaer,E.,andO’Donnell,O.“HorizontalEquityinHealthCareUtilization:EvidencefromThreeHigh-IncomeAsianEconomies.”EQUITAPProject:WorkingPaperNo.6.

Lustig,N.,etal.2013.“TheImpactofTaxesandSocialSpendingonInequalityandPovertyinArgentina,Bolivia,Brazil,Mexico,PeruandUruguay:AnOverview.”CEQWorkingPaperNo.13.NewOrleans:TulaneUniversity.

Lustig,N.2016.“InequalityandFiscalRedistributioninMiddleIncomeCountries:Brazil,Chile,Colombia,Indonesia,Mexico,PeruandSouthAfrica.”JournalofGlobalizationandDevelopment7(1):17-60.

Lustig,N.2017.“TheImpactofTaxesandSocialSpendingonIncomeDistributionandPovertyinLatinAmerica:AnApplicationoftheCommitmenttoEquity(CEQ)Methodology.”No.1714.NewOrleans:TulaneUniversity,DepartmentofEconomics.

Mackenbach,J.P.,Kunst,A.E.,Cavelaars,A.E.,Groenhof,F.,Geurts,J.J.andEUWorkingGrouponSocioeconomicInequalitiesinHealth,1997.SocioeconomicinequalitiesinmorbidityandmortalityinwesternEurope.Thelancet,349(9066),pp.1655-1659.

Marmot,M.G.,Stansfeld,S.,Patel,C.,North,F.,Head,J.,White,I.,Brunner,E.,Feeney,A.andSmith,G.D.,1991.HealthinequalitiesamongBritishcivilservants:theWhitehallIIstudy.TheLancet,337(8754),pp.1387-1393.

MartinsenL.etal.2017.“DoLessPopulousCountriesReceiveMoreDevelopmentAssistanceforHealthperCapita?Longitudinalevidencefor143countries,1990–2014.”BMJGlobalHealth2018,(3).doi:10.1136/bmjgh-2017-000528

Mitton,C.,Smith,N.,Peacock,S.,Evoy,B.,andAbelson,J.2009.“PublicParticipationinHealthCarePrioritySetting:AScopingReview.”HealthPolicy,91:219-28.

Moser,K.A.,Leon,D.A.andGwatkin,D.R.,2005.Howdoesprogresstowardsthechildmortalitymillenniumdevelopmentgoalaffectinequalitiesbetweenthepoorestandleastpoor?AnalysisofDemographicandHealthSurveydata.Bmj,331(7526),pp.1180-1182.

Mulenga,A.andAtaguba,J.E.O.2017.“AssessingIncomeRedistributiveEffectofHealthFinancinginZambia.”SocialScience&Medicine189:1-10.

Murray,C.J.,Xu,K.,Klavus,J.,Kawabata,K.,Hanvoravongchai,P.,Zeramdini,R.,Aguilar-Rivera,A.M.,andEvans,D.B.2003.“AssessingtheDistributionofHouseholdFinancialContributionstotheHealthSystem:ConceptsandEmpiricalApplication.”HealthSystemsPerformanceAssessment:Debates,MethodsandEmpiricism12.Geneva:WorldHealthOrganization.

O’Donnell,O.,VanDoorslaer,E.,Rannan-Eliya,R.P.,Somanathan,A.,Adhikari,S.R.,Akkazieva,B.,Harbianto,D.,Garg,C.C.,Hanvoravongchai,P.,Herrin,A.N.,andHuq,M.N.2008.“WhoPaysforHealthCareinAsia?”JournalofHealthEconomics27(2):460-475.

O'Neill,K.,Takane,M.,Sheffel,A.,Abou-Zahr,C.andBoerma,T.,2013.Monitoringservicedeliveryforuniversalhealthcoverage:theServiceAvailabilityandReadinessAssessment.BulletinoftheWorldHealthOrganization,91(12),pp.923-931.

OECD.2015.“FiscalSustainabilityofHealthSystems:BridgingHealthandFinancingPerspectives.”

