thinking about equity in health financing: a...

ThirdAnnualUHCFinancingForumGreaterEquityforBetterHealthandFinancialProtection

ThinkingaboutEquityinHealthFinancing:AFramework

ApaperpreparedtoinformdevelopmentofthediscussionpaperfortheForum

Washington,D.C.April20-21,2018

Thispaperisnotforquotation.ItwillbefurtherdevelopedaftertheForumtotakeaccountofthediscussion.Writtencommentsarealsowelcome.PleasesendtoKentRansonatmranson@worldbank.org

TableofContents

Summary,......................................................................................................................................................2

Section1:Introduction.................................................................................................................................4

Section2:PrinciplesofEquityandFairnessinHealthFinancing..................................................................5

Section3:HealthFinancingSystems............................................................................................................9

Section4:InequalitiesandInequitiesAssociatedwithHealthFinancing...................................................12

UHCOutcomes........................................................................................................................................12

RevenueGeneration/Mobilization.........................................................................................................13

Pooling....................................................................................................................................................16

Purchasing..............................................................................................................................................18

Summary.................................................................................................................................................19

Section4:UnacceptableTrade-offs............................................................................................................21

Section5:AccountabilityandFairnessofProcess......................................................................................24

Section6:TrackingProgress.......................................................................................................................27

Section7:SomeGlobalConsiderations......................................................................................................29

Section8:ApplyingtheFramework............................................................................................................30

Countries.................................................................................................................................................30

TheGlobalCommunity...........................................................................................................................30

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Summary1

KeyMessages

1. Healthfinancingpolicy,withitscomponentsofrevenuegeneration,poolingandpurchasing,hasmultipleobjectivesinadditiontoequity,someofwhichmightconflictwiththeequityobjective.Differentviewsofsocialjusticelegitimatelyinfluencetheweightpeopleandcountriesdecidetogivetoequityinanygivendecision.

2. UniversalHealthCoverage(UHC)offersthepromiseofequity-allpeoplereceiveaffordablehealthservices,orgoodquality,accordingtoneed.However,onthepathtoUHC,inequalitiespersistandsomehealthfinancingpolicychoicescanmakethemworseandtoooftenhealthfinancingpoliciesaredevelopedwithoutathoroughconsiderationoftheconsequencesonequity.

3. BasedlargelyontheprinciplesofUHC,thefollowingcriteriaweredevelopedtoguidedecisionsaboutwhichoftheinequalitiesinhealthoutcomes,andthoseassociatedwitheachfinancingfunction,areunfair,andthereforeinequitable:a. Benefits:Coverageofhealthservices,ofgoodquality,shouldbeaccordingtoneed.Onthepath

toUHC,priorityisgiventocoverthosewiththegreatesthealthneeds;b. Burden:Financialcontributionsshouldbede-linkedfromserviceuseandbasedonabilitytopay.

Aspartofthis,peopleshouldbeprotectedfromfinancialhardshipassociatedwithOOPs.OnthepathtoUHC,priorityisgiventofinanciallyprotectingpeoplewiththeleastabilitytopay.

4. Afterconsideringtherangeofotherpossibleobjectivesofhealthfinancingpolicy,asetofpolicyoptionsthatareregardedasunacceptablebecausetheyfurtherexacerbateinequitiesisderived–reproducedbelow.

TenUnacceptableTrade-offsLinkedtoHealthFinancingPolicies

Financingcontributionstothesystem:

Itisunacceptableto:

1. Increase out of pocket payments (OOPs) for universally guaranteed personal health services without an exemption system2 or compensating mechanisms

2. Raise additional revenues for health in ways that make contributions to the public financing system less progressive without compensatory measures that ensure that the post-tax, post-transfer final income distribution is not more unequal

3. Raise additional revenues for universally guaranteed personal health services through voluntary, prepaid and pooled financing arrangements based largely on health status, including pre-existing conditions and risk factors

Benefitsfromthesystem:

4. Change per capita allocations (of domestic general government revenue or donor funds) across prepaid and pooled financing schemes that worsen inequities, unless justified by differences in need or the availability of funds from other sources3.

5. Within financing schemes, change per capita allocations from higher to lower 1ThisnotedrawsonpresentationsmadebyChristophKurowskiandAmandaGlassman,aswellastheensuingdiscussion,atameetinginEquityofFinancingUHC,Oslo,7-8September2017.2Proofthatthesesystemsandmechanismsiscritical.3Thisincludeschangestorequirementsforcounterpartfundingtakingdomesticresourcesfromrelativelyunder-fundedareastothosethatarerelativelywellfunded.

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autonomous, administrative units, that worsen inequities, unless justified by differences in need or the availability of funds from other sources

6. Within schemes or pools, change allocations of funds across diseases that worsen inequities, unless justified by differences in need or the availability of funds from other sources

7. Introduce high cost, low benefit interventions to a universally guaranteed service package before close to full coverage with low cost, high benefit services is achieved

8. Increase the availability and quality of personal health services that are universally guaranteed in ways that exacerbate existing inequalities unless justified by differences in need

9. Increase the availability and quality of core public health functions in ways that exacerbate existing inequalities unless justified by differences in need

10. Expand the availability and quality of key inputs to produce a universally guaranteed set of personal health services in ways that exacerbate existing inequalities unless justified by differences in need

5. Countriescanfollowaprocessofidentifyingtheirownunacceptabletrade-offsforfinancingpolicy

basedontheirowninequitiesandviewofsocialjustice,perhapsusingthetrade-offsdevelopedhere.Theprocessrequiresthreeworkstreams:a. Makingequityconcernsfundamentaltoallhealthfinancingpolicydebates.Thiswillenable

countriestoidentifyandredresscurrentinequalitiesandtoavoidinadvertentlyexacerbatingexistinginequitiesastheymoveforward;

b. Developingasystemofprocessfairnessandaccountabilityinhealthfinancingsothatthepublictruststhewaydecisionsaremadeandisinvolvedinthem,recognizingthattherewillnotbeuniversalagreementabouttheoutcomes;

c. Trackprogressinawaythattheimpactonequitycanbeevaluatedregularly.Thisrequiresdatadisaggregatedbythesocioeconomiccharacteristicsimportanttoacountry,butmostcommonlybyincome/wealth,genderandplaceofresidence.

6. Theglobalcommunitycanhelptofacilitatethisby:systematicallyintroduceequityconsiderationsinallbi-andmulti-lateralengagementsonhealthfinancingpolicywhileassessingtheequityimplicationsoftheirfinancialsupporttothehealthsectortoavoidunacceptablechoices;usetheirfinancialandtechnicalsupporttobuildcountrycapacitiesandinstitutionstoimplementtherecommendedapproach;continuetodevelopthetools,methodsandapproachesessentialtocarryoutthecountryworkstreamsandprovidethemasglobalpublicgoods.

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Section1:Introduction

Thispaperproposesaframeworkforthinkingaboutequityinhealthfinancing.TheframeworkaimstoguidehealthfinancingpolicydecisionsonthepathtowardUniversalHealthCoverage(UHC)andreflects–inadditiontoconceptsofequityandfairness-thevaluesandprinciplesinherenttothisgloballyadoptedgoal(UnitedNations2018).UHCmeansthatallpeoplecanusethepromotive,preventive,curative,rehabilitativeandpalliativeservicestheyneed,withthequalityrequiredtobeeffective,whilealsoensuringthattheuseoftheseservicesdoesnotexposethemtofinancialhardship(WHO2010).

Theframeworkbuildsonalargebodyofworkexploringthemeaningofequityandfairnessinhealthfinancing,fiscalpolicy,andmorerecently,UHC(e.g.Wagstaff&VanDoorslaer2000;Murrayetal.2003;Xuetal.2007;O’Donnelletal.2008;VanDoorslaer&O’Donnell2011;Bastagli,Coady&Gupta2012;Ottersen&Norheim2014;WHO2014;Clements,Gaspar&Gupta2015;Mulenga&Ataguba2017;Fleurbaey&Maniquet2017;Wooetal.2017).Thetermsrelatetotheideathatcertaininequalitiesinboththefinancialburdenofcontributingtohealthsystemsandinthebenefitsderivedfromthemareinequitableandunfair.However,beyondthat,thereislittleconsensusontheboundariesandcontentofthetermsequityandfairnessandwhetherandhowtheyaredifferentso,followingtheWHOConsultativeGrouponMakingFairChoicesonthePathtoUHC,inthispaperthetermsareusedinterchangeably(WHO2014).

TheframeworkidentifiesasetofinequalitiesassociatedwithUHCthatareunfairandhealthfinancingpolicytrade-offsthatmightbeencounteredonthepathtowardsUHCthatareunacceptablefromanequitystandpointbecausetheywouldfurtherexacerbateexistinginequities.Thepaperdoessointhree-steps.Thefirstistodevelopasetofguidingprinciplesoffairnessinthedistributionofbenefitsreceivedfromhealthsystemsandthefinancialcontributionstothem(SectionB).Thesecondistoidentifyasetofinequalitiesassociatedwithhealthfinancingdecisions.Thethirdistousetheprinciplesoffairnesstodeterminewhichoftheseinequalitiescanbedeemedunfairor,inotherwords,thatconstituteinequities.BoththesecondandthirdstepareinSectionD,beforewhichisabriefdescriptionofthehealthfinancingsystemandtheassociateddecisionsthatcanreduce,orincrease,inequities.

SectionEthenrecognizesthatreducinginequitiesisonlyoneofthepossibleobjectivesofhealthfinancingpolicy.Sometrade-offsbetweenequityandotherpolicyobjectivescannotberejectedunilaterallyonfairnessgroundsbecausetheyrepresentdifferentviewsabouttheappropriateweighttobegiventoeachobjective.Ontheotherhand,thereareasetofpolicychoicesonthepathtoUHCthatareunacceptableinthattheyriskexacerbatingexistinginequities,presentedhereasunacceptabletrade-offs.

Thepaperthenmovesintotherelatedquestionsoffairnessofprocessasacomplementtofairnessinoutcomes(SectionF)andtheneedtobeabletotrackprogressifequityonthepathtoUHCistobeimproved(SectionG).SectionHsuggestshowcountriesmightapplytheframeworkfortheirowndecision-making.Thefinalsection,SectionI,complementstheframeworkthatwasdevelopedfromacountryperspectivewithsomeequityconsiderationsforhealthfinancingfromaglobalperspectiveincludingconsiderationsoffaircontributionstohealthacrosscountries.

