Towards

universal coverage in the majority world

Transversal findings & lessons learnt, a summary
1 1 2 1 1 1
Werner Soors , Jeroen De Man , Pascal Ndiaye , Fahdi Dkhimi , Remco van de Pas & Bart Criel
ITM, Department of Public Health, Research Unit Equity & Health, August 2015

With the present brief, the research unit Equity & Health of the Institute of Tropical Medicine (ITM,
Antwerp) aims to provide the Belgian Directorate-General for Development Cooperation and
Humanitarian Aid (DGD) a synthesis of lessons learnt on progress towards universal health
coverage (UHC), in particular with regard to challenges, necessary conditions and best practices as
faced by national policymakers in the majority world3.

The objectives are to answer the following two research questions:

(1) What is known from the existing literature on conditions and practices for advancing towards
UHC in low- and middle-income countries?
(2) What are the necessary conditions and best practices for advancing towards UHC in Belgian
partner countries, and what are the lessons learnt from other countries that are considered
successful in attaining UHC?

To produce the present brief, the research team followed a two-stage process:
(1) A scoping review of the existing literature4, exploring five dimensions of UHC (the classic triad
of population coverage, service coverage and financial protection, plus quality of care and –
crosscutting all former dimensions – equity)5 within a political economy framing that takes into
account institutional design and organizational practice of UHC policies and actors;
respectively6, to build up the evidence base required to answer the first research question;
(2) A qualitative synthesis of the collected evidence, within the established framework and
applying the principles of critical interpretive synthesis7, to enable answering the second
research question.

1
Unit Equity & Health (formerly Health Fiancing), Department of Public Health, ITM, Antwerp
2
Independent consultant, Brussels
3
A term slowly replacing ‘developing countries’ – highlighting the fact that the people in these countries are indeed the majority
of mankind, thus defining people by what they are, not by what they lack. See, among others: ‘Majority World’ – a new word for a
new age http://masalai.wordpress.com/2009/02/11/majority-world-a-new-word-for-a-new-age/
4
Given the broad research question (“What is known from...?”), and the context and path dependency of UHC policies – entailing
exploration of discussion notes, reports and other types of grey literature that would easily be excluded from a systematic review,
a scoping review is arguably a first choice in this case. More than other forms of literature review, a scoping review maximizes
breadth of inquiry (ideally specifying its dimensions and boundaries, e.g. making use of a framework that guides the review from
data selection up to reporting), without necessarily sacrificing depth of inquiry. For the basics of scoping studies, see Arksey H,
Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology: Theory and
Practice 2005, 8(1): 19-32, and Levac D, Colquhoun H, O’Brien K. Scoping studies: advancing the methodology. Implementation
Science 2010, 5: 69.
5
Indeed, the classic dimensions of ‘population coverage’, ‘service coverage’ and ‘financial protection’ are not sufficiently
comprehensive. Arguably, service coverage as such is insufficient where quality of care is sub-standard. Similarly, no dimension of
coverage can be truly universal without ensuring equity.
6
The term ‘political economy’ covers a range of overlapping or even different interpretations in different disciplines. Our
interpretation focuses on a recognized mechanism in collective decision-making, namely the interplay between the rules of the
game and what stakeholders actually do, conceptualized by North as respectively ‘institutional design’ (ID, “formal and informal
rules, enforcement characteristics of rules, and norms of behavior that structure repeated human interaction”) and ‘organisational
practice’ (OP, the practice of “groups of individuals bound together by some common purpose to achieve certain objectives”). We
argue that considering the OD/IP interplay adds substantial insight into origins, current state and conditions for improvement in
each of the three classic dimensions (population coverage, service coverage and financial protection) of UHC in a given context.
For the basics of ID and OP, see North D. Institutions and economic growth: an historical introduction. World Development 1989,
17(9): 1319-1332, and North D. Economic performance through time. The American Economic Review 1994, 84 (3): 359-368.
7
Dixon-Woods M, Cavers D, Agarwal S, et al. Conducting critical interpretive synthesis of the literature on access to healthcare by
vulnerable groups. BMC Research Methodology 2006, 6: 35.

1
Based on the agreed five dimensions within a political economy arena, a framework for data
collection and analysis was elaborated, based on the three-dimensional UHC cube of the World
Health Report 2008, with the following modifications:
(1) Integration of the quality aspect in the service coverage dimension;
(2) Consideration of equity as a core feature of each dimension (population coverage, service
coverage and financial protection);
(3) Consideration of equitable re-design of existing coverage policies (inner cube) in each
dimension as prerequisite for expansion (curved part of the arrows in inner cube);
(4) Consideration of expansion of each dimension as justifiable only when equitable (straight part
of the arrows in outer cube);
(5) Conceptualisation of the cube(s) as embedded in and resulting from a political economy
dynamic, shaped by the interplay between institutional design (structure, rules of the game)
and organizational practice (agency, behaviour of the actors);
(6) Assessment of design and practice (more or less favourable for UHC) in their particular context
and background (context and path dependence).

The resulting framework for data collection and preliminary analysis can be summarised in the
following graphical representation:

Towards(UHC(in(the(majority(world,(a(framework(
The$challenge$of$equitable$coverage$and$its$poli6cal$economy

Equitable(
expansion(
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protec@on

Equitable( Equitable(
expansion( expansion(
of(popula@on( of(service(
coverage coverage
Financial'protec-on

More(favourable( More(favourable(
ins@tu@onal(design organisa@onal(prac@ce

Po ge
p ula era
-o cov
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ove rvi
'se
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e ality
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Less'favourable' Less'favourable'
ins-tu-onal'design organisa-onal'prac-ce

In search for a balance between scope and feasibility, DGD and the ITM research unit agreed
to focus the process (review and synthesis) on four Belgian partner countries: DR Congo, Peru,
Senegal and Uganda, plus Ghana and Thailand for relevant lessons. In a parallel exercise,
commissioned by P4H8, the ITM research unit applied the same framework to a scoping review
in search of necessary conditions and best practices for UHC in Bangladesh, Cambodia, Kenya
and Tanzania.

8
P4H stands for Providing for Health, a platform for social health protection through information exchange and dialogue, and
through coordination of support across sectors and cooperation levels. P4H members are the World Health Organization (WHO),
the International Labour Organization (ILO), the World Bank, the African Development Bank (AfDB), France, Germany, the USA,
Spain and Switzerland. See http://p4h-network.net/about-p4h/

2
Sources used for data collection were PLoS Medicine, PubMed, the LSHTM collection Resilient
and Responsive Health Systems, P4H Intranet, the World Bank Open Knowledge Repository,
Google Scholar, and the research unit’s own database on UHC.

