Transitions in Health Financing
Universal health coverage is taking off in countries as varied as South Africa, India, Rwanda, Indonesia, and the United States, with governments around the world engaging in serious political and technical discussions on how to expand health coverage. Still others are considering such reforms, but are struggling to navigate the legal, financial, and political frameworks of their countries to determine the best path toward reform.
The Opportunity
The Transitions in Health Financing research initiative is part of the Rockefeller Foundation's strategy on Transforming Health Systems. In the context of that strategy, the goal of this research initiative is to foster greater understanding of the factors influencing health spending in low and middle income countries, in an effort to assess further the economic feasibility of and imperative for universal health coverage (UHC).
Our Work
The research will support and synthesize the evidence and research findings on a pre-identified set of key issues, culminating in the publication of seven journal-ready articles concerning: (1) the determinants of health spending, (2) case studies of progress towards UHC, (3) the relationship between health spending and health outcomes, (4) the relationship between health expenditure and impact on UHC, (5) the challenges facing UHC, (6) the policy space that enables countries to achieve UHC despite inhibiting demographics, and (7) an overview of UHC evidence and strategies for achieving universal health coverage.
A more in-depth description of each paper and links to each as they are completed are below:
- The determinants of health spending: This paper analyzes how total health spending and its components (public vs. private, out of pocket vs. prepaid or insured) depend on income (level, composition and distribution), demographic factors, government revenues and other causes. It assesses whether health spending evolves smoothly or goes through clear moments of transition in how much is spent and on what. It finds little evidence for discontinuities in health spending in most countries over recent decades.
- Progress toward universal health coverage: This study shows how universal health coverage has emerged from a range of policies that work within the context of particular economic, political, institutional and technological trends. It suggests how these policies influence the pace and shape of universal health coverage particularly with reference to critical choices regarding the breadth and depth of coverage and between access to care and financial protection.
- Health spending and health outcomes: This paper investigates health outcomes across countries in relation to health spending and the structure of health coverage in terms of the share of the population eligible for benefits, the extent of cost-sharing and the range of services included. It tests the hypothesis that higher spending and broader coverage to lead to better population health outcomes. However, these relationships are likely to vary according to, for example, the type of spending and depth of coverage.
- Health expenditure and impact on universal coverage: This paper assesses systematic patterns in national health spending as countries approach UHC. It analyzes the direction and magnitude of changes in public and private spending on health care with particular attention to changes in private out-of-pocket payments for health care—as an indicator of the degree of financial protection—relative to changes in coverage. It estimates the effect of increased coverage on public spending and private out-of-pocket spending.
- The universal coverage financing challenge: This paper analyzes the financing sources and strategies for achieving UHC in 8 countries from Africa, Asia, and Latin America. It assesses the stability of trends toward UHC through economic and political cycles. It also investigates the implications of these different strategies for equity. It concludes with estimates of the transition costs that block or delay expansion.
- Why policy matters: This paper analyzes the experiences of outliers – countries that have made significant progress toward or even reached universal health coverage despite relatively low levels of income and expenditure. It identifies a series of contextual factors, particularly related to female literacy and geography, which appear to be conducive to progress. Further analysis identifies the policy space that makes such countries successful.
- Transitions in health financing towards universal health coverage: This paper outlines how efforts to help low- and middle-income countries expand access to health care services and financial protection are often short-sighted, assuming constrained health spending near current levels and misreading the historical record of how countries actually achieve universal health coverage. By taking a long-term perspective, both backwards and forwards, it is possible to develop more realistic and better strategies for achieving universal health coverage.