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Section2:PrinciplesofEquityandFairnessinHealthFinancing

Considerationsaboutwhatisequitableinthedistributionofthefinancialburdenofcontributingtothehealthsystemandinthebenefitsderivedfromitvarywithperceptionsofsocialjustice.Thetwomostcommoninthedebateabouthealthfinancingareprobablytheegalitarianandthelibertarianviewpoints(e.g.WagstaffandvanDoorslaer2000).4Theegalitarianviewsuggestspredominantpublicfinancingwithhealthservicesdistributedaccordingtoneedandfinancialcontributionsaccordingtotheabilitytopay.Coveragewithhealthservicesisdecoupledfromthefinancialcontributions.

Theextremeofthelibertarianviewisthathealthservicesareprivatelyfinancedandpeoplereceivethemaccordingtotheirabilityandwillingnesstopay.Anytransferstothepooraredependentonindividualactsofcharity.Alessextremeversion,sometimescalledsufficientarianliberalism,maintainspredominantprivatefinancingbutwithlimitedpublicinvolvementthatensuresasafetynetforthepoor.Thissafetynetallowsthemtoobtainasufficientstandardoflivingincludingalevelofhealthservicecoverage.

4Awidevarietyofotherapproachestosocialjusticealsoexist.Thesearesimplythetwomostcommoninthecurrentdebatesabouthealthfinancingpolicy.

Box1:PrinciplesofFairnessKEYMESSAGES

§ UHCholdsthepromiseofequity-allpeoplereceiveaffordablehealthservices,orgoodquality,accordingtoneed-butwithtwomajorcaveats:1. First,formanycountriesUHCisadistantfutureandtheprinciplesinherentinUHCprovidelittle

guidancehowtochartanequitablepathtowardsthatgoal.Whilethereisgeneralconsensusaboutgivingprioritytotheworseoff,theextentvariesaccordingtoviewsofsocialjustice.Moreover,apolicyobjectiveofreducinginequityassociatedwithhealthfinancingdecisionscanconflictwithothersocialobjectivessuchasincreasingemploymentorimprovingefficiencywhereviewsofsocialjusticealsoinfluencetherelativeweightpeopleorcountriesdecidetogivetoequity.

2. Second,whileUHCisclearaboutequityinthedistributionofhealthbenefits,whenitcomestohowmuchpeopleshouldcontributefinanciallyitfocusesexclusivelyonequityinprotectionfromfinancialhardshiplinkedtotheneedtomakeout-of-pocketpayments(OOPs)forhealthservices.Itissilentaboutothersourcesoffinancingforhealthsuchasinsurancepremiumsandtaxes.TheconcernwithfinancialhardshipduetoOOPsimplicitlysuggests,however,amandateforprepaidandpooledfinancingwithcontributionsaccordingtoabilitytopay.

§ Accordingly,thefollowingprinciplesareusedtoguidehealthfinancingpolicychoices:o Benefits:Coverageofhealthservices,ofgoodquality,shouldbeaccordingtoneed.Onthepath

toUHC,priorityisgiventocoverthosewiththegreatesthealthneeds.o Burden:Financialcontributionsshouldbede-linkedfromserviceuseandbasedonabilitytopay.

Aspartofthis,peopleshouldbeprotectedfromfinancialhardshipassociatedwithOOPs.OnthepathtoUHC,priorityisgiventofinanciallyprotectingpeoplewiththeleastabilitytopay.

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Underthisformoflibertarianism,theinvolvementofgovernmentfinanceforsafetynetsimpliessomedecouplingoffinancialcontributionsfromtherighttoserviceutilizationthoughnotasmuchasintheegalitarianview:thepoorcannotpay,orcannotpayfullyfortheservicestheyneed,andtherestofsocietyneedstofinanceasufficientsetofservicesforthem.Beyondthat,however,marketforcesrule.

Thereissomedebateaboutthemetriconwhichanyconcernwithequityshouldfocus–perhapshealthoutcomes,theuseofservices,usegivenneed,orsomeconceptofaccesstoneededservices.HerewedrawontheprinciplesinherentintheconceptofUHCwhichimpliesthatthefocusshouldbeonequityinaffordablecoveragewithneededservices.Onthebenefitside,theUHCconceptclearlyreflectstheegalitarianprincipleofdistributionofhealthservicesaccordingtoneed:andtheconcernisnotonlywithcoverageoftheseservices,butalsotheireffectivenessasakeydimensionoftheirquality–withthetwodimensionscommonlycapturedbytheconceptofeffectivecoverage.5

Theprincipleofdistributionofservicesbasedonneedhasimplicationsontheburdensideaswell:mostimportantly,thatrevenuegenerationsystemsinvolvingoutofpocketpayments(OOPs)shouldnotdeterpeoplewhocannotaffordthemfromusinghealthservices.However,inotherwaystherelationshipbetweentheUHCconceptandegalitarianprinciplesislessexplicitandnotasstraightforwardontheburdenside.UHCcallssimplyforprotectionfromfinancialhardshipbecauseoftheneedtopayout-of-pocket.Financialhardshipfromout-of-pocketpayments(OOPs)hastwowidelyaccepteddefinitions:first,OOPsthatpushpeopleintopovertyordeeperintopoverty,andsecond,OOPsthathavecatastrophic,butnotnecessarilyimpoverishingeffectsonhouseholds.Examplesofcatastrophiceffectsincludeforegoneconsumptionofessentialgoodsandservices-suchaseducation,clothing,housing,food,severedepletionofassetsorexcessiveborrowingtomeethealthcarecosts.UHC,therefore,impliesthatnooneshouldsufferfinancialhardshipfromoutofpocketpayments–implyingequityinaffordablecoveragewithneededservices-butitissilentonquestionsofequityinotherfinancialcontributionstothesystemsuchastaxesandinsurancepremiums.

ThepracticalapplicationofUHCprinciples,however,hasfoundthatmovingawayfromOOPstoprotectpeoplefromfinancialhardshiphingesonfinancingarrangementsconsistentwithequalitarianviewpoints.Protectionfromfinancialhardshiprequiresdecouplingfinancialcontributionsfromserviceutilization-giventhepotentiallylargedirectcostsofhealthproductsandservices,notonlyforthepoor,butmostincomegroups.Whiledecouplingisinprinciplepossiblethroughanyformorprepaymentandpooling,thishasonlybeenachievedatscale–i.e.coveringtheentirepopulation-throughcompulsoryprepaidandpooledfinancing.6Givenmanyofthepoorwillnotbeabletocontributefinancially,inpracticethismeanslinkingfinancialcontributionstoabilitytopayinsomeway.7

Formostcountries,UHCremainsadistantfutureandfewcountriescanafforduniversalcoveragewithallhealthinterventionsthatcanprolonglifeorimproveitsqualitywhileensuringfinancialprotectionfor5TheacceptanceofUHCasagoalofhealthsystemdevelopmentdoesnot,however,automaticallyimplypeopleareegalitarian–forexample,theymightsimplythinkUHCisgoodforeconomicgrowthorforpeaceandsecurity.6Compulsoryprepaymentincludestaxesandothergovernmentcharges,someofwhichareusedtofinancehealthservices.ItalsoincludescompulsoryinsurancecontributionsasinmostEuropeansystems,paideitherbyindividualsand/ortheiremployers.7ThereissomedebateaboutwhetherattainingtheUHCoutcomeoffinancialprotectionshouldgobeyondOOPsandincludeprotectionfromfinancialhardshipduetoothercostsassociatedwithserviceutilization,suchastransportationfeesoropportunitycostsoftime,whichincludeslossesofincome.ThishasnottraditionallybeenincludedintheconceptofUHC,soisnotdiscussedfurther.

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all.ThisraisesthequestionofequityonthepathtowardUHC.TheconceptofUHCimpliesequalityinaffordablecoveragewithneededservicesinthelongrun,aswehaveseen,butitissilentontheroleofequityonthepathtoUHC.Thegeneralconceptsofequityandfairnesssuggestthatsomeprioritybegiventotheworse-offintermsofbothneedandabilitytopay–i.e.peoplewhoarethesickestandthosethatarepoor.Indeed,thisisalsoconsistentwiththesufficientarianviewofprovidingsufficienthealthservicesforthepoor,however,withthecaveatthatUHCobligesgovernmentstoprogressivelymovetowardthefullrealizationofUHCoutcomes(Baltussenetal.2017).Drawingontheconceptsofequity,fairnessandthevaluesandprinciplesinherenttotheconceptofUHC,theWHOConsultativeGrouponMakingFairChoicesonthePathtoUHCproposedasetofprinciplestodetermineinequalitiesandpolicychoicesthatareunfair(WHO2014;Ottersen&Norheim2014).Basedontheearlierarguments,thesearerefinedas:

1. Benefits:Effectivecoverageofservicesisaccordingtoneed.OnthepathtoUHC,priorityisgiventocoverthosewiththegreatesthealthneeds.

2. Burden:Financialcontributionsarebasedontheabilitytopayandindependentofserviceuse.OnthepathtoUHC,priorityisgiventocover(undersuchfinancingarrangements)thosewiththeleastabilitytopay.

Theseprinciplesarealsoconsistentwiththeideaofprogressiveuniversalismwhicharguesthat,onthepathtoUHC,thepoorestshouldbenefitatleastasmuchastherich(Gwatkin&Ergo2011;Gwatkin2014;Jamisonetal.2013).Itisimportanttorecognizethattheseprinciplesarenotabsoluteandrequiretrade-offswithsocialobjectivesotherthanequityandfairness,asdiscussedsubsequently.Atthesametime,theseprinciplesleaveroomforinterpretation.Forexample,faircontributionbasedonabilitytopaymightbeinterpretedasfaircontributionsforallhealthfundingfromanegalitarianperspective,orforthefundingrequiredtocoveronlytheessentialhealthneedsofthepoorfromasufficientarianperspective.8Theprincipleofcontributionsaccordingtoabilitytopaycanbeinterpretedthattherichpaymorethanthepoor,orthattherichpayahigherproportionoftheirincomesthanthepoor–typicallydefinedasprogressivecontributions.9Andevenwhenthisquestionissettled,perceptionsabouthowmuchmoretherichshouldpaywillvary.