The following keywords were used: ‘universal health’9, ‘population coverage’, ‘service
coverage’, ‘quality’, ‘financial protection’, ‘out-of-pocket’/’OOP’, ‘equity’, ‘political’/’politics’,
‘institutional design’, ‘organisational practice’, and the country names. Boolean operators
were applied and the initial selection was limited to publications of the last decade (2005
onwards). Earlier publications were taken into account if and only if they were needed to make
sense of the search results from the last decade.

Two researchers then independently screened all results for relevance. This was done
stepwise, first on title, then on abstract, ultimately on full text. Duplicates were eliminated
from the list of included documents, and snowballing technique was applied to the reference
list of all included documents. Ultimately, 518 country-related publications were included for
analysis10. Besides, 240 generic documents were included, on UHC but not linked to a
particular country.

An overview of the selection is given in the following table:

9
Following Jesse Bump’s logic, our first search term was ‘universal health’, because it also captures ‘universal health insurance’
and ‘universal health financing’, which would have been excluded by searches for the full term ‘universal health coverage’. See
Bump J. The long road to universal health coverage: a century of lessons for development strategy; Seattle, 2010.
10
In the later analytical stage (critical interpretive synthesis), the collected data for African countries were triangulated with
evidence as presented by African researchers at the AfHEA (African Health Economics and Policy Association) conference ‘The
post-2015 African health agenda and UHC: opportunities and challenges’ (Nairobi, 11-13 March 2014), in which two of our
researchers had participated (WS as main rapporteur, PN as scientific coordinator). For an overview of the evidence presented at
the AfHEA conference, see http://afhea.org/docs/abstract-book-FV.pdf.

3
The present brief focuses on the transversal findings and lessons learnt from both research
exercises11.

Expanding population coverage

No other dimension of universal coverage receives as much attention from researchers and
policymakers as population coverage. Still, in the countries under study – with the exception of
Thailand and to a much lesser extent Ghana – progress in population coverage is painfully
slow.

Where population coverage is narrowly conceptualised as insurance coverage, progress in

effective coverage12 is often lagging behind. This is by no means a new or unknown
phenomenon. Joseph Kutzin already in 1998 posited that the insurance function of a health
system (effective health care risk protection), and not mere membership of an insurance
scheme, should be considered a policy objective13. Anne Mills in 2007 noted: “Inclusion within
a financing scheme does not guarantee access to benefits (health care)”14.

Moreover, while population coverage is on the rise in most countries – with the DRC being the
deplorable exception15, expansion of population coverage is rarely equitable – with Thailand
arguably again a positive outlier.

In Bangladesh, a low-income South Asian country four decades ago considered as a hopeless case
16
and today lauded for its ‘good health at low cost’ , wealth and gender inequities remain largely
unchanged. The country’s fast-growing urban slum populations, considered transient and thus
17
excluded from service planning, face a problematic catch-22 .
In Cambodia, a low-income Southeast Asian country, health improvements lag behind economic
progress and are less pronounced among poor and rural than among wealthy and urban
18
populations. Health equity funds somehow improved the poor’s access, but neither their demand
for services nor utilisation. Prioritisation of service coverage for targeted groups over population
19
coverage has led to the near poor becoming an uncovered and growing ‘missing middle’ .

11
Country-specific findings and lessons learnt will be dealt with in country briefs. References are limited to core publications; the
complete reference list is available upon request (wsoors@itg.be).
12
Effective coverage, a term first used by PAHO in the 1990s before being endorsed by WHO and the World Bank, is not
population coverage but a metric of health system performance composed of need, use and quality. Effective coverage quantifies
“the gap between actual and potential benefits from health services” and can be defined as “the fraction of potential health gain
that is actually delivered to the population through the health system, given its capacity”. See Lindelow M, Nahrgang S,
Dmytraczenko T et al. Assessing progress toward universal health coverage: beyond utilization and financial protection, in Toward
universal health coverage and equity in Latin America and the Caribbean: evidence from selected countries (T Dmytraczenko & G
Almeida, eds); Washington, 2015, and Ng M, Fullman N, Dieleman J, et al. Effective coverage: a metric for monitoring universal
health coverage. PLoS Medicine 2014, 11: 9.
13
Kutzin J. Enhancing the insurance function of health systems: a proposed conceptual framework, in Achieving universal coverage
of health care (S Nitayarumphong & A Mills, eds); Bangkok, 1998.
Mills A. Strategies to achieve universal coverage: are there lessons from middle income countries? London; 2007.
14

15
Expansion of universal coverage in the RDC is still intangible, and poorly documented.
16
See, among others, Chowdhury A, Bhuiya A, Chowdhury M, et al. The Bangladesh paradox: exceptional health achievement
despite economic poverty. Lancet 2013, 382(9906): 1734-1745, and Pérez Koehlmoos T, Islam Z, Anwar S. Health transcends
poverty: the Bangladesh experience, in Good health at low cost 25 years on: what makes a successful health system? (D
Balabanova, M McKee & A Mills, eds); London, 2011. Two and a half decades earlier, the mantra ‘good health at low cost’ had
been attributed to the Indian state of Kerala. Bangladesh’ achievement, though remarkable, pales by comparison.
17
See, among others, Rashid S. Strategies to reduce exclusion among populations living in urban slum settlements in Bangladesh.
Journal of Health, Population and Nutrition 2009, 27(4): 574-586.
18
Health equity funds (HEFs) are third-party schemes that reimburse empaneled health facilities for a defined range of services to
(usually) pre-identified beneficiaries. Introduced in 2000, HEF today are found all over the country, on their own or in combination
with contracting, pay-for-performance, community health schemes and/or additional targeting instruments.
19
See, among others, Fernandes Antunes A, Jacobs B. The transition to universal health coverage in Cambodia: it is about the
poor… but not only; Phnom Penh, 2014.

4
 20
In Ghana, a middle-income West African country , the National Health Insurance Scheme (NHIS)
introduced in 2003-2004 makes provision for exemption of the poor but applies exemptions for
21
other population groups to the disadvantage of the poor . Regional disparities also persist. In 2012,
22
36% of the population was effectively enrolled in the NHIS .
In Kenya, a low-income East African country, inequitable disparities in service utilisation between
poor and wealthy, and rural and urban, seem resistant to change.

