Pooling financial resources for universal health coverage: options for reform

Abstract

Universal health coverage (UHC) means that all people can access health services of good quality without experiencing financial hardship. Three health financing functions-revenue raising, pooling of funds and purchasing health services-are vital for UHC. This article focuses on pooling: the accumulation and management of prepaid financial resources. Pooling creates opportunities for redistribution of resources to support equitable access to needed services and greater financial protection even if additional revenues for UHC cannot be raised. However, in many countries pooling arrangements are very fragmented, which create barriers to redistribution. The purpose of this article is to provide an overview of pooling reform options to support countries who are exploring ways to enhance redistribution of funds. We outline four broad types of pooling reforms and discuss their potential and challenges in addressing fragmentation of health financing: (i) shifting to compulsory or automatic coverage for everybody; (ii) merging different pools to increase the number of pool members and the diversity of pool members' health needs and risks; (iii) cross-subsidization of pools that have members with lower revenues and higher health risks; and (iv) harmonization across pools, such as benefits, payment methods and rates. Countries can combine several reform elements. Whether the potential for redistribution is actually realized through a pooling reform also depends on the alignment of the pooling structure with revenue raising and purchasing arrangements. Finally, the scope for reform is constrained by institutional and political feasibility, and the political economy around pooling reforms needs to be anticipated and managed.

Time to abandon amateurism and volunteerism: addressing tensions between the Alma-Ata principle of community participation and the effectiveness of community-based health insurance in Africa

“…In a context of resource scarcity, foreign aid volatility and low capacity in the community, it might be difficult to uphold the principles of community decision in resource management and CBHI enrolment if UHC is to be taken seriously. As WHO suggests in its analysis of CBHI schemes, ‘mandatory enrolment of the population’ has become necessary,4 as has the professionalisation of their management, which is not synonymous with privatisation. Moreover, mandatory enrolment and professionalisation can only be achieved effectively if African states commit themselves to taking seriously their citizens’ health by substantially increasing (as did Rwanda) public financing of the health system and subsidising members’ contributions 21 23.…”

“…Thus, at the international level, there are increasing calls for an end to the voluntary nature of this type of insurance mechanism, with respect to both participation in governance and payment of premiums 4 20 21. In fact, ‘No country has effectively progressed towards UHC through voluntary health insurance’ 22.…”

“…In Africa, the development of community-based health insurance (CBHI: autonomous, not-for-profit, voluntary member-based organisations based on solidarity3) is, along with primary health centre management committees, a core component of this participation strategy. Indeed, a key characteristic of CBHI is that ‘the community is involved in driving its setup and in its management.’4 Yet despite a momentum observed in the development of CBHI schemes nearly three decades ago5 6—generally referred to as health mutuals (mutuelles de santé) in francophone countries—numerous studies have highlighted the difficulties encountered in actually implementing user participation: the low contributive capacity of populations, resulting in low enrolment rates and a very limited amount of premiums; very unequal consideration of the needs of beneficiaries (variability in the package of care covered, insufficient quality of care, tensions between CBHI schemes and health service providers); limited benefits for the poorest, who are not involved and the voluntary nature of enrolment and amateurism of management 7–11…”

“…The development of CBHI has been part of the current movement to promote universal health coverage (UHC) since the mid-2000s 2. In the spirit of Alma-Ata, this commentary examines the relevance of community participation in CBHI, considered by WHO to be one of many instruments for moving towards UHC 4…”

Recommendations to improve the insurance coverage for physiotherapy services in Iran A multi-criteria decision making approach

“…Therefore, integrating the insurance funds or consolidation the small insurance funds can be policy options to improve this situation. Participants were discussed that current fragmentation has reduced efficiency and capacity for cross-subsidization, as mentioned in previous evidence [35,36].…”