Moreover,theseparationofprinciplesforbenefitsandburdenmayalsorequiretrade-offs.Shouldcountriesgiveprioritytoexpandingtherangeofqualityservicesavailableforthosewiththegreatesthealthneeds,orexpandingfinancialprotectiontothosewiththeleastabilitytopay?Orshouldtheydoamixofthetwo–ifso,whatweightshouldbegiventoeachcomponent?Andevenwithineachcomponent,policy-makerswillfaceadditionaltrade-offs:forexample,intermsofbenefits,whethertoincreasecoverageorimprovethequalityofavailableservices.AnswersrequireanassessmentnotonlyoftheextenttowhichpolicyoptionswilladvanceprogresstowardUHCattheaggregatelevel,thatis,acrossthevariousdimensionsandoutcomesofUHC,butalsohowthesealternativeswillreduceinequalitiesdeemedunfair.

8TheConsultativeGroupinterpreteditasfaircontributionstoanessentialpackagethatwouldbeguaranteedtoeveryone,andthenexpandedovertimeasmoreresourcesbecomeavailable.9Inthetaxationliterature,thetermprogressivehasbeenusedtodescribewheretheshareoftotalincomecontributedriseswithincome.Regressiveistheopposite.However,sometimesthetermsareusedtomeanthatthepoorpaymorethantherichinabsolute,notnecessarilyproportionalterms.Inthispaperweusetheterminitsstrictsense.

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Theseparationbetweenbenefitsandburdenalsocontrastswithsomerecentworkthatseekstoassesswhethergovernmentfiscalpoliciesoverall–including,butnotrestrictedtohealth–improveequity.Thefocusofthatworkhasbeenontheimpactoffiscalpolicyon“final”income:thedistributionofpre-taxgrossincomeiscomparedwiththedistributionofpost-taxfinalhouseholdincome(e.g.Lustigetal.2013;Lustig2016,2017,2018;Jellemaetal.2017).Finalincomesubtractsouttaxes,socialsecuritycontributionsandchargesfromgrossincomeandaddsinbenefitseachhouseholdreceivesincashorkindfromthegovernment(e.g.sicknessorunemploymentbenefits,childallowances,theuseofsubsidizedhealthoreducationservices)10.Fiscalpolicieswherethepoorhaveagreatershareoffinalincomethangrossincomeareconsideredfairerthanthosethatdonotachievethistypeofredistribution.

Thisconceptoffairnessfocusesonthenetimpactoffiscalpolicyonindividualsandgroupsofindividuals–paymentsminusbenefits.Theservicesreceivedinkindarevaluedattheircostofprovisionindependentofanyassessmentoftheextenttowhichpeopleneededtousetheservices.TheconceptofUHCisdifferent,however,onthebenefitside.Itaskswhetherpeoplewhoneedtousehealthservicesreceivethem,atgoodquality.Use,contingentonneeds,iscriticaltotheideaofUHC,sowemaintaintheseparationofburdenandbenefitsasthebasisforourassessmentoffairnessinhealthfinancing,drawingonprinciples1and2above.

10Thereisnoagreementonwhetherpensionsshouldbeincludedhere,oraspartofthepre-taxgrossincome.Lustigetal.dothecalculationsbothways.

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Section3:HealthFinancingSystems

Healthfinancingarrangementsinfluencetheabilityofhealthsystemstoensurethatservicespeopleneedareavailable,ofqualityandaffordable:theessenceofUHC.Healthfinancingsystemstypicallyconnectawiderangeofhealthsystemactorsthroughacomplexnetworkoffundflows(Rechel,Thomson,andVanGinneken2010).Thesystemdesignandperformancedependonchoicesinthreeinter-linkedhealthfinancingfunctions–generatingormobilizingthenecessaryfinancialresources,poolingthemtospreadfinancialrisksassociatedwithillness,andusingthemtopurchaseorprovidehealthservices(Gottret&Schieber,2006)(WHO,2010)(McIntyre&Kutzin,2016).Purchasingcanbedividedintotwocomponents:whattopurchaseandhowtopurchase(Box2).

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Ineachofthesehealthfinancingfunctions,decisionsimpactonequityandfairness.Therearethreeimportantconsiderationstobearinmind.

First,theabilityofthehealthfinancingsystemtotransformtherevenuesraisedintoneededhealthservices,ofquality,withfinancialprotection,dependsonacomplexinterplaybetweenthediversedecisionsmadeaboutresourcegeneration,poolingandpurchasing.Eachindividualdecisionmatters,butitisthecombinationofdecisionsthatiscrucialforUHC.

Second,rapidprogresstowardsUHCandthemaintenanceofpastgainsrequiresabroadsetofhealthsystemactionsinadditiontothoserelatedtohealthfinancing.Amongothers,theseincludeactivitiesto

Box2:HealthFinancingFunctions

Revenuegeneration/mobilizationinvolvesraisingthefinancialresourcesneededtodevelopandrunahealthsystem.Contributionstypicallycomefromindividuals/households,firms,andsometimesexternalsourcesintheformofdevelopmentassistanceforhealth(DAH).Somecontributionsarehealth-specific,andsomegointogeneralgovernmentrevenueatdifferentlevelsofthegovernmentsystem,partofwhichis,inturn,allocatedtofinancehealth.

Poolingrequiresdecisionsaboutwhetherandhowfinancialcontributionstothehealthsystemarespreadacrossindividualstoreducethefinancialriskassociatedwithunexpectedillnessandmedicalexpenses.Out-of-pocketpayments(OOPs)areoneextreme,whereindividualsorhouseholdspaydirectly(entirelyorpartly)fortheservicestheyobtain.ThereisnorisksharingwithOOPs:thepeoplewhouseservicesmustpaythecost.Theendofthespectrumisinsystemswheregovernmentsfundthebulkofhealthservicesthroughgeneralgovernmentrevenues,whichcanbeheldbynationaland/orsub-nationallevelsofgovernment.Insystemswithsocialhealthinsurance,therecanbemultiplepoolsifdifferentpopulationgroupsarecoveredfromdifferentfundsoriffundscompete(e.g.Switzerland,theNetherlands),orasinglesocialhealthinsurancefund.Inthecaseofmultiplefunds,governmentsfrequentlytransferresourcesacrossthepoolsasaformof“riskequalization,"inordertoensurethatfundscoveringpeoplewithadisproportionatelyhighriskofincurringlargecostsdonotsufferfinanciallycomparedtothosethatcoverdisproportionallylowriskpeople.Governmentrevenuestypicallyalsosupplementsocialhealthinsurancepool(s).

Purchasingrequiresdecisionsabouthowtheavailablefundsshouldbeusedtopurchase1(orprovide)healthservices–personalservices(prevention,promotion,treatment,rehabilitation,palliation)andessentialpublichealthfunctionslikepopulation-basedpromotionandprevention,outbreakreadinessandresponse,andhealthsystemgovernance.Therearetwointer-relateddecisions:whattopurchaseandhowtopurchase.Thefirstinvolvesdecisionsaboutrationingandentitlements,includingwhatservicesshouldbeuniversallyavailableoravailabletopeoplecoveredbythepurchaser.Thesecondrequiresdecisionsabouthowtopayprovidersandsuppliersofinputsandservicestoencouragequalityandefficiency.

1. Theterm“purchase”isusedheretocapturethepurchaseofservicesortheinputsthatareusedto

provideservices.

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ensurethereare:sufficient,motivatedhealthworkers;goodqualityhealthinfrastructure;arangeofqualityhealthservices;essentialmedicinesandothermedicalproductsavailablewhentheyareneeded;healthworkers,infrastructure,medicinesandmedicalproductsareavailablewheretheyareneeded;strongleadershipandgovernance;andinformationthatisbothrelevantandtimelyenoughtoinfluencedecisions.

Third,thesocioeconomicconditionsinacountry,andactionstakeninothersectorstoaddressthem,influencehowfeasibleitistocollectrevenuesforhealth,tospreadriskandtopurchaseneededservices.Forexample,raisingincometaxesincountrieswhereahighproportionofthepopulationworksintheinformalsectororpeoplearepoormaynotachievethedesiredresults.Strategiestoincreasetherateofformalizationortoreducepovertyareimportanttoimproverevenuegeneration,buttheyarebeyondthecontrolofthehealthsector.

Forthesereasons,theremainderofthispaperusestheterm“inequalitiesassociatedwithhealthfinancing”ratherthan“healthfinancinginequalities”.Moreover,theframeworkconsidershealthsysteminequalities,aslongasthereisaclearlinkwithhealthfinancing-eveniftheyarealsoinfluencedbyotherpartsofthehealthsystem,othersectorsandunderlyingsocioeconomicdeterminants.UHCasakeyoutcomeisoneexampleofthis.Theavailabilityofresources,thenatureofpoolinganddecisionsmadeaboutwhattopurchaseclearlyimpactontheextentofcoveragewithneededservices,theirqualityandaffordability,buttherearemanyotherdeterminantsaswell.Theframework,however,doesnotextendthefocustoconsideringinequalitiesbeyondUHCtohealthoutcomes,wheredirectlinkswithhealthfinancingaremoredifficulttotrace.

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Section4:InequalitiesandInequitiesAssociatedwithHealthFinancing

Thissectionpresentstypesofinequalitiesassociatedwithhealthfinancing,thenappliestheprinciplesdevelopedinsectionBtodeliberateaboutwhichinequalitiescanbearedeemedunfair.ThesectionstartswithinequalitiesinUHCoutcomesbeforeexploringinequalitiesassociatedwithdecisionsmadeinthethreehealthfinancingfunctions-revenuemobilization,poolingandpurchasing-thatimpactoninequalitiesinUHCoutcomes.

Tounderstandinequalities,itisimportanttospecifyunitsofanalysis.Onthebenefitsside,inequalityanalysistypicallyfocusesonindividuals/householdsorgroupsofpeople–forexample,groupsofindividualsbyincome,gender,geographicregion,ethnicorigin,affiliationwithpoolingarrangements,legalstatusofresidency,andhealthproblem/diseasetype.Onthecontributionside,inequalitiesrelatetofirmsaswellasindividuals/households,asdiscussedsubsequently.

UHCOutcomes

Typesofinequalities

ThetwoUHCoutcomesareeffectivecoverageofneededhealthservicesandprotectionfromfinancialhardship.Theunitsofanalysisforconsideringinequalitiesintheseoutcomesareindividuals/householdsorgroupsofindividuals/households.

Effectivecoverageofhealthservicesrequiresthatpeoplenotonlyobtainthehealthservicestheyneed,butthattheservicesareofsufficientqualitytobeeffective.Protectionfromfinancialhardshipmeansfirstandforemostprotectionfrombeingpushedintopovertyfromout-of-pocketpayments(OOPs)forhealthproductsandservicesbutalsoprotectionfromneedingtoreallocatebudgetsfromothernecessitiestopayforhealthservices.