Kenya’s 10/20-policy odyssey

In 2004, to provide more equitable access for its population, the Government of Kenya (GoK)
introduced what be became known as the 10/20 policy – replacement of user fees by flat registration
fees of 10 an 20 shilling at dispensaries and health centres respectively, plus exemptions for under-5’s,
pregnant women, the poor and patients with priority conditions. While the policy may have led to a
shift towards pro-poor distribution and is still in place, health workers’ adherence fell over time: the
potential to ensure adherence was constrained by the facilities’ need for revenue to cover basic
operating cost. In 2010, the GoK introduced a Health Sector Services Fund (HSSF) to compensate
facilities for lost revenue associated with user fee removal under the 10/20 policy.
Opwora A, Waweru E, Toda M, et al. Implementation of patient charges at primary care facilities in Kenya: implications of low
adherence to user fee policy for users and facility revenue. Health Policy and Planning 2014, 30(4): 508-517.

In Peru, a middle-income South American country, historical geographical and wealth-related

disparities are slowly remedied by coordinated efforts to strengthen primary care, to improve
distribution and remuneration of human resources for health, and to harmonize fragmented health
sub-systems, within a frame of mandatory health insurance membership and complemented by a
range of multi-sectorial initiatives.
In Senegal, a low-income West African country, 80% of the population is still uncovered by any form
of health insurance. From the 2008 first national strategy onwards, efforts are made to move from
scattered initiatives towards a consistent UHC policy.
In Tanzania, a low-income East African country, progress towards equitable population coverage is
more pronounced than in the neighbouring Kenya and Uganda. Efforts towards UHC address both
health-financing issues, such as harmonization of risk pools, and health systems strengthening,
including a primary health care development programme.
In Thailand, a middle-income Southeast Asian country, population coverage was spectacularly
23
boosted with the inclusion of 18 million previously uninsured citizens in the Universal Coverage
24
Scheme (UCS), as part of what became known as the 2001 30-Baht reform . Most remarkably, the
Thai government implemented this reform in the aftermath of the Asian financial crisis, on a tight
25
budget , preceding the global promotion of universal coverage and against internal opposition,
particularly of the medical profession.

Thailand’s progress in population coverage and equity

The Thai reform reduced the likelihood that someone goes without formal treatment when sick by 11%
and increased inpatient admissions by 18%. Both effects are most pronounced amongst the elderly.
The increase in outpatient care is greatest for the poor and rural populations.
Limwattananon S, Neelsen S, O’Donnell O, et al. Universal coverage on a budget: impacts on health care utilization and out-of-
pocket expenditures in Thailand. Rotterdam, 2013.

20
Ghana reached middle-income status in 2011. When passing its NHIS Law (Act 650) in 2003, it was still a low-income country. It
had entered the Heavily indebted Poor Country (HIPC) Initiative in 2001.
21
Kerbile E, van der Geest S. Repackaging exemptions under National Health Insurance in Ghana: how can access to care for the
poor be improved? Health Policy and Planning 2013, 28: 586-595.
22
Otoo N, Awittor E, Marquez P, et al. Universal health coverage for inclusive and sustainable development: country summary
report for Ghana. Washington, 2014.
23
Representing 25-30% of the population.
24
Called 30-Baht because of a co-payment of 30 Bath (approximately 0.75 US$) per patient contact, from which the poor, elderly
and children where exempted, and which was abolished altogether in 2006.
25
About 3.5% of GDP in 2001. Total health expenditure doubled between 2001 and 2010, but was still under 4% of GDP in 2010.

5
 In Uganda, a low-income East African country, inequitable coverage disparities persist, despite the
abolition of public-sector user fees in 2001. Health system deficiencies have pushed rich and poor
toward the private sector. For half a decade now, the Government of Uganda (GoU) considers and
negotiates the gradual rollout of a National Health Insurance Scheme (NHIS) with multiple insurance
components.

Expanding service coverage

In all countries under study, quality of care and equity in service delivery are important
challenges. Quality of care is a necessary condition for substantial expansion of service
coverage, which points to the need for health systems strengthening hand-in-hand with UHC
efforts. Supply-side deficiencies including lack of quality of care also limit the impact of non-
systemic efforts to increase equity in service delivery. Where expansion in service coverage
has been substantial, as in Thailand and Ghana, cost containment is an issue.

In Bangladesh, healthcare consumption is on the rise, but much more in quantity than in quality of
services: “The coverage of many critical health services is still quite low. The country’s health system
is struggling to meet basic standards for quality of care because of a shortage of skilled health
workers, the large number of unregulated private service providers, irregular supplies of drugs,
inadequate public financing, high out-of-pocket expenses, and lack of proper monitoring and
26
supervision mechanisms” .
Inequity is an unresolved issue, as illustrated by the provision of maternal care: while skilled birth
27
attendance increased, the rich-poor gap in service utilisation also increased . Appropriateness of
care is another issue: the latest Urban Health Survey documented proportions of C-section rates
ranging from 16% in slum areas (where institutional deliveries make up 37% of the total) to a
28
worrying 44% in non-slum areas (where institutional deliveries make up 65% of the total) .
In Cambodia, because of lack of access for the poor and persistent deficiencies in public service
provision, a range of targeted initiatives saw the light, among them a Cambodian innovation: health
equity funds (HEFs). While HEFs have been relatively successful in expanding access to health care
for the poor, their effectiveness in in improving quality of care was and is constrained by prevailing
29
levels of low wages, low resourcing, inadequate training an unregulated private practice . By
contrast, performance-based incentive schemes – and particularly so the nationwide Government
Midwifery Incentive Scheme (GMIS) introduced in 2006 – noticeable improved service access, service
30
quality and health outcomes .
Lack of confidence in government health services remains a major determinant of service
31
utilisation .
In Ghana, the NHIS’ benefit package is the same for all population groups and fairly comprehensive.
Nevertheless, overall distribution of benefits from healthcare utilisation remains pro-rich, and more
so in the private sector. The exceptions are public sector inpatient care, which shows a pro-poor
32
distribution of benefits, and primary care, which is neither pro-rich nor pro-poor .

26
Huda T, Khan J, Ahsan K, et al. Monitoring and evaluating progress toward universal health coverage in Bangladesh. PLoS
Medicine 2014, 11(9): e1001722.
27
Hajizadeh M, Alam N, Nandi A. Social inequalities in the utilization o maternal care in Bangladesh: have they widened or
narrowed in recent years? International Journal for Equity in Health 2014, 13.
28
National Institute of Population Research, Measure, ICDDR. Bangladesh urban health survey 2013. Dhaka, 2014.
29
Kelsall T, Seiha H. The political economy of inclusive healthcare in Cambodia. Manchester, 2014.
30
Ir P, Chheng K. Evaluation of Government Midwifery Incentive Scheme in Cambodia: exploration of the scheme effects on
institutional deliveries and health system. Phnom Penh, 2012.
31
Annear P, Ahmed S. Institutional and institutional barriers to strengthening universal coverage in Cambodia: options for policy
development. Melbourne, 2012.
32
Aikkazili J, Garshong B, Aikins M, et al. Progressivity of health care financing and incidence of service benefits in Ghana. Health
Policy and Planning 2012, 27: i13-i23.