Ottersen,T.andNorheim,O.F.2014.“MakingFairChoicesonthePathtoUniversalHealthCoverage.”OnbehalfoftheWorldHealthOrganizationConsultativeGrouponEquityandUniversalHealthCoverage.BulletinoftheWorldHealthOrganization2014(92):389.doi:http://dx.doi.org/10.2471/BLT.14.139139

Ottersen,T.,Moon,S.,andRøttingen,J.A.2017.“TheChallengeofMiddle-IncomeCountriestoDevelopmentAssistanceforHealth:Recipients,Funders,Both,orNeither?”HealthEconomics,PolicyandLaw12(2):265-284

Ottersen,T.,Kamath,A.,Moon,S.,Martinsen,L.,andRøttingen,J.A.2017.“DevelopmentAssistanceforHealth:WhatCriteriadoMulti-andBilateralFundersUse?”HealthEconomics,Policy,andLaw12(2):223-244.

Ottersen,T.andSchmidt,H.2017.“UniversalHealthCoverageandPublicHealth:EnsuringParityandComplementarity.”AmericanJournalofPublicHealth17(2):248-250.

Petricca,K.andBekele,A.2017.“ConceptualizationsofFairnessandLegitimacyintheContextofEthiopianHealthPrioritySetting:ReflectionsontheApplicabilityofAccountabilityforReasonableness.”DevelopingWorldBioethics00:1–8.https://doi.org/10.1111/dewb.12153

Pietschmann,E.2014.“ForgottenorUnpromising?TheElusivePhenomenonofUnder-aidedCountries,SectorsandSub-NationalRegions.”GermanDevelopmentInstitute,Studies80.http://edoc.vifapol.de/opus/volltexte/2015/5612/pdf/Studies_80.pdf

Rao,M.,Katyal,A.,Singh,P.V.,Samarth,A.,Bergkvist,S.,Kancharla,M.,Wagstaff,A.,Netuveli,G.andRenton,A.,2014.ChangesinaddressinginequalitiesinaccesstohospitalcareinAndhraPradeshandMaharashtrastatesofIndia:adifference-in-differencesstudyusingrepeatedcross-sectionalsurveys.BMJopen,4(6),p.e004471.

RashtriyaSwasthyaBimaYojana(RSBY).2018.OverviewofStateWiseenrolment.http://www.rsby.gov.in/statewise.aspx?state=4

Rechel,B.,Thomson,S.,andVanGinneken,E.2010.“HealthSystemsinTransition:TemplateforAuthors.”WHOfortheEuropeanObservatoryonHealthSystemsandPolicies,Copenhagen.

Resnik,D.B.,MacDougall,D.R.,andSmith,E.M.2018.“EthicalDilemmasinProtectingSusceptibleSubpopulationsfromEnvironmentalHealthRisks:Liberty,Utility,Fairness,andAccountabilityforReasonableness.”TheAmericanJournalofBioethics18(3):29-41.

Restrepo-Méndez,M.C.,Barros,A.J.,Wong,K.L.,Johnson,H.L.,Pariyo,G.,França,G.V.,Wehrmeister,F.C.andVictora,C.G.,2016.Inequalitiesinfullimmunizationcoverage:trendsinlow-andmiddle-incomecountries.BulletinoftheWorldHealthOrganization,94(11),p.794.

RoweG.andFrewerL.J.2005.“ATypologyofPublicEngagementMechanisms.”Science,Technology,andHumanValues30:251-90.

Rumbold,B.,Baker,R.,Ferraz,O.,Hawkes,S.,Krubiner,C.,Littlejohns,P.,Norheim,O.F.,Pegram,T.,Rid,A.,Venkatapuram,S.,andVoorhoeve,A.2017.UniversalHealthCoverage,PrioritySetting,andtheHumanRighttoHealth.TheLancet390(10095):712-714.

Sabik,L.M.andLie,R.K.2008.“PrioritySettinginHealthCare:LessonsfromtheExperiencesof

EightCountries.”InternationalJournalforEquityinHealth7:4.

Saksena,P.,Hsu,J.andEvans,D.B.,2014.Financialriskprotectionanduniversalhealthcoverage:evidenceandmeasurementchallenges.PLoSmedicine,11(9),p.e1001701.

Schedler,A.1999.“ConceptualizingAccountability.”InTheSelf-restrainingState:PowerandAccountabilityinNewDemocracies,editedbyA.Schedler,L.Diamond,andM.F.Plattner.Boulder,Co:LynneRiennerPublishers.