Thefollowinginequalitiescanbeobserved:

• Differencesacrosspeopleorgroupsineffectivecoveragewithhealthservicesofalltypes(personalhealthservices,publichealth(includingnon-personalhealthservices)andgovernancefunctions.11Forexample,thepoororpeopleinruralareastypicallyobtainamorelimitedrangeofservices,frequentlyoflowerquality,thantherichorpeopleinurbanareas.

• Somepeopleorgroupsarepushedintopovertyorfurtherintopovertyduetoout-of-pocketpayments(OOPs)forhealthservices. TheincidenceofimpoverishingOOPsistypicallymuchhigheramongthenear-poorthanrichergroups.

• DifferencesacrosspeopleorgroupsintheincidenceorextentofcatastrophicOOPsforhealthservices.Thiscanoccurforanumberofreasons:variationintheneedtousehealthservices;differencesinthewayuserchargesarelevied(e.g.whenwomenandchildrenareexemptedfromsomeuserfeesbutnotmen);orhouseholdswithparticularcharacteristics(e.g.thoseheadedbywomen)havelowercapacitytopaythanthoseofotherhouseholds.

Inequalitiesdeemedunfair11TherehasbeensomedebateaboutwhethertheconceptofUHCincludespublichealthandnon-personalhealthservices(Ottersen&Schmidt2017).Wearguethatitdoes.Thefactthattherearerarelyco-paymentsorchargesfortheseservicessimplymeansthereisnofinancialcatastropheorimpoverishmentassociatedwiththem,andeffectivecoverageismoreimportantinthiscasethanfinancialprotection.

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Healthypeopledonotneedtousecurativehealthservices,sodifferencesincoveragewithhealthservicesareonlyunfairiftheydonotreflectdifferencesinneed.Ontheotherhand,equalityincoveragecanbeunfairiftherearedifferencesinneed.SoTable1defineswhendifferencesinservicecoverageareunfair.

IntermsofOOPs,thereissomecontroversyaboutwhenfinancialcatastropheisunfair.Themajorpointofcontentionrelatestocountries,SriLankaforexample,wherericherpeoplechoosetooptoutofusingtheservicesthatareuniversallyavailablefrompublicfunds.If,indoingso,theyincurhealthexpendituresdeemedtobecatastrophic,shouldthisbeconsideredunfair?Thereisnouniversalagreement,soasacompromise,theframeworkproposedhereconsiderscatastrophicOOPsasunfairwhentheyoccurduetolackofaccesstoservicesguaranteedundercompulsoryprepaidandpooledfinancingarrangementsorbecausepeopleneedtopayOOPfortheseguaranteedservices.

ThelogiccanalsobeextendedtoimpoverishingOOPspayments.Wheretheyareincurredbecausepeoplecannotgetaccesstoservicesthataretheoreticallyguaranteed,orbecausetheypayOOPforthoseservices,isimpoverishmentduetoOOPsconsideredhereasunfair.Allinequities(unfairinequalities)inUHCoutcomesaresummarizedinTable1.

Table 1. Inequities in UHC Outcomes

1. Differencesintheeffectivecoverageofhealthservices(includingnon-personalhealthservices)andgovernancefunctionsunlessjustifiedbydifferencesinhealthneeds.12

2. Nodifferencesineffectivecoverageofhealthserviceswhentherearedifferencesinhealthneeds.13

3. Somepeopleorgroupsarepushedintopoverty,ordeeperintopovertyduetoOOPsbecauseoflackofaccessto,orinusingservicesguaranteedbycompulsoryprepaidandpooledfinancingarrangements.

4. DifferencesacrosspeopleandgroupsintheincidenceorextentofcatastrophicOOPsbecauseoflackofaccessto,orinusingservicesguaranteedbycompulsoryprepaidandpooledfinancingarrangements.

Thenextsub-sectionsconsiderinequalitieslinkedtodecisionsinthethreehealthfinancingfunctionsthatcanimpactinequalitiesinUHCoutcomes.

RevenueGeneration/Mobilization

Typesofinequalities

Therearefiveprinciplesourcesofdomesticfinancing:

• Taxesandchargesthatarenothealth-specificandwhichflowintogeneralgovernmentrevenuesatcentralorsub-nationallevel;

• Health-specifictaxesandcharges,mostcommonlycompulsorysocialhealthinsurancecontributions,butincludingalsoanytaxesandchargesthatareearmarkedforhealth,suchasthoseontobaccooralcoholproductsormobilephoneuse;14

12Horizontalequity13Verticalequity

14

• Governmentborrowing,whetherhealthornothealthspecific,wherefuturegenerationshavetopayforservicesthatareenjoyedbypeoplelivingtoday;

• Voluntaryhealthinsurancepremiums;

• Out-of-pocketpayments,whetherasformsofcost-sharingorforservicesnotcoveredatallfromanyofthesourcesabove.

Developmentassistanceforhealth(DAH)isnotconsideredinthissectiononinequityinfinancialcontributions,giventhattheseinequitiesaremoreglobalthandomestic.DAHthoughisdiscussedasasourceofdomesticinequalitiesinwhobenefitsfromtheavailablefunds,inthesectionsonpoolingandpurchasing,whiletheinternationalperspectiveonDAHisconsideredthefinalsectionofthepaper.

Withrevenuegeneration,individualsorhouseholdsarenottheonlyeconomicagents.Firmsalsocontribute:theypaytaxesandchargesthatarenothealth-specific,sometimescontributetosocialhealthinsuranceonbehalfofemployees,subsidizevoluntaryhealthinsuranceorpaydirectlyforhealthservicesforstaff.15Thepublicfinanceliteraturedoesnotconsiderfirmsseparatelytoindividualsforequityanalysisonthegroundsthatfirmspayincomestoindividuals(employees,shareholders)sothat,intheend,itistheoverallinequalityacrossindividualsthatiscritical.Governmentssimplychoosetotaxfirmsforconvenience.

Whileweacceptthelogic,weproposetobesomewhathereticalbycontinuingtoconsiderfirmsseparately.Thepublicdebatefrequentlyfocusesonwhetherfirmspaysufficienttaxescomparedtoindividuals,andwhethersomefirmsaretreatedmorefavourablythanothers–forexample,theThirdInternationalConferenceonFinancingforDevelopment,heldinAddisAbabainAugust2015toheraldthebeginningoftheSDGera,affirmedthatcountrieswouldseekto“ensuretransparencyinallfinancialtransactionsbetweengovernmentsandcompaniestorelevanttaxauthorities.Wewillmakesurethatallcompanies,includingmultinationals,paytaxestothegovernmentsofcountrieswhereeconomicactivityoccursandvalueiscreated…”(AddisAbabaActionAgenda,2015,paragraph23).Accordingly,forthisdocumentthemaintypesofinequalitiesacrosssourcesoffundingare:

• DifferencesacrosspeopleandgroupsintheincidenceofOOPsforhealthservices

• Differencesacrosspeopleandgroupsinnetcontributionstothepublicfinancesystem(including,butnotlimitedtohealth)16

• Differencesacrossfirmsintheirnetcontributionstothepublicfinancesystem,perhapsbecauseoftaxholidaysorexemptionsfrompayingsocialinsurancecontributions.Firmmayalso“transfer”profitstopartofthefirmthatisresidentinacountrywithalow-taxregime.

• Differencesacrossindividualsorgroupsincontributionstovoluntaryprepaidandpooledfinancingarrangements.

Inequalitiesdeemedunfair

14Taxesonproductsharmfultohealtharenotalwayshypothecatedforhealthinwhichcasetheyfallintotypea.15Somesourcesoffinance,suchassovereignwealthfundsandstateenterprises,contributetogovernmentrevenuesundera)above,butdonotlendthemselvestotheanalysisofinequalitiesincontributionsacrosseitherhouseholdsorfirms.Inequalitiesinwhobenefitsfromallgovernmentrevenuesarediscussedinsubsequentsections.16Netcontributionsaregrosscontributionsminustransfersreceivedincashorkind

15

Turningnowtotheissueofwhichoftheseinequalitiescanbeconsideredunfair,asdiscussedintheprevioussectionthereisbroadagreementthatunaffordableout-of-pocketpaymentsforservicesinaguaranteedpackageareunfair,whethertheypreventsomepeoplefromusinghealthserviceswhentheyneedthem,orpushsomewhousethemintopoverty,deeperintopovertyorresultinfinancialcatastrophe.

Anumberofdifferentviewpointsarepossiblewhenitcomestowhatisunfairintermsofothertypesoffinancialcontributions.Contributionstohealthareonlyonepartofthetotalfinancialcontributionofhouseholdsandfirmstogovernmentfinances.Oneviewisthatitisthefairnessoftheoverallcontributionthatcountsratherthanthefairnessofeachcomponent–onepart,sayhealthfinancing,couldbeveryprogressivetobalanceregressivelyinanotherpart,sayinfinancingeducation.17Oronemethodofraisingfundsmightberegressive(perhapsVAT)butisoffsetbyprogressivitywithotherinstruments(e.g.incometax).Eventhen,governmentscanbalanceoutanyunfairnessinfinancialcontributionsbyensuringthatthepoorandvulnerablereceivefiscaltransfersfromthefundsthatareraisedtocompensate,sofairnessisdeterminedbythewaythatnetcontributions(cashcontributionsminustransfersincashandkind)aredistributedacrossthepopulation.

Analternativeviewisthatinequalitiesinhealthfinancing,orinacomponentofitsuchassocialhealthinsurancecontributions,areimportantbecausetheycanmaketheentiresystemevenlessfair.Forthispaper,weleantowardsthefirstinterpretationandarguethatgovernmentsneedtotrade-offanumberofobjectiveswhenchoosinginstrumentsforraisingrevenues.Theyincludethepossibleyield(howmuchisraised)andthecostsofcollectionandenforcement,aswellasquestionsoffairness.Governmentscanbalancetheseobjectivesacrossinstruments,andbyusingtheproceedstocompensate,soitistheoverallfinancingsystemthatmustbethefocusfordecisionsaboutfairness.Forthisreason,wedonotconsiderSHIcontributionsthatareregressive-therichdonotpayahigherproportionoftheirincomesthanthepooroftenbecausecontributionsarecapped-asnecessarilyunfair.Fiscalpolicycancompensatethepoorforthisinequalityinotherways.