6

Ghana’s struggle with cost containment
Until 2008, the NHIS applied fee-for-service reimbursement to the healthcare providers. Increased
service utilisation led to escalation claims. In 2008 then, the National Health Insurance Authority
(NHIA) shifted to what is called the Ghana Diagnostic Groups (G-DRG) payment system, with fixed
tariffs including bundled payment for outpatient care. G-DRG however had little impact on cost
containment, and claims for outpatient care rose to 70% of total claims cost. By 2012, a World Bank
study posited that the NHIS was not financially viable and could become insolvent as early as 2013.
The NHIA reacted by trying to contain costs without compromising expansion, piloting capitation
payment for primary care and addressing growth in drug expenditure.
Schieber G, Cashin C, Saleh K, et al. Health financing in Ghana. Washington, 2012.
National Health Insurance Authority. 2012 annual report. Accra, 2012.
Otoo N, Awittor E, Marquez P, et al. Universal health coverage fur inclusive and sustainable development: country summary report
for Ghana. Washington, 2014.

In Kenya, poorly developed infrastructure, shortage of human resources and medical supplies, and
limited management capacity all negatively affect quality and equity of public service provision.
Since 2010, direct funding of peripheral facilities through the Health Sector Services Fund (HSSF) has
33
improved quality of care, staff motivation and patient satisfaction . Concomitantly, the National
Health Insurance Fund (NHIF) introduced quality control mechanisms at hospital level.
In Peru, Local Health Administration Committees (CLAS, Comunidades Locales de Administración de
Salud), private entities for community co-management of local health services since 1994, have
34
improved quality of care and equitable coverage . A 2001 evaluation led by Halfdan Mahler
described CLAS as “one of the world’s best demonstrations of rapid expansion with decentralization
35
of the Alma Ata model of community based primary health care” . After having survived serious
36
opposition of the Peruvian Medical Federation, CLAS was consolidated by law in 2007 .
37
In 2009, an essential health insurance plan (PEAS, Plan Esencial de Aseguramiento en Salud) not
only laid down a compulsory minimum package of services to be covered by all (still fragmented)
insurers, but also the quality requirements for the delivery of these services.
Despite these efforts and the results achieved, challenges are still manifold, in terms of quality and
equity.
In Senegal, of the range of social health protection schemes that cover about one fifth of the total
population, none offers comprehensive service coverage. A 2013-2017 strategic plan announced a
38
minimum and a complementary benefit package for all schemes , but elaboration is still pending.
39
Data for measurement of service coverage, quality and equity are largely lacking .
In Tanzania, poorly developed infrastructure, shortage and inequitable distribution of human
resources and medical supplies, high levels of absenteeism and low productivity all negatively affect
quality and equity of public service provision. A 2008-2009 initiative with financial incentives in
understaffed districts proved unsuccessful; currently, results-based financing is being piloted to
40
improve staff motivation and productivity .
In Thailand, policymakers were very aware that sudden expansion of population coverage came with
a risk and applied a range of preventive supply-side measures to prevent medical spending from
rocketing: (1) a closed-end capitation-based budget; (2) gatekeeping access to specialist care; (3)

33
Waweru E, Nyikuri M, Tsofa B, et al. Review of Health Sector Services Fund implementation and experience. Nairobi, 2013.
34
Altobelli L. Case study of CLAS in Peru: opportunity and empowerment for health equity. Lima, 2008.
35
Mahler H, Taylor C, Taylor-Ide D, et al. Memorandum on findings and recommendations for Peru’s national system of community
co-managed primary health care. Lima, 2001.
36
Congreso de la República. Ley que establece la cogestión y participación ciudadana para el primer nivel de atención en los
establecimientos de salud del Ministerio de Salud y de las Regiones (Ley Nº 29124). Lima, 2007.
37
Ministerio de Salud. Plan Esencial de Aseguramiento en Salud (PEAS): plan de beneficios del PEAS. Lima, 2009.
38
Ministère de la Santé et de d’Action Sociale. Plan stratégique de développement de la Couverture Maladie Universelle au
Sénégal, 2013-2017. Dakar, 2013.
39
Tine J, Faye S, Nakhimovsky S, et al. Universal health coverage measurement in a lower-middle-income context: a Senegalese
case study. Bethesda, 2014.
40
Verheijen T, Magezi Ndamira B, Biseko D, et al. Equity in public services in Tanzania and Uganda. Washington, 2011.

7
 prospective payment of hospitals for inpatient treatment; and (4) from 2006 onwards, a single public
41
purchaser of care and medicines for UCS beneficiaries . But benefit packages of the three public
42
health insurance schemes are still not harmonised, and finding ways to minimise the increasing
43
reliance on high-cost tertiary care is a core part of Thailand’s unfinished agenda .
In Uganda, poorly developed infrastructure, shortage and inequitable distribution of human
resources and medical supplies, high levels of absenteeism and low productivity all negatively affect
quality and equity of public service provision. Service coverage presents both geographic and socio-
economic inequalities. Targeting hard-to-reach-and-stay (HTRS) areas has improved staffing and to
44
some extent service quality and (geographic) equity . The provision of subsidies to private non-
45
profit health providers, since 1997, had less impact on (socio-economic) equity than desired .
46
Results of a results-based financing pilot were disappointing .

Expanding financial protection

Assessing financial protection at country level is no straightforward exercise. Two common

indicators to assess financial protection are the incidence of catastrophic health expenditure
due to out-of-pocket payments, and the incidence of impoverishment due to out-of-pocket
payments47. Both indicators have their disadvantages. Catastrophic health expenditure (CHE)
over time and space has been measured in a variety of ways in terms of available resources
(shares of total expenditure, non-food expenditure or expenditure net of basic needs) and
thresholds (shares ranging from 10 to 40% of the resources mentioned before): CHE figures
are thus hardly comparable48. Besides, it can be argued that CHE as indicator of financial
protection only expresses a fraction (‘the tip of the iceberg’) of the financial hardship that UHC
per definition wants to avoid. Incidence of impoverishment (II) has two major disadvantages.
First, households that are already below the poverty line are not accounted for when still
made poorer because of out-of-pocket payments. Second, different countries (and different
authors) use different poverty lines, resulting in incidences that are hard to compare or even
to make sense of.
These considerations – and for practical purposes the lack of data on CHE and II in our country
series – has led us to focus on levels and trends of out-of-pocket payments (OOP) as proxy for
(lack of) financial protection49. Even so, assessing equity in financial protection remained a
difficult task, as this would require stratified OOP data, which only in a minority of countries
are (partly) available50.