Shapiro,E.andTalmon,N.2017.“ACondorcet-ConsistentParticipatoryBudgetingAlgorithm.”

Simonet,D.2017.“PublicValuesandAdministrativeReformsinFrenchHealthCare.”JournalofPublicAffairs17(3).

Skirbekk,V.,Ottersen,T.,Hamavid,H.,Sadat,N.,andDieleman,J.L.2017.“VastMajorityofDevelopmentAssistanceforHealthFundsTargetThoseBelowAgeSixty.”HealthAffairs36(5):926-930.

Sousa,A.,Dal,M.andCarvalho,C.2012.“Monitoringinequalitiesinthehealthworkforce:thecasestudyofBrazil1991-2005”PLoSOne.7(3):e33399.doi:10.1371/journal.pone.0033399.

Speybroeck, N., G. Paraje, A. Prasad, P. Goovaerts, S. Ebener, D.B. Evans, 2012. "Inequalityindicators of access to human resources for health: measurement issues", GeographicalAnalysis,44(2):151-161,2012.

Steele,C.A.2017.“PublicGoodsandDonorPriorities:ThePoliticalEconomyofDevelopmentAidforInfectiousDiseaseControl.”ForeignPolicyAnalysisp.orx002.

Stewart,E.A.,Greer,S.L.,Wilson,I.,andDonnelly,P.D.2016.“PowertothePeople?AnInternationalReviewofTheDemocratizingEffectsofDirectElectionstoHealthcareOrganizations.”TheInternationalJournalofHealthPlanningandManagement31(2).

Summers,L.2018.“Taxesforhealth:Evidenceclearstheair.”CommentaryinTheLancetTaskforceonNCDsandeconomics.

UnitedNations.2018.“TheSustainableDevelopmentGoals:17GoalstoTransformOurWorld.”http://www.un.org/sustainabledevelopment/sustainable-development-goals

Urquieta-Salomon,JandVillarreal,H.2016.“EvolutionofhealthcoverageinMexico:evidenceofprogressandchallengesintheMexicanhealthsystem.”HealthPolicyandPlanning31,28-36doi10.1093/heapol/czv015

VanDoorslaer,E.andO’Donnell,O.2011.“MeasurementandExplanationofInequalityinHealthandHealthCareinLow-IncomeSettings.InHealthInequalityandDevelopment.London:PalgraveMacmillan.

VanMinh,H.,Phuong,N.T.K.,Saksena,P.,James,C.D.,andXu,K.2013.“FinancialBurdenofHouseholdOut-of-PocketHealthExpenditureinVietNam:FindingsfromtheNationalLivingStandardSurvey2002–2010.”SocialScienceandMedicine96:258-263.

Vassall,A.,Shotton,J.,Reshetnyk,O.K.,Hasanaj-Goossens,L.,Weil,O.,Vohra,J.,Timmermans,N.,Vinyals,L.,andAndre,F.2014.“TrackingAidFlowsforDevelopmentAssistanceforHealth.”GlobalHealthAction7(1):23510.

Verbist,G.andFigari,F.2014.“TheRedistributiveEffectandProgressivityofTaxesRevisited:AnInternationalComparisonAcrosstheEuropeanUnion.”FinanzArchiv:PublicFinanceAnalysis70(3):405-429.

Victora,C.G.,Wagstaff,A.,Schellenberg,J.A.,Gwatkin,D.,Claeson,M.andHabicht,J.P.,2003.Applyinganequitylenstochildhealthandmortality:moreofthesameisnotenough.TheLancet,362(9379),pp.233-241.

Victora,C.G.,Barros,A.J.,França,G.V.,daSilva,I.C.,Carvajal-Velez,L.andAmouzou,A.,2017.Thecontributionofpoorandruralpopulationstonationaltrendsinreproductive,maternal,newborn,andchildhealthcoverage:analysesofcross-sectionalsurveysfrom64countries.TheLancetGlobalHealth,5(4),pp.e402-e407.

Wagstaff,A.andVanDoorslaer,E.,2000.Equityinhealthcarefinanceanddelivery.Handbookofhealtheconomics,1,pp.1803-1862.

Wagstaff,A.,O'Donnell,O.,VanDoorslaer,E.andLindelow,M.,2007.Analyzinghealthequityusinghouseholdsurveydata:aguidetotechniquesandtheirimplementation.WorldBankPublications.