Thequestionofinter-firmfairnessincontributionshasnotmuchdiscussedinthehealthfinancingliterature,noristhequestionofthefairdivisionoffinancingburdenbetweenhouseholdsandfirms.Wesuggestthatthisisanoversightatleastintermsofthewayvotersthink,andthatitispossibletousetheprincipleofpaymentaccordingtocapacitytopayoutlinedearliertocategorizeatleastonetypeofinequalityrelatingtofirmsasunfair.Inter-temporalunfairnessbetweengenerations,whengovernmentsorhouseholdsborrowtofundtheirexpenditures,includingforhealth,hasonlyjuststartedtobediscussedinrelationtohealthfinancing(e.g.Daniels2011).Itis,inanycase,broaderthanhealth.Itisnowbeingactivelyconsideredinthepublicfinanceliteratureandwillnotbediscussedfurtherhere(e.g.Kotlikoff2018).

Intermsofprivateinsurance,therearedebatesaboutwhetheritisunfairthatsomepeoplecanafforditandotherscannot.Herewefocusoninsurancethatchargesdifferentpremiumsaccordingtoriskprofilesorpre-existingconditions.ThisiscontrarytotheprincipleofseparatingoutpaymentsfromtheneedtousehealthservicesoutlinedinsectionB,soisunfair.

17Forexample,valueaddedtaxesaresometimesregressiveinthatthepoorpaythesameabsoluteamountastherich.However,itisfrequentlyeasiertoraisetaxesinthiswaysogovernmentsmightacceptsomeregressivityhereandcompensatebyadditionalprogressivityinincomeorcompanytaxes.

16

ThesuggestionsforthetypeofinequalitiesinrevenuegenerationthatareunfairaresummarizedinTable2.TheybuildontheprincipleofSectionBthatpeopleshouldcontributeaccordingtotheircapacitytopay,butwiththeprovisothathealthfinancingisonlypartofthefiscalsystem.

Table 2. Inequities associated with revenue generation/mobilization

1. Somepeopleorgroupsarepushedintopoverty,ordeeperintopovertyduetoOOPsbecauseoflackofaccessorinusingqualityservicesguaranteedbycompulsoryprepaidandpooledfinancingarrangements(alsopartofTable1,butacomponentofrevenuegeneration).

2. DifferencesacrosspeopleandgroupsintheincidenceorextentofcatastrophicOOPsbecauseoflackofaccessorinusingqualityservicesguaranteedbycompulsoryprepaidandpooledfinancingarrangements(alsopartofTable1).

3. DifferencesacrosspeopleandgroupsintheincidenceofOOPsthatdeterthemfromusingqualityservicesguaranteedbycompulsoryprepaidandpooledfinancingarrangements(implicitinTable1).

4. Revenuegenerationsystemswithdifferencesacrosspeopleandgroupsinnetcontributionstothepublicfinancesystem(including,butnotlimitedtohealth)whichmakethepost-tax,post-transferfinalincomedistributionlessequalthanthepre-taxdistribution

5. Revenuegenerationsystemswithdifferencesacrossfirmsintheirnetcontributionstothepublicfinancesystemsthatcannotbejustifiedbysomecompensatingbenefitfortheeconomy

6. Differencesacrossindividualorgroupsincontributionstovoluntaryprepaidandpooledfinancingarrangementsbasedlargelyonhealthstatus,includingpre-existingconditionsandriskfactors.

Eventhoughothertypesofinequalityassociatedwithrevenuemobilizationdonotfeatureinthesetofinequities–e.g.thequestionofwhetheraVATisprogressiveorregressive–itisstillimportantforpolicy-makerstounderstandthenatureofinequalitiesassociatedwitheachofthedifferentrevenuegenerationinstruments.Thisallowsgovernmentstoconsiderhowbesttobalanceoutthetrade-offsbetweenthedifferentobjectives–raisingsufficientrevenue,limitingthecostsofcollectionandenforcement,andensuringfairness–ortoredressotherinequalitiesinrevenuegeneration.

Pooling

Typesofinequalities

Theimpactofpoolingonserviceuseandfinancialprotectionisthetopicofasubsequentsection.Thefocushereisoninequalitiesineligibilityorabilitytobenefitfrompooledfundsandtheamountofpooledfundingavailableperperson.

Healthfinancingsystemsoftentendtobehighlyfragmentedintodifferentpoolsthroughvariousmechanismsincluding:governmentpoolsfinancedfromconsolidatedrevenues,withlowerlevelsofgovernmentreceivingtransfersfromhigherlevelsandsometimesalsoraisinglocaltaxesandotherrevenues;differenttypesofsocialhealthinsuranceschemes;andprivatehealthinsurance.Inlow-andmiddle-incomecountries,community-basedhealthinsuranceisincludedinprivateinsurancebecauseofitsvoluntarynature,eventhoughitmightstillbenefitfromgovernmentsubsidies.DAHisalsoasourceofpooledfundsinmanycountries,whetherpassingthroughgovernmentbudgetsoradministeredseparately.

17

Differenttypesofpoolingarrangementscanleadtodifferenttypesofinequalities.Somepoolsmightoffer“better”coveragethanothersbecausetheyhavemoremoneyperpersonadjustedforneed.Somepeoplemaysimplynotbenefitfromanytypeoffinancialprotectionfrompoolingeitherbecausetheyarenoteligibleorfaceotherbarrierstotheirparticipations,whileothersareeligibletobenefitfrommultiplepools.

Therangeofinequalitiescanbesummarizedas:

• Differencesineligibilityacrosspeopleandgroupstoparticipateinanypoolordifferencesineligibilityacrosspeopleandgroupstoparticipateinparticularpools

• Differencesacrosspeopleandgroupsinenrolmentwithprivatehealthinsuranceincludinginsuranceforservicesnotguaranteedbycompulsoryprepaidandpooledfinancingarrangements

• Differencesinpercapitaallocations(ofdomesticgeneralgovernmentrevenueordonorfunds)toprepaidandpooledhealthfinancingschemes(includingpubliclyfundedhealthservices,socialhealthinsurance,voluntaryinsurance)18

• Withinfinancingschemes,differencesinpercapitaallocationsfromhighertolowerautonomous,administrativeunits

• Withinschemesorpools,differencesinallocationsoffundsacrossdiseases.


TherelevantequityprinciplefromsectionBisthateffectivecoverageofhealthservicesshouldbeaccordingtoneed,andthatonthepathtoUHC,priorityisgiventocoverpeoplewiththegreatestneeds.Inaddition,allpeopleshouldbeprotectionfromfinancialhardshipassociatedwithOOPs,withthepoorgivenpriority.Thisrequiresequalityineligibilitytobecoveredfrompooledfunds,andintheamountofpooledfundingavailableperperson,unlessdifferencescanbejustifiedbydifferencesineitherhealthorfinancialneed.19Table3accountsfordifferencesinneedwhenderivingthetypesofinequalitiesinpoolingthatcanbeconsideredunfair.

18Healthcarefinancingschemesarethemaintypesoffinancingarrangementsthroughwhichhealthservicesarepaidforandobtainedbypeople.HerewerefertopooledschemesratherthantoOOPs,includingnationalorsub-nationalhealthservicesfundedfromgovernmentrevenues(sometimeswithdonorfundsaswell),socialhealthinsurance,voluntaryinsurance(OECD2011).19Poolingarrangementsallowforverticalequityacrossthepeoplecoveredbythepool–peoplewhoaresick,forexample,usepooledfundsandthosewhoarehealthydonotneedto.Thisallowsthoseingreatestneedtogetthemostbenefit.

18

Table 3. Inequities Associated with Pooling

1. Ineligibilityofpeopleandgroupstoparticipateinanypoolordifferencesineligibilityacrosspeopleandgroupstoparticipateinspecificpoolsunlessjustifiedbydifferencesinneed20

2. Differencesacrosspeopleandgroupsinenrolmentwithprivatehealthinsuranceincludinginsuranceforservicesnotguaranteedbycompulsoryprepaidandpooledfinancingarrangementsunlessjustifiedbydifferencesinneed

3. Differencesinpercapitaallocations(ofdomesticgeneralgovernmentrevenueordonorfunds)acrossprepaidandpooledschemesunitsunlessjustifiedbydifferencesinneedortheavailabilityoffundsfromothersources

4. Withinfinancingschemes,differencesinpercapitaallocationsfromhighertolowerautonomous,administrativeunitsunlessjustifiedbydifferencesinneedortheavailabilityoffundsfromothersources

5. Withinschemesorpools,differencesinallocationsoffundsacrossdiseasesthatarenotjustifiedbydifferencesinneedortheavailabilityoffundsfromothersources

Notalloftheunfairinequalitiescanbeaddressedbythehealthfinancingsystemalone.Forexample,theaffordabilityofprivatehealthinsuranceismediatedbyincomeinequalitiesinsocietywhilethetargetingofDAHisrarelydecidedentirelybythehostcountry.Aswithrevenuegeneration,someoftheinequitiesassociatedwithhealthfinancingarebroaderthanthehealthfinancingsystemandrequireactionselsewhere.

Purchasing

Typesofinequalities

Asdescribedearlier,purchasingreferstodecisionsmadeaboutwhattopurchaseandhowtopayfortheservicesorinputsthatarepurchased(orprovided).InequalitiesincoveragewithneededserviceswasdiscussedintheearliersectiononinequalitiesinUHCoutcomes.Themostobviousformofinequalityinpurchasingisassociatedwithdifferencesintherangeofservicespurchasedfrompooledfundsofthevarioustypes,sothereisadirectlinktothediscussionofinequalitiesinpoolingintheprevioussection.However,someisalsolinkedtotheavailabilityandqualityofservicesthatcanbepurchasedout-of-pocket.

Mostattentionhasbeenfocusedoninequalitiesintheavailabilityof,andaccessto,personalhealthservices(personalprevention,treatment,rehabilitation,palliation),butinequalitiesinthebroaderpublichealthfunctions,includingnon-personalhealthservicesalsoexist.

Theinequalitiesassociatedwiththepurchasingfunctionaresummarizedbelow:

• Differencesinentitlementsofguaranteedservicepackages,implicitorexplicit,acrosspeopleandgroups.Entitlementsreflecttheservicesandlevelsoffinancialprotectiontowhichpeopleareentitleddejure.WhetherpeoplereceivetheseentitlementsdefactowasconsideredaninequityinUHCoutcomesearlier(Table1);

20Differencesinneedincludebothhealthandincome.Thosewithlowerhealthneedmorehealthservices,andthosethatarepoorarelessabletopayforneededhealthservices.