41
Limwattananon S, Neelsen S, O’Donnell O, et al. Universal coverage on a budget: impacts on health care utilization and out-of-
pocket expenditures in Thailand. Rotterdam, 2013.
42
UCS since 2001, plus the already existing Civil Servant Medical Benefit Scheme (CSBMS) for government employees, retirees and
dependants, and Social Security Scheme (SSS) for private-sector employees.
43
Evans T, Chowdhury A, Evans D, et al. Thailand’s Universal Coverage Scheme: achievements and challenges. An independent
assessment of the first 10 years (2001-2010). Nonthaburi, 2012.
44
Verheijen T, Magezi Ndamira B, Biseko D, et al. Equity in public services in Tanzania and Uganda. Washington, 2011.
45
Ministry of Health. 2009/2010 health financing review. Kampala, 2011.
46
Ssengooba F, McPake B, Palmer N. Why performance-based contracting failed in Uganda: an “open-box” evaluation of a
complex health system intervention. Social Science & Medicine 2012, 75(2): 377-386.
47
Two harder to understand and much lesser used indicators are poverty depth, expressed as the extent to which out-of-pocket
payments worsen a household’s pre-existing level of poverty, and the mean catastrophic overshoot, defined as the average
amount by which households affected by catastrophic expenditures pay more than the threshold used to define catastrophic
health expenditure. See, among others: Boerma T, Eozenou P, Evans D, et al. Monitoring progress towards universal health
coverage at country and global levels. PLoS Medicine 2014, 11(9): e1001731.
48
Saksena P, Hsu J, Evans D. Financial risk protection and universal health coverage: evidence and measurement challenges. PLoS
Medicine 2014, 11(9): e1001701.
49
It was reassuring to see, ex post, that the 2015 WHO/World Bank’s global monitoring report also focused on OOP to assess
financial protection. See Boerma T, Evans D, Evans T, et al. Tracking universal health coverage: first global monitoring report.
Geneva, 2015.
50
Availability of stratified CHE and II data in most countries is even less than that of stratified OOP data.

8
Judged by the WHO target for OOP and at aggregate country level51, financial protection is
unsatisfactory in all countries under study, with progress in less than half of these countries.
In all countries except Ghana, financial protection is hampered by fragmentation of insurance
schemes and other social protection initiatives. Where progress is made in financial
protection, there is in most cases no evidence of equitable progress, with the solitary
exception of Thailand in our series.

In Bangladesh, OOP spending is still on the rise and represents currently an alarming 2/3 of total
52
health expenditure (THE) . Every year, 4-5 million Bangladeshi are pushed into poverty due to
53
healthcare spending, with millions more – particularly the poor – deterred from seeking care .
In Cambodia, historically known for dramatically catastrophic healthcare spending, we see a mixed
picture: OOP is still on the rise – reaching 61% of THE – whereas CHE is declining, at least in part
54
because of the existence of health equity funds (HEF) . But only 20% of the poor use HEF cards or
55
similar, and 5% of card users are actually wealthy . To these inequities in financial protection add
the neglect of people with chronic conditions and the older population: people of 60 and above
56
account for only 6% of the population, but for 50% of all OOP .
In Ghana, OOP decreased from 44 to 37% of THE over the last decade, but still a mixed picture
appears: while one study (data from two districts, in 2007) documented that NHIS affiliation
marginally reduced OOP and substantially reduced the likelihood of CHE, the latter more so among
57
the poor than among the general population , another study (country-wide data, in 2011)
documented significantly more NHIS cardholders among the wealthiest (20% of men and 29% of
women in the top quintile) then among the poorest (10% of men and 17% of women in the bottom
58
quintile) .
In Kenya, OOP decreased from 43 to 25% of THE over the last decade, but mainly because donor
59
funding rose from 6 to 28%; the contribution of a range of insurance schemes is marginal . The poor
60
still contribute a larger proportion of their income to health care than the rich , and
61
impoverishment is a frequent phenomenon among the near poor .
In Peru, OOP stabilised around 36% of THE, whereas CHE slightly came down in the general
population. Among the poor, OOP came down thanks to the subsidised SIS (Seguro integral de
Salud), but not so CHE. Efforts to harmonise fragmented insurance pools have been largely
unsuccessful and even resulted in money flowing from the SIS to EsSalud (Seguro Social de Salud del
62
Perú, the scheme for formal sector workers and their dependents) .
In Senegal, estimates of OOP vary between 57% (in 2002, WHO estimate) and 38% (in 2005, National

51
In 2010, Xu and colleagues calculated that OOP should be less than 20% of total health expenditure (THE) to reduce considerably
the incidence of CHE in a country. The WHO adopted reduction of OOP to less than 20% as a target in its 2010 World Health
Report, but recognised that such was no easy task for low-income countries, who could set intermediate targets. See Xu K,
Saksena P, Jowett M, et al. Exploring the thresholds of health expenditure for protection against financial risk. Geneva, 2010, and
World Health Organization. The World Health Report – Health systems financing: the path to universal coverage. Geneva, 2010.
52
World Bank, HLSP/Matt McDonald. Bangladesh health sector profile. Washington, 2010.
53
Adams A, Ahmed T, El Arifeen S, et al. Innovation for universal health coverage in Bangladesh: a call to action. Lancet 2013,
382(9910): 2104-2111.
54
Annear P, Grundy J, Ir P, et al. The Kingdom of Cambodia health system review. Geneva, 2015.
55
Sobrado C, Neak S. Where have all the poor gone? Cambodia poverty assessment 2013. Washington, 2014.
56
Axelson H, Eang R. Out-of-pocket expenditure on health in Cambodia: analysis of date from the Cambodian socio-economic
survey. Phnom Penh, 2015.
57
Nguyen H, Rajkotia Y, Wang H. The financial protection effect of Ghana National Health Insurance Scheme: evidence from a
study in two rural districts. International Journal for Equity in Health 2011, 10:4.
58
Schieber G, Cashin C, Saleh K, et al. Health financing in Ghana. Washington, 2012.
59
Ministry of Medical Services, Ministry of Public Health and Sanitation. Kenya national health accounts 2009/10. Nairobi, 2010.
60
Chuma J, Okungu V. Viewing the Kenyan health system through an equity lens: implications for universal coverage. International
Journal for Equity in Health 2011, 10(1): 22.
61
Chuma J, Maina T. Catastrophic health care spending and impoverishment in Kenya. BMC Health Services Research 2012, 12:
413.
62
Vermeersch C, Medici A, Narvaez R. Universal health coverage for inclusive and sustainable development: country summary
report for Peru. Washington, 2014.

