Abstract
BackgroundMany low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups. This paper assesses the institutional design aspects of such financing arrangements and their performance with respect to universal health coverage progress in LMIC of the European region.MethodsThe study is based on a literature review and review of secondary databases for the performance assessment.ResultsSuch financing arrangements currently exist in 13 LMIC of that region, with strong commonalities in institutional design: This includes a wide range of different eligible population groups, mostly mandatory membership, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. Performance is more varied. Enrolment rates range from about 65 % to above 95 %, and access to care and financial protection has improved in several countries. Yet, inequities between income quintiles persist.ConclusionsBudget transfers to health insurance arrangements have helped to deepen UHC or maintain achievements with respect to UHC in these European LMICs by covering those outside formal sector work, and in particular vulnerable population groups. However, challenges remain: a comprehensive benefit package on paper is not enough as long as supply side constraints and quality gaps as well as informal payments prevail. A key policy question is how to reach those so far uncovered.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-016-0321-0) contains supplementary material, which is available to authorized users.
Highlights
Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups
This paper focuses on the specific institutional design features of the contribution exemption arrangements using budget transfers in EURO LMIC
Country and scheme overview This paper includes 13 countries in the European region with a health insurance type scheme plus government revenue transfers, i.e. Albania, Bulgaria, Bosnia & Herzegovina, Georgia, Kyrgyzstan, Lithuania, Montenegro, Republic of Moldova, Romania, the Russian Federation, Serbia, The Former Yugoslav Republic of Macedonia (TFYR Macedonia) and Turkey. This is a mix of both lower- and upper-middle income countries, with Kyrgyzstan having moved to the group of lower middleincome countries only in 2013
Summary
Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups. Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced payroll taxes and a social health insurance (SHI) agency after the political transition in the late 1980s Prior to this transition, these countries were characterized by high levels of financial protection and Mathauer et al International Journal for Equity in Health (2016) 15:57 groups from payroll taxes as they are unable to pay insurance contributions by themselves due to no, very low or unsteady income. Delinking entitlement from directly paying contributions and using general tax funding to maintain or expand coverage via a health insurance type mechanism, i.e. via a separate pooling and purchasing agency, is widespread in the WHO European Region While taking on this specific focus on state budget transfers to health insurance type schemes, this is not to say that this is the only viable health financing mechanism and path to progress towards and deepen UHC
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