19

• Differencesacrosspeopleorgroupsintheavailabilityandqualityofpersonalhealthservices.Availabilitymeansherethatservicesexistandpeoplecanusethem.Thisincludesdifferencesacrossdiseasesintheavailabilityandqualityofserviceswhensomearewellfundedfromdonorfundsandothersarechronicallyunderfunded;

• Differencesacrosspeopleandgroupsintheavailabilityandqualityofcorepublichealthfunctions21,forexample,population-basedhealthpromotion,surveillance,outbreakcontrol;

• Differencesacrosspeopleorgroupsintheavailabilityofkeyservicesinputs,forexample,healthworkers,equipment,medicines,andinfrastructure.


Aswiththepoolingfunction,thefairnessprincipleofcoveragewithhealthservicesaccordingtoneedisusedtodeterminewhichoftheinequalitiesareunfairwhereneedincludesthehealthneedsandtheneedforfinancialprotection.Inequalitiesintheavailabilityofhealthservicesareonlyunfairifthepopulationscoveredhaveequalneed,forexample.Equalityintheavailabilityofservicesisonlyfairifpeoplehavethesameneeds.Table4suggestshowfairnesscanbebroughtintothediscussionabouttheseinequalities.

Table 4. Inequities Associated with Purchasing

1. Differencesinentitlementsofguaranteedservicepackagesacrosspeopleandgroupsunlessjustifiedbydifferencesinneed

2. Differencesacrosspeoplesandgroupsintheavailabilityandqualityofuniversallyguaranteedpersonalhealthservicesunlessjustifiedbydifferencesinneed.

3. Differencesacrosspeopleandgroupsintheavailabilityandqualityofcorepublichealthfunctionsunlessjustifiedbyneed

4. Differencesacrosspeopleorgroupsintheavailabilityofkeyinputstoproduceauniversallyguaranteedsetofpersonalhealthservicesunlessjustifiedbydifferencesinneed

Again,thefactthataninequalityisjudgedtobeunfairdoesnotmeanthatitiseasytoredressit.Forexample,despitedecadesofexperiments,itisverydifficulttoattractandkeephighlytrainedhealthprovidersinruralareas.Comparedtoacounterfactualofhavingnoprovidersatall,communityhealthworkersmightbeanimportantimprovement.Itdoesnot,however,detractfromthefactthatsomepeopleareservedlargelybyrelativelyuntrainedcommunityhealthworkersandothersbybettertrainedpeople,somethingthatisunfair.Overtime,itwouldbedesirabletoincreasetherangeofskillsandservicesavailabletothepopulationlivinginruralareastoredressthisinequity.

Summary

21Essentialpublichealthfunctions,servicesoroperationsareusuallydefinedtoincludeallactivitiesrelatingtohealthexceptthedeliveryofpersonalhealthservices.Thenamesfortheelementsincludeddiffer,butcanbesummarizedas:healthgovernance(e.g.developingandenforcinglaws,assuringquality,raisingfunds,developingtheworkforce,organizationalstructuresandcompetences),organizationanddeliveryofnon-personalhealthservicessuchaspopulationpreventionandhealthpromotion,monitoringandevaluation,healthprotectionincludingoccupationalandfoodsafety,outbreakresponseandcontrol,monitoringandevaluation,andpublichealthresearch-see,forexample,CDC2018,WHO2017,WHO2018.

20

ThisstepbystepsummaryoftheinequalitiesthatcanbeobservedinUHCoutcomes,thenthoserelatedtothethreehealthfinancingfunctionsofresourcegeneration,poolingandpurchasing,isusefulforunderstandingthenatureofhealthfinancinginequitiesbutissomewhatartificialfromapolicyperspective.Policydecisionsareofteninterlinked–forexample,thedecisionaboutwhowillbecoveredbyanewformofsocialhealthinsurance(pooling)israrelymadeindependentlyofthedecisionaboutwhatservicesshouldbecovered.Thequestionofwhatservicesshouldbecoveredrequiresconsiderationofthedepthofcoveragetobeoffered–i.e.whatproportionofthecostswillbecoveredbythehealthinsurance.

Itisalsoimportanttonotethatsomeoftheotherinequalitiesthathavebeenidentifiedarenotnecessarilydeemedtobeuniversallyunfairbasedontheprinciplesdevelopedearlier.Theyshould,however,bequantifiedandunderstoodtohelpinthepolicyprocess.ReducinginequalityassociatedwithSHImight,forexample,beanoptionforincreasingtheequityofcontributionstotheoverallfiscalsystem,evenifitisnotpossibletoarguethatinequalityinSHIcontributionsis,byitself,unfair.

TheyentiresetofinequalitiesandinequitiesisreproducedintheAnnexalongwiththeassociatedunacceptablepolicychoicesandtrade-offs.

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Section4:UnacceptableTrade-offs

Thefactthataninequalityisdesignatedasunfairisonlythefirststep.Governmentshavedifferentobjectiveswhendevelopingpolicy,andreducinginequityisonlyone.Thetrade-offsbetweenobjectivesareslightlydifferentforrevenuegenerationthanfordecisionsaboutpoolingandpurchasingmadesubsequently.

Forrevenuegeneration,governmentsthinkabouttheyieldofvariousrevenuecollectioninstruments,theircostsofadministration,collectionandenforcement,andthepoliticalconstraintstotheiracceptanceandimplementationinadditiontotheequityimplications.Asarguedearlier,theymaywellintroduceanewtaxbecauseitwillhaveahighyieldwithlowtransactioncosts,evenifitissomewhatregressive.Anybiasagainstthepoorandvulnerablecouldfirst,beminimized,andsecond,beoffsetbyhowtheadditionalrevenueisused.

Anotherexamplerelatestotaxesonproductsharmfultohealth.Themainroleforthesetaxesistoimprovehealthratherthantogenerateresourcesforincomeredistributioneventhoughtheysometimesraisesubstantialrevenuesaswell.Regressivityinfinancialcontributions,likelyinthecaseoftobaccoproductsforexample,isoffsetbythegreatesthealthbenefitsaccruingtothepoor(whousetobaccoproductsmorethantherich)andcanbefurtheroffsetbydecisionsabouthowtousetherevenuesofthisandothertaxesinwaysthatbenefitthepoor(Summers2018).

Governmentsmightalsogivetaxholidaysorexemptsomefirmsfrompayingsocialsecuritycontributionstoattractthemtoinvest,andprovideemployment,inthecountry.Theobviousunfairnessthatintroducesinthecontributionsofdifferentfirms,theymightfeel,iscompensatedbytheprovisionofadditionalincome-earningopportunitiestothepopulation.

Forpoolingandpurchasing,governmentsalsohavemultipleobjectives.Theyseektoincreaseaggregatelevelsofcoveragewithneededhealthservicesandfinancialprotection,encourageefficiencyandqualityamongproviders,bepreparedforpossiblefuturehealthemergencies,andreduceinequalitiesincoverage.Theseobjectivescansometimescompete.Forexample,ensuringthatisolatedcommunitieshaveaccesstoneededhealthservicescanbemoreexpensiveperpersoncoveredthanincreasingserviceavailabilityinmorepopulatedareas.

TheWHOConsultativeGrouprecognizedthatdifferentsocietieswilllegitimatelymakethistypeoftrade-offindifferentways,butneverthelesssoughttoidentifyifthereareanytrade-offsitfeltwereinacceptablebasedontheprinciplesoffairnesstheyhaddeveloped.

Oneunacceptabletrade-offwaslinkedtorevenuegeneration.Itconsideredthequestionofwhatgovernmentsshoulddotoreplacerevenueslostthroughtheabolitionorreductioninuser-chargesasastrategytoimprovefinancialprotectionandremovebarrierstoaccessingservices.Thistrade-offwas:

1. ItisunacceptabletoreduceOOPsandincreaseprepaymentinawaythatmakesoverallhealthfinancinglessprogressive.

Theotherunacceptabletrade-offstheGroupproposedwererelatedtohowtodefineandthenexpandapackageofhealthservicesguaranteedtoallpeoplethroughaprocessthatwasseentobeprocedurallyfair.Inthis,itwouldbeunacceptableto:

22

2. Expandcoverageforlowormediumpriorityservicesbeforeclosetofullcoveragewithhighpriorityservicesisachieved.

3. Providehigh-cost,low-healthbenefitinterventionsbecausetheyprotectpeoplefinancially,whenlow-cost,highhealth-benefitinterventionshavenotbeenfullyimplemented.

4. Expandmoreservicestothewell-offbeforethepoorarecoveredforthedefinedessentialservices.

Forthispaper,wearguethatthethirdproposalisapplicableprobablyonlyattheextreme.Inchoosingaguaranteedpackageofbenefits,itislikelythatdecision-makersandthepopulationwouldbewillingtotrade-offsomedecreaseinpopulationhealthlevelsforincreasedfinancialprotection.WehavealsoexpandedconsiderationofthefairnessofrevenuemobilizationbeyondonlythequestionofOOPsconsideredbytheConsultativeGroup.Accordingly,wemodifyandexpandtheseproposalstoalargersetofproposedunacceptabletrade-offsforbroaderhealthfinancingpolicydevelopment(Table5).TheyarereproducedinAnnex1inatablethatbuildsupfromtheidentifiedinequalities,totheassociatedinequities,andthentotheunacceptabletrade-offsassociatedwiththem.

Table 5. Unacceptable trade-offs linked to health financing policies

Contributionstothesystem:

Itisunacceptableto:

1. Increase OOPs for universally guaranteed personal health services without an exemption system22 or compensating mechanisms

2. Raise additional revenues for health in ways that make contributions to the public financing system less progressive without compensatory measures that ensure that the post-tax, post-transfer final income distribution is not more unequal

3. Raise additional revenues for universally guaranteed personal health services through voluntary, prepaid and pooled financing arrangements based largely on health status, including pre-existing conditions and risk factors

Benefitsfromthesystem:

4. Change per capita allocations (of domestic general government revenue or donor funds) across prepaid and pooled financing schemes that worsen inequities, unless justified by differences in need or the availability of funds from other sources23.

5. Within financing schemes, change per capita allocations from higher to lower autonomous, administrative units, that worsen inequities, unless justified by differences in need or the availability of funds from other sources

6. Within schemes or pools, change allocations of funds across diseases that worsen inequities, unless justified by differences in need or the availability of funds from other sources

7. Introduce high cost, low benefit interventions to a universally guaranteed service package before close to full coverage with low cost, high benefit services is achieved

8. Increase the availability and quality of personal health services that are universally guaranteed in ways that exacerbate existing inequalities unless justified by differences in need

22Proofthatthesesystemsandmechanismsiscritical.23Thisincludeschangestorequirementsforcounterpartfundingtakingdomesticresourcesfromrelativelyunder-fundedareastothosethatarerelativelywellfunded.