9
 Health Account) of THE. Absence of recent and particularly of stratified data does not allow for
identifying trends or equity characteristics. A subsided scheme targeted to the older population –
Plan Sésame, launched in 2006 – failed to include the poorest and the most vulnerable among the
63
target population .
In Tanzania, OOP decreased from 42% of THE in 2002 down to 27% in 2012, reaching again 32% in
2013. Over the same time, donor funding rose to 48% of THE, and insurance contribution remained
64
the same at a marginal 3% of THE . Fragmented risk pools and inefficient exemption policies keep
financial protection low in an inequitable manner. Efforts to enhance risk pooling by integrating the
Community Health Funds (CHF-TIKA) in the National Health Insurance Fund (NHIF) have met with
65
resistance from the NHIF .
In Thailand, the introduction of the 30-Baht reform halved OOP expenditure for UCS affiliates as
66
related to their household expenditure (2000-2004) . As share of THE, OOP dropped to 13% in
67
2012 .

Thailand’s progress in financial protection and equity

The UCS led to a significant increase in government health spending and a marked decline in OOP
expenditure. Most importantly, the rich-poor gap in OOP expenditure was eliminated. The UHC
increased equity in public subsidies, overall health expenditure becoming pro-poor. Incidence of
impoverishment dropped from 2.7% in 2000 to 0.5% in 2009.
Evans T, Chowdhury M, Evans D, et al. Thailand’s Universal Coverage Scheme: achievements and challenges. An independent
assessment of the first 10 years (2001-2010). Nonthaburi, 2012.

In Uganda, the 2001 abolition of user fees had no lasting effects on OOP expenditure, which started
68
to rise again between 2003 an 2006 . By 2010, OOP expenditure accounted for 49% of THE, with
69
public and donor funding accounting for 15 and 36% respectively . Private resources comprise
dozens of very small risk pools, through community health insurance and some corporate health
insurance schemes. With high fragmentation and virtual absence of cross-subsidization, impact on
70
financial protection and equity is minimal .

Political economy: institutional design & organisational practice

While context- and path-dependency as expected lead to different pictures, important

transversal findings and patterns can be distinguished here, such as the core role of health
systems strengthening when embarking on and sustaining UHC policies, and the explicit
political nature of fragmentation/harmonisation processes.
71
In Bangladesh, the design of service provision and social health protection (SHP) measures is very
fragmented, with private providers (mainly NGOs) being predominant actors. A two-way exchange
between the state and NGO actors, combined with substantial donor funding, is held responsible for

63
Parmar D, Williams G, Dkhimi F, et al. Enrolment of older people in social health protection programs in West Africa: does social
exclusion play a part? Social Science & Medicine 2014, 119: 36-44.
64
Dutta A. Prospects for sustainable health financing in Tanzania: baseline report. Washington, 2015. The 3% contribution of
insurance schemes becomes even more marginal when compared to the population coverage of insurance schemes, estimated at
16-22% in 2015.
65
Borghi J, Maluka S, Kuwawenaruwa A, et al. Promoting universal financial protection: a case study of new management of
community health insurance in Tanzania. BMD Health Research Policy and Systems 2013, 11(1): 21.
66
Limwattananon S, Neelsen S, O’Donnell O, et al. Universal coverage on a budget: impacts on health care utilization and out-of-
pocket expenditures in Thailand. Rotterdam, 2013.
67
Rousseau T. Thailand social health protection: report of study visit 24-27 June 2014. Brussels, 2014.
68
Nabyonga Orem J, Mugisha F, Kirunga C, et al. Abolition of user fees: the Uganda paradox. Health Policy and Planning 2011,
26(S1): ii41-ii51.
69
Government of Uganda. National Health Accounts FY 2008/09 and FY 2009/10. Kampala, 2013.
70
Cm Z, Kyomuhang R, Jn O, et al. Is health care financing in Uganda equitable? African Health Sciences 2009, 9(2): 52-58.
71
Including separate responsibilities for urban and rural care in the public sector.

10
 what has been termed ‘good health at low cost’ but also for the ‘Bangladesh paradox’: relatively
72
good health despite enormous deficiencies .
Governance of the health system is weak, and hardly inclined to improve in the presence of strong
NGO-donor links. Government leadership is often questioned. At local level, governance has become
more participatory and the health system more responsible where the service providers, local
73
government and the community have joined forces in what has been called ‘joined tension’ .
In Cambodia, restructuring of the health system after decades of conflict has been mainly donor-
driven since 1996, including a range of innovations including health equity funds and contracting
arrangements, with national government becoming more directive in setting policy lines from 2002
onwards.
The current picture is one of a range of stakeholders – government and international actors
including donors, technical experts and NGOs – in which the government has the last word, yet the
external actors still have a sizeable influence, and from which the health workforce and the general
public are largely absent. The latter democratic deficit is further complicated by lack of governance
of the private sector and Cambodia’s track record of what has been termed patronage and
clientelism, an elite pact (by rent-seeking businessmen, politicians, generals and technocrats) and
74
generalised corruption .
In Ghana, government commitment to improving the NHIS has been strong and sustained since
inception. The National Health Insurance Authority, created by the 2003 Act 650, includes a wide
range of actors including the Ministry of Health (MoH), Ghana’s public provider network (the Ghana
Health Service), private providers, insurance schemes, the National Insurance Commission, and
consumers. National support for the NHIS became independent from changes in the party in power.
In 2012, a new National Health Insurance Act (Act 852) improved governance and introduced
administrative and operational reforms, thereby effectively integrating all district mutual health
75
insurance schemes (DMHIS) under the unified NHIS risk pool .
In Kenya, healthcare provision benefited from changing institutional design, with the devolution of
responsibility for service delivery to county level under a new Constitution in 2010. The current
picture is complex, with devolved services and national yet fragmented social health protection
76
mechanisms .
Technical proposals for harmonisation start emerging, but government oversight and leadership is
limited, and donor alignment sub-optimal. Contradicting views and restrained involvement of
important national stakeholders protract overall process and progress, while donor-driven initiatives
77
still add up to fragmentation .
In Peru, from an institutional point of view, health governance responsibilities are divided between
the Ministry of Health (MinSA) and the National Superintendence of Health (SuSalud,
Superintendencia Nacional de Salud), whereas public service provision outside the capital was
decentralised to Regional Health Authorities (DIRESA, Direcciones Reginales de Salud, 2004-2009) in
parallel with EsSalud providers under the Ministry of Labour and still other providers for the Armed
Forces. Insurance pools remain fragmented although a regulatory framework is in place since the
78
introduction of a National Health Insurance Law in 2009 . Negotiation between all these actors is
laborious, and policy directives tend to change with changing governments.