Wagstaff,A.,2008.Measuringfinancialprotectioninhealth(Vol.4554).WorldBankPublications.

Wagstaff,A.andEozenou,P.,2014.CATAmeetsIMPOV:aunifiedapproachtomeasuringfinancialprotectioninhealth[PolicyResearchWorkingPaperSeries:6861].WashingtonDC:TheWorldBank

Wagstaff,A.andLindelow,M.,2014.Arehealthshocksdifferent?EvidencefromamultishocksurveyinLaos.Healtheconomics,23(6),pp.706-718.

Wagstaff,A.,Bredenkamp,C.andBuisman,L.R.,2014.Progressonglobalhealthgoals:arethepoorbeingleftbehind?.TheWorldBankResearchObserver,29(2),pp.137-162.–healthoutcomes;coverage.

Wagstaff,A.,Flores,G.,Smitz,M.F.,Hsu,J.,Chepynoga,K.andEozenou,P.,2017a.Progressonimpoverishinghealthspendingin122countries:aretrospectiveobservationalstudy.TheLancetGlobalHealth.

Wagstaff,A.,Flores,G.,Hsu,J.,Smitz,M.F.,Chepynoga,K.,Buisman,L.R.,vanWilgenburg,K.andEozenou,P.,2017b.Progressoncatastrophichealthspendingin133countries:aretrospectiveobservationalstudy.TheLancetGlobalHealth.

WorldBank.2012.“Mexico’sSocialProtectionSysteminHealthandtheFinancialProtectionofCitizenswithoutSocialSecurity”.WashingtonDC

WorldHealthOrganization.2010.“TheWorldHealthReport2010:HealthSystemsFinancing,thePathtoUniversalCoverage.”Geneva:WHO.

WorldHealthOrganization.2014.Makingfairchoicesonthepathtouniversalhealthcoverage.FinalreportoftheWHOConsultativeGrouponEquityandUniversalHealthCoverage,WHO,Geneva.http://www.who.int/choice/documents/making_fair_choices/en/

WorldHealthOrganizationandtheInternationalBankforReconstructionandDevelopment.2017.“Trackinguniversalhealthcoverage:2017globalmonitoringreport.”TheWorldBank,WashingtonDC.

WorldBank.NigeriaHealthFinancingSystemAssessment-WorldBankDiscussionpaper(forthcoming).WorldBank:Washington,DC

Wong,K.L.,Restrepo-Méndez,M.C.,Barros,A.J.andVictora,C.G.,2017.Socioeconomicinequalitiesinskilledbirthattendanceandchildstuntinginselectedlowandmiddleincomecountries:Wealthquintilesordeciles?.PloSone,12(5),p.e0174823.

Woo,J.,Bova,E.,Kinda,T.,andZhang,Y.S.2017.“DistributionalConsequencesofFiscalAdjustments:WhatDotheDataSay?”IMFEconomicReview,pages1-35.

Xu, K., Evans, D.B., Kawabata, K., Zeramdini, R., Klavus, J. andMurray, C.J., 2003. Householdcatastrophichealthexpenditure:amulticountryanalysis.Thelancet,362(9378),pp.111-117.

Xu, K., Evans, D.B., Kawabata, K., Zeramdini, R., Klavus, J. andMurray, C.J., 2003. Householdcatastrophichealthexpenditure:amulticountryanalysis.Thelancet,362(9378),pp.111-117.

Xu,K.,Evans,D.,Carrin,G.,Aguilar-RiverA.M.,Musgrove,T.,andEvans,T.2007.“ProtectingHouseholdsfromCatastrophicHealthSpending.”HealthAffairs26(4).

Yamin,A.E.,2008.Sufferingandpowerlessness:thesignificanceofpromotingparticipationinrights-basedapproachestohealth.HealthandHumanRights,11:5-22.

Yamin,A.E.2010.“TowardTransformativeAccountability:ApplyingRights-BasedApproachtoFulfillMaternalHealthObligations.”SUR-InternationalJournalonHumanRights,12:95.

Yamin,A.E.2017.«TakingtheRighttoHealthSeriously:ImplicationsforHealthSystems,Courts,andAchievingUniversalHealthCoverage.”HumanRightsQuarterly39(2):.341-368.

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