23

9. Increase the availability and quality of core public health functions in ways that exacerbate existing inequalities unless justified by differences in need

10. Expand the availability and quality of key inputs to produce a universally guaranteed set of personal health services in ways that exacerbate existing inequalities unless justified by differences in need

Thesepropositionsareausefulstartingpointtothinkaboutthedevelopmentofhealthfinancingpoliciesinwaysthatexplicitlyaddressinequityandunacceptabletrade-offs.

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Section5:AccountabilityandFairnessofProcess

Theprevioussectionarguedthatpeoplecanreasonablydisagreeabouttherelativevaluetogivetothedifferentpolicyobjectiveslinkedtoeachdecisionandhowtheyshouldbebalanced,partlyreflectingdifferentviewsofsocialjustice(WHO2014).Recognizingthis,agrowingbodyofliteraturesuggeststhatkeypolicydecisionsshouldbemadethroughaprocessthatallpeopleseeaslegitimate.OneexampleistheAccountabilityforReasonablenessframeworkwhichhasbeenappliedlargelytodecisionsaboutwhichhealthservicesshouldbemadeavailablefortheavailablepooledfunds–i.e.therationingpartofthepurchasingfunction(Daniels2000;Daniels2008;DanielsandSabin2008;Daniels2016;WHO2014;Petricca&Bekele2017).Undertheframework,fourconditionscontributetothelegitimacyoftheprocessofchoosinginterventions.

1. Publicity: Details of decisions made on how to ration health resources need to be readily available to the public, along with the justification for those decisions – e.g. why a new technology or medicine was, or was not, accepted for public subsidy;

2. Relevance: The organization or authority making the decision about the use of scarce resources must provide a reasonableexplanation of the criteria it uses to make decisions that provide “value for money” in meeting the varied health needs of the population for the resource constraints;

3. Revisionandappeals: Mechanisms for challenge and appeal need to be available with opportunities to modify decisions over time if new evidence becomes available;

4. Regulation: Formal rules are needed to ensure the first three conditions are fulfilled. Therelevanceconditionwasdevelopedbecause,whilefairmindedpeoplemayreasonablydisagreeontherelativeweightstogivetodifferentcriteriathatcouldbeusedinallocatingresources,theyshouldbeabletoagreeonthecriteriawhichneedtobeclearlyenunciatedandexplained.Theuseoftheterm“valueformoney”asacriterionintherelevancecondition,however,hasledtosomedebateaboutthewholeAccountabilityforReasonablenessframework:forexample,whetherthisbiasesthedecision-makingprocessinawaythatgivestoomuchweighttocost-effectivenessanalysisattheexpenseofequityconsiderations, and whether additional criteria (to cost-effectiveness and equity) need to be introduced as well to fully inform rationing decisions (e.g. WHO 2014; Baltussen et al. 2017; Badano 2018).

Despite this, theapproachhasbeenexploredinavarietyofpriority-settingenvironments,andafrequentrecommendationisthatsomeorganizationorbodyneedstobeestablishedtoensurefairnessintheprocessoftakingdecisionsaboutwhichhealthinterventionsandtechnologiesshouldbefundedfortheavailableresources.Forexample,theWHOConsultativeGrouparguedthatoneoptionwouldbetoestablisha“standingnationalcommitteeonprioritysettingtohandleparticularlydifficultcases”(WHO2014).

TheAccountabilityforReasonablenessapproachcanbeseenasresponsetothebroaderconceptofensuringgovernmentaccountability.Answerabilityandenforceabilityarefundamentaltoaccountability,underwhichindividualsandinstitutionsmakingdecisionsaffectingthepopulation’swellbeingmustprovideinformationaboutthedecisionstheymake,justifythem,andfacecensureorsanctionsforanymisconduct(Schedler1999;WHO2014).Themostcommonmotivationforwhyaccountabilityisrequiredderivesfromthehumanrightsframework,whichseestheStateasactingonbehalfofitscitizens(Yamin2000;Farmer2003).Policydecisionsthataffectpeople’srightsneedtobejustifiedtothepeopleaffectedbythemandsubjecttopublicscrutinythroughafairprocess,perhaps

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backedupbythejudiciary(Gruskin&Daniels2008;Rumboldetal.2017;Yamin2017).Informedpublicscrutinyinturnrequiresafunctioningmonitoringsystem,transparencyandaccesstoinformation,andmeaningfulpublicparticipationinprocesses(Yamin2008).Mostattentioninapplyingtheseprinciplestohealthhasfocussedonwaystoinvolvethepublicindecisionsbeforetheyaremade.Specificone-offdecisionshavebeendebatedbythepublicinconsensusconferences,townmeetings,orcitizen’sjuriesorpanels,forexample(Rowe&Frewer2005;Abelsonetal.2008;Mittonetal.2009;WHO2014).Civilsocietyinputstolongertermdecisionmakinghave,insomecountries,beenformalizedthroughrepresentationonbodiessuchashospitalboards,localgovernmenthealthauthorities,prioritysettingcommitteesorinstitutions,ortheboardsofhealthinsurancefunds(Sabik&Lie2008;Glassman&Chalkidou2008;Stewartetal.2016;Byskovetal.2017;Giedion&Guzman2017;Simonet2017).Theseprocessestendtohavebeenappliedtopurchasingdecisions:howtousetheavailablefunds.Furtherupstreaminthefinancingfunction,formsofparticipatorybudgetinghavealsobeendevelopedtoengagecitizensinformaldecisionsabouthowtoallocategovernmentbudgetsacrosscompetingneeds,insettingsasdiverseasBrazil,Cameroon,Europe,Peru,SriLankaandNewYorkCity(WHO2014;Kasdan&Markman2017).Thistypeofapproachcaninfluencehowmuchgovernmentmoneyisallocatedtohealth,forexample.Citizenengagementhas,however,beengenerallylimitedtobudgetdecisionsbylowerlevelsofgovernment–e.g.municipalities–andusuallyrestrictedtoarelativelysmallproportionofthebudget(Shapiro&Talmon2017).Thereisalsolimitedevidenceonitsimpact,eitherintermsoftheextentofpublicdebatethatthisfacilitatesortheoutcomesthatresultfromit(Campbell,Craig&Escobar2017).LessdirecthavebeeneffortsbycivilsocietyorganizationssuchastheAfricanHealthBudgetNetworktoinfluencegovernmentallocationstohealththroughadvocacyortoencourageAfricangovernmentstoadheretotheagreementmadeinAbujaDeclarationof2001toallocate15%oftheirbudgetstohealth(AfricaHealthBudgetNetwork2018).TheprinciplesbehindtheAccountabilityforReasonablenesscriteria,combinedwithaffordstoensurepublicdebateandinvolvement,couldbeappliedtoanyofthekeyhealthfinancingdecisionsaroundrevenuegeneration,poolingorpurchasing:publicinformationaboutthedecisionsthataremadeandtheirmotivation,thedirectinvolvementofthepublicinreachingdecisions,aprocessofappealandreviewandclearcriteriathatsetoutwhatfactorsshouldinfluencethedecisions.Criteriaforreasonablenesswoulddifferdependingonthequestion.Forexample,questionsrelatingtocontracting–whichhealthservicesorinputsshouldbepurchasedandatwhatprice–wouldneedtoconsiderfactorssuchasefficiency,thecostsofadministrationandenforcement,incentivesforquality,theriskoffraudetc.Theextenttowhichthepubliccouldfeasiblybeengagedineachtypeofdecisionwouldneedtobedeterminedonacase-by-casebasis,butbroadpublicdebatewouldbewarranted.Thequestionofoveralltaxpolicy-decisionsabouthowmuchtoraise,whoshouldcontributeandwhen–requires,perhaps,moreconsideration.Thesedecisionsareusuallymadeinparliaments,asrepresentativesoftheinterestsofcitizens.Changestotaxpolicyareusuallythesubjectofwidepublicdebate,aswellasdebateinparliament.Therewillbedifferentviewsaboutwhetherthisisasufficientprocesstoensureaccountabilityandfairnessinprocesses.Ontheonehand,itcouldbearguedthatthecostsofaddinganadditionallayerofcomplexitytore-enforceprocessfairnesscannotbejustifiedwhenthepurposeofaparliamentistorepresentthepeople.Ontheotherhand,itcouldbearguedthatinmanycountries,parliamentariansarerelativelywellremuneratedandamajoritycomefromthemoreaffluencepartsofsociety.Theyhaveaconflictofinterestwhenitcomestoraisingmoretaxesormaking

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ataxsystemmoreequal,sootherwaysofinfluencingthesedecisionsneedtobefound.Thisdebateandoptionsforre-enforcingaccountabilityinthisareawillbeexploredfurtherattheForum.

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Section6:TrackingProgress

FairdecisionsonthepathtoUHCcannotbemadeifpolicy-makersdonotknowwhomissesoutonneededservices,andwhosuffersseverefinancialhardshipbecausetheyhavetopayforthehealthservicestheyreceiveoutofpocket.Moreover,policymakerscannotadjusttheirpoliciesovertimeunlesstheyknowifthingsaregettingbetterorworse.Thisrequiresmeasuringlevelsandinequalitiesincoverageandtrackingprogressovertime.

ItalsorequiresdrillingdowntothecomponentsofthehealthfinancingsystemthatinfluenceinequalitiesinUHCoutcomes,describedearlier,toseeiftheinequitiesassociatedwithrevenuegeneration,poolingandpurchasingarebeingreduced.Inequitiesinthedistributionofhealthworkersandotherinputssuchasessentialmedicinesalsoneedtobemonitoredaspartofthepurchasingfunctionbecausetheyinfluencewhethertheservicespeopleneedareavailableclosetothem,andofgoodquality.

Accordingly,partoftheprocessofsupportingfairnessandequityonthepathtoUHCistoensurethenecessarydataareavailable,inatimelyfashion,thattheyareanalysedappropriatelyandtransmittedtopolicymakersinawaythattheycanunderstandandacton(seeHosseinpooretal2018).Partoffairnessofprocessistoalsoensurethatdataaresharedwiththepublicandotherstakeholdersinawaytheycandigest.

Thisrequiresachangeinthewaycountriesroutinelymonitorandevaluateprogressintheirhealthsystems,largelythroughroutinerecordsofattendanceandtreatmentathealthfacilities,supplementedbyothersourcessuchascancerregistriesthatvaryacrosscountriesinnumberandquality.Thisgenerallydoesnotprovideinformationonthebaseline–whoneedsservices–oronquality,oronfinancialprotection.