72
Pérez Koehlmoos T, Islam Z, Anwar S. Health transcends poverty: the Bangladesh experience. In Good health at low cost 25 years
on: what makes a successful health system? (D Balabanova, M McKee & A Mills, eds); London, 2011.
73
See, among others, Adams A, Ahmed T, El Arifeen S, et al. Innovation for universal health coverage in Bangladesh: a call to
action. Lancet 2013, 382(9910): 2104-2111, and Ahmed S, Evans T, Standing H, et al. Harnessing pluralism for better health in
Bangladesh. Lancet 2013, 382(9906): 1746-1755.
74
See, among others, Kelsall T, Seiha H. The political economy of inclusive health care in Cambodia; Manchester, 2014.
75
Otoo N, Awittor E, Marquez P, et al. Universal health coverage for inclusive and sustainable development: country summary
report for Ghana. Washington, 2014.
76
Providing for Health. Priorities for successful devolution of health services in Kenya: a briefing note. 2012: 16.
77
See, among others, Ministry of Health. Health financing reforms for universal health coverage in Kenya: a technical concept note;
Nairobi, 2014, and Ravishankar N, Thakker A, Lehmann J. Kenya country report: African health markets for equity; Nairobi, 2013.
78
Vermeersch C, Medici A, Narvaez R. Universal health coverage for inclusive and sustainable development: country summary
report for Peru. Washington, 2014.

11
 In Senegal, the 2012 change of government was a moment of hope and led among other things to
79
renewed agenda setting and the 2013-2017 Strategic Plan for the Development of UHC . A closer
look at this plan is rather disappointing, as the amount of rhetorical discourse is hardly matched by
evidence-informed strategies or health system strengthening efforts, and useful indicators for
80
monitoring of progress are largely lacking . The plan puts forward voluntary affiliation to community
health insurance (CHI) schemes of informal sector workers as key part of the UHC strategy, in spite
of the well-known limitations of such approach, though it considers but hardly elaborates
subsidisation of CHI and the establishment of a National Health Solidarity fund (Fonds National de
Solidarité Santé) and an Independent Fund for Universal Social Protection (Caisse Autonome de
Protection Sociale Universelle), thereby echoing lessons learnt from the Ghanaian experience.
Unsurprisingly, declared expected results – expansion of CHI coverage to 27% in 2013, to 46% in
2014, to 50% in 2015 – are still distant dreams. Surprisingly, the plan received very little critique
from Senegal’s external donors and development partners.
In Tanzania, service provision is decentralised; social health protection (SHP) is still fragmented. The
political party in power is a strong advocate for harmonisation of SHP but operational actors are
reluctant to change. Donor alignment with the UHC agenda, envisaging the creation of a Mandatory
Single National Health Insurance (SNHI), is strong and technical progress (a 2013 costing study, a
2015 fiscal space analysis) impressive. Yet, government support at top level is still uncertain and the
81
risk exists that the momentum for SNHI will be lost after the upcoming elections .
In Thailand, the 2001 reform that introduced the Universal Coverage Scheme did not come out of
the blue. From a technical point of view, its feasibility was conditional on decades of health system
strengthening preceding the reform, including the development of health districts and due attention
82
to human resources . From a political point of view, its inception was the result of purposeful
networking by a group of committed young doctors within the national bureaucracy. Political
commitment, and popular support, is still important today, as illustrated by the vehement defence
of the UCS in national media after it came under attack of the prime minister for allegedly being “a
83
populist policy that will bankrupt state hospitals” . Political economy, particularly the difficult
alignment of all actors involved, is also key in the current efforts to do away with fragmentation and
84
harmonise the three existing schemes .

Thailand: UCS and the blitz of the Rural Doctors’ Society

In political science, the term ‘regulatory capture’ is often used to describe the take-over of state
agencies by external interest groups aiming at profit maximisation. By contrast, the term
‘developmental capture’ (by bureaucrats aiming at public benefit) was first used to describe the critical
role played by Thailand’s Rural Doctor’s Society (RDS) in agenda setting and implementation of
universal coverage.
The RDS was founded in 1978 by progressive young doctors working in Thailand’s poorest rural
hospitals. Over the next decade, members of RDS started working in the Ministry of Public Health and
set up the Sampran Forum for health systems strengthening. Accumulating experience and status, RDS
members rose to the top ranks of civil service by the end of the century. In the run-up to the 2001
elections, RDS managed to convince the Thai Rak Thai party (TRT) to put UHC on its agenda, despite
not ranking as a preference in voters polls. TRT won the elections, and the reform was started before
the policy had even been passed by parliament. The RDS network sought and found international
support (WHO, ILO) and outwitted its national opponents (within the medical profession).
Harris J. “Development capture” of the state: explaining Thailand’s universal coverage policy. Journal of Health Politics, Policy and
Law. 2015, 40(1): 165-193.

79
Ministère de la Santé et de l’Action Sociale. Plan stratégique de développement de la Couverture Maladie Universelle au Sénégal,
2013-2017. Dakar, 2013.
80
Tine J, Faye S, Nakhimovsky S, et al. Universal health coverage measurement in a lower-middle-income context: a Senegalese
case study. Bethesda, 2014.
81
See, among others, Ally M, Dutta A. Resource pool for a single national health insurer in Tanzania. Dar Es Salaam, 2015.
82
Rousseau T. Thailand social health protection: report of study visit 24-27 June 2014. Brussels, 2014.
83
Bangkok Post. Hands off our healthcare. July 3, 2015.
http://www.bangkokpost.com/opinion/opinion/611692/hands-off-our-healthcare
84
Bangkok Post. Agency to oversee health plans. December 22, 2014.
http://www.bangkokpost.com/news/general/451388/agency-to-oversee-health-plans

12
 In Uganda, the process towards a unifying national health insurance has been longer and less
successful than in other East African countries, despite backing by the party in power for nearly
three decades and by the Ministry of Health (MoH). One group of authors distinguishes three phases
85
in this process: before 2000, between 2000 and 2006, and 2006 onwards . Before 2000, a first
feasibility study on health insurance was commissioned in 1996, and social health insurance (SHI)
was proposed as the financing mechanism towards UHC in the National Health Policy elaborated in
1999. Between 2000 and 2006, a second feasibility study was followed by consultations with
external experts and study visits to countries with SHI in place, the establishment of a SHI secretariat
in 2005 and a cabinet paper in 2006 that directed the MoH to draft a bill on establishing SHI. From
2006 onwards, the process stagnated into lengthy disputes with opposing national actors,
particularly a reluctant National Social Security Fund (NSSF) and influential private insurers. A newly
established National Task Force (NTF) produced a revised SHI bill in 2008; a four-ministries cabinet
sub-committee redrafted the bill in 2011, shifting from an envisaged unique SHI to a NHIS with
multiple components so as to keep the private insurers on board. Today, negotiations are still
86
lingering and no NHIS is yet established.

Transversal findings & lessons learnt

In this concluding section, we present the main results of our qualitative, critical interpretive
synthesis. We focus on findings we were able to recognise throughout the individual country
cases (transversal findings), ideally confirmed by findings outside our series (at global level).
We present them as potential lessons learnt, not as action points, strictly adhering to
professional ethics: (part of) our function as researchers is to provide quality evidence for
policymaking; it is the mandate of policymakers – not ours – to lay down policy directives.

Our transversal findings and lessons learnt cover six interrelated areas of concern: health
systems strengthening, the choice of health financing mechanisms, fragmentation vs.
harmonisation of health financing, the need for a political approach, the need for better data
and monitoring, and fiscal space for progress in UHC.

(1) Health systems strengthening

Not only is quality of care in all cases under study a major determinant of progress in
service coverage, it eventually also influences population coverage and financial
protection, and equity in each dimension. Health systems strengthening (HSS), leading to
quality of care, can thus be considered a condition for progress towards UHC.
Where health systems strengthening is deficient, progress towards UHC ranges from sub-optimal (Senegal is
one example) to imperceptible (DRC).
Where health systems strengthening goes hand-in-hand with UHC policies, progress towards UHC becomes
consolidated and stronger (Ghana, Peru to a lesser extent).
Where health systems strengthening precedes UHC policies, progress is strong from the very start (Thailand).

This finding has practical consequences, in current times where the global promotion for
UHC seems to overshadow the discourse for health systems strengthening. Evidence
strongly suggests that HSS efforts should be part of all UHC policies. Where health
systems are particularly weak, it might be wise to focus on HSS first.

Our case for health systems strengthening resonates with one of the conclusions of a recently

85
Basaza R, O’Connell T, Chapčáková I. Players and processes behind the national insurance scheme: a case study of Uganda. BMC
Health Services Research 2013, 13: 357.
86
Uganda Insurers Association. The insurance industry proposes changes to the National Health Insurance Scheme.
http://uia.co.ug/the-insurance-industry-proposes-changes-to-the-national-health-insurance-scheme

13
published Government of Japan / World Bank two-year multi-country87 research programme
on progress towards universal health coverage88. Reich and colleagues concluded that
“countries need to match their commitment to UHC with their capacity to deliver health
services”, thereby focusing on the need to improve availability and distribution of human
resources for health. Our evidence suggests that strengthening is needed in all building blocks
of health systems.

(2) The choice of health financing mechanisms

Our review does not allow drawing conclusions on comparative advantage of tax-based
versus insurance-based health financing mechanisms for UHC, as all countries in our
series had opted for an insurance-based approach. It does allow however to notice that
countries that rely partially (Bangladesh, Cambodia, Kenya, Tanzania, Uganda,…) or
mainly (Senegal) on schemes based on voluntary affiliation, have serious difficulties to
progress towards UHC.
This finding has practical consequences. Evidence suggests the need to reconsider
support for development of community health insurance (CHI) and other forms of
voluntary health insurance.

This finding confirms a lesson repeatedly expressed by eminent health economists:

Compulsion, with subsidisation for the poor, is a necessary condition for universality89. No
country has ever attained universal coverage by relying mainly on voluntary contributions to
insurance schemes, whether they are run by non-governmental organisations, commercial
companies, communities or governments90.

(3) Fragmentation versus harmonisation of health financing

In all countries under study where health financing is fragmented, i.e. where separate risk
pools exist, financial protection remains sub-optimal and usually inequitable.
This finding has practical consequences. Evidence suggests that in countries where health
financing is fragmented, harmonisation of risk pools, at least by introducing cross-
subsidisation, ideally reaching a unified risk pool, should be considered a policy priority.

(4) The need for a political approach
In all countries under study where health financing is fragmented, and where efforts are
made towards harmonisation, this happens to be an extremely difficult task, which is
essentially political as it is conditional on bringing in line a range of actors with different
interests and power stakes.
This finding has practical consequences, including for UHC policy support by external
actors. Evidence suggests that to make progress towards UHC more successful by ./.

87
This programme studied progress towards UHC in 11 countries of which 4 overlapped with our series: Bangladesh, Ghana, Peru
and Thailand. The other countries included were Brazil, Ethiopia, France, Indonesia, Japan, Turkey and Vietnam.
88
Reich M, Harris J, Ikegami N, et al. Moving towards universal health coverage: lessons from 11 country studies. Lancet 2015.
http://dx.doi.org/10.1016/S0140-6736(15)60002-2
89
Fuchs V. What every philosopher should know about health economics. Proceedings of the American Philosophical Society 1996,
40(2): 186-196.
90
Kutzin J. Anything goes on the path to universal coverage? No. Bulletin of the World Health Organization 2012, 90: 867-868.

14
 ./. harmonising and eventually unifying risk pools, technical support has to be
complemented by political support and capacity building.
When external actors would decide to include political support in their development
cooperation, this raises a number of questions: Is there a need to adapt the skill profile of
staff in development cooperation? How to match ethics and political interference? …

(5) The need for better data and monitoring

Finding sufficient, coherent and comparable data for monitoring process toward UHC was
not an easy task. For monitoring process in the equity aspects of UHC – which needs
stratified data – the task was even more difficult.
This finding might have practical consequences for UHC policy support. External actors
might add efforts for data collection and monitoring to their support package, or make
their support conditional on it.

This finding confirms the need for better data and monitoring as increasingly expressed by a
range of key actors in health policy (WHO, the World Bank,…)91.

(6) Fiscal space for progress in UHC
A question repeatedly popping up in health policy circles is “Does this country have
enough fiscal space for UHC?” At least two country cases in our series suggest that a
more important question might be “Do we want fiscal space for health?”
Both Thailand and Ghana answered this question positively. Thailand did so after a
serious crisis, introduced UCS and became an economic stronghold in its region. Ghana
introduced its NHIS and moved up from low- to middle-income country. While a univocal
causal relationship between UHC and economic progress might be hard to prove,
evidence suggests that UHC can indeed contribute to economic progress and wellbeing,
beyond health.

91
See, among others, Hosseinpoor A, Bergen N, Koller T, et al. Equity-oriented monitoring in the context of universal health
coverage; PLoS Medicine 2014, 11(9): e1001727, Hosseinpoor A, Bergen N, Magar V. Monitoring inequality: an emerging priority
for health post-2015; Bulletin of the World Health Organization 2015, 93: 591-592, and Boerma T, Evans D, Evans T, et al. Tracking
universal health coverage: first global monitoring report. Geneva, 2015.

15