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      Pooling arrangements in health financing systems: a proposed classification

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          Abstract

          Objectives

          The function of pooling and the ways that countries organize this is critical for countries’ progress towards universal health coverage, but its potential as a policy instrument has not received much attention. We provide a simple classification of country pooling arrangements and discuss the specific ways that fragmentation manifests in each and the typical challenges with respect to universal health coverage objectives associated. This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences.

          Methods

          The paper is based on a review of published and grey literature in PubMed, Google and Google Scholar and our information gathered from our professional work in countries on health financing policies. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification.

          Findings

          We propose eight broad types of pooling arrangements: (1.) a single pool; (2.) territorially distinct pools; (3.) territorially overlapping pools in terms of service and population coverage; (4.) different pools for different socio-economic groups with population segmentation; (5.) different pools for different population groups, with explicit coverage for all; (6.) multiple competing pools with risk adjustment across the pools; and in combination with types (1.)-(6.), (7.) fragmented systems with voluntary health insurance, duplicating publicly financed coverage; and (8.) complementary or supplementary voluntary health insurance. However, we recognize that any classification is a simplification of reality and does not substitute for a country-specific analysis of pooling arrangements.

          Conclusion

          Pooling arrangements set the potential for redistributive health spending. The extent to which the potential redistributive and efficiency gains established by a particular pooling arrangement are realized in practice depends on its interaction and alignment with the other health financing functions of revenue raising and purchasing, including the links between pools and the service benefits and populations they cover.

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          Most cited references53

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          The Market for "Lemons": Quality Uncertainty and the Market Mechanism

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            Universal health coverage in Indonesia: concept, progress, and challenges

            Indonesia is a rapidly growing middle-income country with 262 million inhabitants from more than 300 ethnic and 730 language groups spread over 17 744 islands, and presents unique challenges for health systems and universal health coverage (UHC). From 1960 to 2001, the centralised health system of Indonesia made gains as medical care infrastructure grew from virtually no primary health centres to 20 900 centres. Life expectancy improved from 48 to 69 years, infant mortality decreased from 76 deaths per 1000 livebirths to 23 per 1000, and the total fertility rate decreased from 5·61 to 2·11. However, gains across the country were starkly uneven with major health gaps, such as the stagnant maternal mortality of around 300 deaths per 100 000 livebirths, and minimal change in neonatal mortality. The centralised one size fits all approach did not address the complexity and diversity in population density and dispersion across islands, diets, diseases, local living styles, health beliefs, human development, and community participation. Decentralisation of governance to 354 districts in 2001, and currently 514 districts, further increased health system heterogeneity and exacerbated equity gaps. The novel UHC system introduced in 2014 focused on accommodating diversity with flexible and adaptive implementation features and quick evidence-driven decisions based on changing needs. The UHC system grew rapidly and covers 203 million people, the largest single-payer scheme in the world, and has improved health equity and service access. With early success, challenges have emerged, such as the so-called missing-middle group, a term used to designate the smaller number of people who have enrolled in UHC in wealth quintiles Q2-Q3 than in other quintiles, and the low UHC coverage of children from birth to age 4 years. Moreover, high costs for non-communicable diseases warrant new features for prevention and promotion of healthy lifestyles, and investment in a robust integrated digital health-information system for front-line health workers is crucial for impact and sustainability. This Review describes the innovative UHC initiative of Indonesia along with the future roadmap required to meet sustainable development goals by 2030.
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              Health financing for universal coverage and health system performance: concepts and implications for policy.

              Unless the concept is clearly understood, "universal coverage" (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. This paper unpacks the definition of health financing for universal coverage as used in the World Health Organization's World health report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of UHC is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level.
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                Author and article information

                Contributors
                mathaueri@who.int
                Journal
                Int J Equity Health
                Int J Equity Health
                International Journal for Equity in Health
                BioMed Central (London )
                1475-9276
                21 December 2019
                21 December 2019
                2019
                : 18
                : 198
                Affiliations
                [1 ]ISNI 0000000121633745, GRID grid.3575.4, Department of Health Systems Governance and Financing, , World Health Organization, ; Avenue Appia, 1211 Geneva, Switzerland
                [2 ]World Health Organization, Tunis, Tunisia
                Author information
                http://orcid.org/0000-0002-9822-9262
                Article
                1088
                10.1186/s12939-019-1088-x
                6925450
                31864355
                329bae1b-73f5-4a1a-88bd-7a51b19703a6
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 18 October 2018
                : 12 November 2019
                Categories
                Research
                Custom metadata
                © The Author(s) 2019

                Health & Social care
                health financing,pooling,fragmentation,equity
                Health & Social care
                health financing, pooling, fragmentation, equity

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