Regularcollectionofdisaggregateddatathatallowthehealthfinancing-relatedinequitiestobemeasuredandtrackedovertimeisoneimportantelementofbringingequityintohealthfinancingpolicymaking.Ataminimum,dataneedtobedisaggregatedbyincome/expenditure/wealth,genderandgeographicallocation(e.g.rural/urban).Countriescanaddonotherdeterminantsthatareimportanttothem,perhapsethnicity,agestructureoffamilies,typeofhealthproblem,dependingontheirproblemsandcapacities.

Methodsforundertakingtherequiredanalysisarealsocritical,butmanyhavealreadybeendeveloped.Forexample,thereisalonghistoryofidentifyinginequitiesinkeyhealthoutcomessuchasadult,maternalandchildmortality(e.g.Marmotetal1991;Mackenbacketal.1997;Gwatkin2000;Victora2003;Moseretal.2005;Barrosetal.2010;Bendavid2014;Wagstaff,Bredenkamp&Buisman2014;Gwatkin2017).Morerecentlyattentionhasmovedtodevelopingthetechniquestomeasureandanalyseprogressinincreasingcoverageandreducinginequalitiesincoveragewithcorehealthinterventions,largelyfocusedonthediseasesthatwerethetargetoftheMDGs(e.g.Raoetal.2014;Alkenbracketal.2015;Restrepo-Méndezetal.2016;Hoganetal.2017;WHO&WorldBank2017;Wongetal.2017;Victoraetal.2017).

TheincidenceoffinancialcatastropheandimpoverishmentduetoOOPs,andanunderstandingofwhichpeoplesufferthemost,hasalsobeenincreasinglydocumentedandanumberofmethodsfordoingthishavebeendeveloped(e.g.Xuetal.2003&2006;Wagstaff&Lindelow2014;Bredenkamp&Buisman

28

2016;Khan,Ahmed&Evans2017;Wagstaffetal.2017aandb;Ghimireetal.2018).Thereare,however,disagreementsaboutwhichofthemethodsisthemostappropriate,soasomestudiesreportresultsusingmultiplemethods(e.g.WHOandWorldBank2017).

Buildingonallthiswork,anoverallapproachtotrackingprogresstowardsUHCthattakesintoaccountthelevelsanddistributionacrosspopulationgroupsinservicecoverageandfinancialprotectionhasbeendeveloped,althoughitdoesnotdrilldowntothealloftheinequalitiesassociatedwiththehealthfinancingfunctionthatwereidentifiedearlier(e.g.Boermaetal.2014;WHOandWorldBank2017).Someofthesemethodshave,however,beendeveloped.Forexamplethoserelatingto:

• thequestionofwhetherfiscalpolicyispro-poor,takingintoaccounttheamountpeoplepayinandreceiveinthewayofsubsequenttransfersincashorkindfromthosefunds(e.g.Lustig2016&2017;Jellemaetal.2017;Lustig2018).

• inequalitiesintheavailabilityofservicesandinkeyinputssuchashealthworkers(e.g.O’Neilletal.2013;WHO2015;Speybroecketal.2012).

Toolstohelpcountryanalystsundertakethisworkarealsonowavailable.Methodologicalguidanceison:howtoestimatevariousindicatorsoftheabsenceoffinancialprotectionandinequalitiesinthem(Wagstaffetal.2007;Wagstaff2008;Saksena,Hsu&Evans2014;Wagstaff&Eozenou2014;WorldBank2018a)and;howtoanalyseinequalitiesinhealthoutcomesandinhealthservicecoverage(Hosseinpoor2016&2018;WorldBank2018a.)

TheWorldBankalsoprovidesatoolaspartofitsADePTResourceCenterthatcountryanalystscanusetouploadtheirhouseholdexpendituresurveydataandproducemostindicatorsofthelackoffinancialprotectionandinequalitiesinthem(WorldBank2018a).Approachestorapidlyassesstheavailabilityandreadinessofkeyhealthservices,whichcanalsobeusedtotrackgeographicinequalities,havebeendevelopedincludingtheServiceAvailabilityandReadinessTool(WHO2018b).

Finally,manyofthecurrentwaysofobtainingdata,particularlyforcoveragewithkeyservicesandwithfinancialprotection,requirerepresentativehouseholdsurveys.Theyaretimeconsumingandrelativelyexpensive.TheWorldBankhasdevelopedaSwiftSurveyapproachasalowcost,rapidwayofmeasuringincomesandtrackingprogressinreducingpoverty(WorldBank2018b).Approachessuchastheseofferhopeoflowercost,moretimelywaysofobtainingthenecessarydatafortrackingprogressinreducingthehealthfinancingassociatedinequitiesaswell.

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Section7:SomeGlobalConsiderations

Manylow-andlower-middleincomecountriesreceiveasubstantialshareoftheirhealthresourcesfromDAH,yettherearemanyinequalitiesinhowDAHisraisedandusedglobally.Forexample,thecontributionsofrichcountriesdiffersubstantially,bothpercapitaandasashareofgrossnationalincome(GNI).ThewayDAHischannelledalsofavourssomepeopleattheexpenseofothers:somemiddle-incomecountriesreceivesubstantiallymorepercapitathananumberoflow-incomecountries;morepopulouscountriesreceivelesspercapitathanlesspopulouscountries;whilemostDAHistargetedatyoungerratherthanolderpeople(Pietschmann2014;Vassalletal.2014;Martinsonetal.2017;Skirbekketal.2017).DAHhasalsobeenveryheavilyorientedtowardstheMDGconditionsofreproductive,maternal,neonatalandchildhealth,andasetofcommunicablediseases.HIV/AIDShasreceivedasubstantiallyhighersharethanwouldbeexpectedfromitsrelativediseaseburden(Chima&Franzini2015;Steele2017).

Morerecently,therehasbeenadebateaboutwhenitisappropriateforrecipientcountriestotransitionfromDAH,withsomeexternalfundersreducingoreliminatingfundingascountriesreachatargetlevelofnationalincomepercapita(Ottersenetal.2017).Atthesametime,themajorityoftheworld’spoornolongerlivesinlow-incomecountries,raisingethicalandpoliticalquestionsabouthowtheinternationalcommunityshouldreactifcountrieswhichhavethefinancialmeanstoimprovehealthamongtheirpoor,donot(Chaumontetal.2017;Ottersen,Moon&Røttingen2017).

Viewsaboutwhichoftheseinequalitiesareunfairrequireaviewofglobalsocialjusticeandhereviewsdivergeatleastasmuchasfordomestichealthfinancingpolicy.Wedonotseektotakeaviewinthispaperwhichhasfocusedlargelyoninequalityatthedomesticlevel,buttheglobalquestionsareimportant,controversial,andworthyoffurtherconsideration.

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Section8:ApplyingtheFramework

Countries

InthesearchforprogresstowardsUHC,aswellasinprotectinggainsmadeinthepast,countriescannotaffordtoconsideronlytheoverallpercentageofthepopulationcoveredwithqualityhealthservicesandfinancialprotection.Afirststepinapplyingtheframeworkistomakeequityconcernsfundamentaltoalltheirhealthfinancingpolicydebates.Thiswillenablethemtoidentifyandredresscurrentinequalitiesandtoavoidinadvertentlyexacerbatingexistinginequitiesastheymoveforward.

Giventhevariationinbeliefsaboutsocialjustice,countrieswillneedchartertheirownwaytakingintoaccountcurrentinequities,theinstitutionsgoverningtheirpolicy-makingprocessesandpublicpolicyprioritiesinadditiontoreducinginequity.Theywillneedtoidentifyunacceptablepolicychoicesortrade-offsalongthelinesdescribedinthisdocument,andcountriesmaywanttobuildonthesetproposedinthisreport.Inaddition,theywillneedtoidentifycriticalinequalitiesinfinancingUHCthatcontributetoinequalitiesinUHCoutcomes,buildconsensusonwhatisconsideredfairandunfair,anddeterminetheweighttheywanttoattachtoequitycomparedtootherpolicyobjectives.Somecountriesmightneedsupportinstrengtheningtheircapacitiestodothis.

Itisnotpossibletoensurethatnoonedisagreeswiththeresultingdecisions,butasecondstepistoensurefairprocessesfordecision-makingthatthepublictrusts.Fairprocessesrequireanengagedpubicawareofthecriteriathatareusedfordecision-making,whatdecisionsaremadeandwhy,andhowthiseffectstheirwellbeing.Italsorequiresadecisionappealsprocesseswithregularlyreviewsofprocedures,andaregulatoryorlegislativeframeworkthatsetstherulesofthegameforfairprocesses.

Fairprocessescanbeembeddedinstrongstructuresandprocessestoensurethegovernmentisaccountableforthehealthfinancingdecisionsthataremade.Accountabilityrequiresnotonlythattherearefairprocesses,butthatthedecisionsaffectingpublicwellbeingaretransparentandjustifiedwithsanctionsformisuseofpublicfundsandtrust.

Thethirdstepistoensurethereisawaytotrackprogressandmakeanynecessarypolicyadjustmentsrapidlyusingsomeofthetoolsandmethodsdescribedearlier.

Thethreestepsshouldbeundertakeninparallel.Theycomplementeachother,buteachhasavalueindependently.Forexample,fairprocessesbenefitfrommonitoringimpact,yetpoordatashouldnotbeanexcusetodelayeffortstostrengthenpublicinvolvementandthetransparencyandaccountabilityofhealthfinancingdecision-makingprocesses.

TheGlobalCommunity

Theglobalcommunitycanhelptofacilitatethisshift,alsoinathree-prongedapproach.Thefirstis,likecountries,tosystematicallyintroduceequityconsiderationsinallbi-andmulti-lateralengagementsonhealthfinancingpolicy.Thisallowsexternalpartnerstoassesstheequityimplicationsoftheirfinancialsupporttothehealthsectorandtoavoidunacceptablepolicychoices.Thesecondistousetheirfinancialandtechnicalsupporttobuildcountrycapacitiesandinstitutionstoapplythethreestepsdescribedabove.Thethirdistocontinuetodevelopthetools,methodsandapproachesessentialtocarryouttheseworkstreamsandprovidethemasglobalpublicgoods.Theglobalcommunitycanalsofurtherthebodyofevidenceofwhatworkstoreduceinequitiesassociatedwithhealthfinancing,butthatisbeyondthescopeofthisreport.

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