Abstract
ObjectivesThe 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.MethodsThe 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.FindingsWe 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.ConclusionPooling 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.
Highlights
Universal health coverage (UHC) is high on the agenda of policymakers around the world, and health financing has been widely recognized as a key area for health system actions to move towards UHC
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
Summary
Universal health coverage (UHC) is high on the agenda of policymakers around the world, and health financing has been widely recognized as a key area for health system actions to move towards UHC. [11].The objectives of this paper are to raise the profile of pooling as a health financing policy instrument and to provide a simple classification of country pooling arrangements through which we discuss the challenges typically associated with how fragmentation manifests in each setting. While we believe that the classifications are useful, they are not a substitute for the detailed work that is needed in any one specific country to fully understand its pooling arrangements, their links to other health financing and system functions and their implications for policy While they are important issues, in this paper we do not explore the source of revenues, nor the institutional-organizational details of how revenues are transferred to a pool
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