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Daily Archives: December 11, 2015

High-income countries Low-income countries Lower-middle-income countries Upper-middle-income countries

Improving the measurement of financial risk protection

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To celebrate international UHC Day on 12 December, GNHE has just published a policy brief on how to improve the measurement of financial risk protection.

This is a companion piece to a similar brief on improving the measurement of health care use (available here).

If you want to read the full financial risk protection brief, click here.


The key messages of the financial risk protection brief are:

  • A key element of Universal Health Coverage (UHC) is financial risk protection (FRP) for all
  • Equitable financial protection means that everyone, irrespective of their level of income, is free from financial hardship caused by using needed health services
  • FRP must be measured alongside, and in addition to, the other dimension of UHC, which is access to needed health services: this is because UHC can only be achieved when both dimensions are addressed
  • Assessment of FRP should go beyond the conventional measures of financial catastrophe and impoverishment from out-of-pocket spending, because these under-estimate the level of financial risk
  • Measurement should seek to be inclusive and comprehensive, covering the whole population (both those who use health services and those who are unable to afford the use of health services when needed)
  • If the traditional measures are used, they should be interpreted accordingly – as simply the proportion of the population who use health services and are consequently impoverished or face financial catastrophe


Ataguba JE, Lu JR, Muiser J, Knaul FM. Assessing progress to UHC – the GNHE perspective: Financial risk protection. Available at:


High-income countries South-East Asia

GNHE launches its 15th UHC country assessment: South Korea

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Tae-Jin Lee, of the School of Public Health at Seoul National University in South Korea, has just published an assessment of the country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.


The author’s main conclusions are:

  • South Korea achieved universal health coverage rapidly.
  • To do so, the government chose a ‘low contribution–limited benefit coverage’ strategy, combined with high co-payments at the time of service utilisation.
  • This inevitably resulted in high out-of-pocket payments, which had implications for financial protection and access to health services.
  • Currently, mandatory National Health Insurance contributions, the largest source of health financing, are regressive, mainly because of a contribution ceiling.
  • This means that low-income households bear a higher financial burden compared to their ability to pay.
  • Consequently, almost 2% of households experienced catastrophic payments at a threshold of 40% of non-food household expenditure in 2000.
  • The impoverishing impact of high out-of-pocket payments was a two-percentage point increase in poverty, affecting around 800,000 Koreans.
  • In addition, many expensive services are not covered under National Health Insurance.
  • Low-income households have to pay for uncovered services on an out-of-pocket basis, or forgo those services.
  • Considering that out-of-pocket payments are progressive, and that high-income households experienced catastrophic payment more frequently than low-income households, it is likely that low-income households have limited access to uncovered services, whether needed or not, compared to their high-income counterparts.
  • Currently, there is much debate on how to expand benefit coverage in South Korea, which is crucial to improving the level of financial protection, increasing the size of the single risk pool, promoting cross-subsidisation and strengthening the purchasing power of government.
  • This requires enhanced revenue collection and an increase in the share of total health expenditure made up by mandatory prepayment, while reducing the share of out-of-pocket payments.
  • For the expansion of benefit coverage, especially to low-income households, it is also necessary to exert purchasing power more actively so as to include additional services that are effective in meeting the health care needs of the population.
  • The National Health Insurance Service needs to pay attention not only to the effectiveness of services but also the cost-effectiveness.
  • Primary care is a good example of a cost-effective set of services. Because the primary care level does not have a gate-keeping function in South Korea, many patients access higher levels unnecessarily and a significant amount of health resources are utilized inefficiently, with no extra health benefit. By re-vitalising the functions of primary care, efficiency in health service utilisation could be improved.
  • Lastly, under the fee-for-service payment system in South Korea, providers have incentives to induce demand for more services than are necessary. Supplier-induced demand threatens the financial sustainability of the single risk pool and could result in reduced financial protection and access in the long run.
  • In order for National Health Insurance to be sustainable, provider reimbursement reform – such as the introduction of an expenditure cap for providers through a global contract – is urgently required in South Korea.


Lee T-J. 2015. Universal health coverage assessment: South Korea. Global Network for Health Equity (GNHE). Available at:

Lower-middle-income countries

A general tax-funded health system in Fiji provides universal health coverage

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Wayne Irava, of The Centre For Health Information, Policy & Systems Research in the College of Medicine, Nursing and Health Sciences at Fiji National University, wrote an assessment of his country’s progress towards UHC for GNHE.

You can read the full assessment here.


Here are the author’s main conclusions:

  • The Fijian health system is largely publicly financed: 66% of total health expenditure was funded through general taxation in 2012.
  • The progressive nature of direct taxes ensures that general taxation is progressive overall.
  • Out-ofpocket expenditure as a share of total health expenditure, while having increased over the past few years, remains relatively low (at approximately 22% in 2012).
  • This out-ofpocket expenditure was largely incurred by people in the higher income brackets of society.
  • What is more, there is very little fragmentation of pooling mechanisms in Fiji. The large majority of health funds are pooled and managed by the Ministry of Health. This integrated pooling enhances income cross-subsidies.
  • Health financing in Fiji is therefore equitable. This indicates that those with the worst ability to pay for health care bear the lowest financing burden (and vice versa).
  • Further, the financial protection indicators of catastrophic health care expenditure and impoverishment due to health care spending are both very low. This means there is a low incidence of households pushed into poverty because of having to pay for health care.
  • With respect to equity of access, government funds are used to provide health services across the range of public health providers at little or no cost to the population. Public facilities provide the majority of outpatient services and the vast majority of inpatient visits.
  • However, because the Ministry of Health is both the pooling organisation and the provider of the majority of health services, there exist inefficiencies that reduce the effectiveness of the Ministry to better address the health care needs of the population.
  • In addition, the skewed distribution of public health services results in better access to health services for the population living in urban areas compared to residents of remote and rural areas.
  • This is aggravated by the small but growing private sector that mainly provides curative outpatient health services in urban areas, on an out-of-pocket basis.
  • In summary, Fiji’s existing health financing system provides a good foundation for achieving Universal Health Coverage goals.


Irava W. 2015. Universal health coverage assessment: Fiji. Global Network for Health Equity (GNHE). Available at: