Category Archives: Lower-middle-income countries

Latin America Lower-middle-income countries

Achieving universal health coverage in Bolivia

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To celebrate the start of a new year, GNHE has published an assessment of progress towards universal health coverage in another country – Bolivia.

You can read the full assessment here.

The author is Cecilia Vidal Fuertes and her main conclusions are:


Bolivia has recently made important progress towards the goal of universal coverage by injecting additional funds (mainly from general revenues) into the health system and pooling them more effectively to spread financial risks. Total health expenditure as a percentage of GDP and total per capita health expenditure have also risen considerably over the past decade.

There have also been efforts to reduce financial barriers to access and the financial risks of illness. Over the past two decades, large inequalities in health outcomes and health service utilisation motivated the implementation and expansion of public insurance schemes, which covered vulnerable populations (pregnant woman, children and the elderly), providing access to government-financed services and eliminating fees for selected health services. As a result, general government expenditure on health as a percentage of total health expenditure rose to 78% in 2013, while out-of-pocket payments fell to 20%.

Despite this progress, there are several challenges in terms of risk pooling and strategic purchasing. In spite of more funds flowing into the system, risk pooling in Bolivia remains very fragmented. There are separate pools at the municipal level to finance national public health insurance schemes, as well as independent pools among social security managerial entities. This affects the efficiency and equity of the overall system and, more specifically, reduces its capacity to provide cross-subsidies between different income groups and health risks.

In terms of purchasing, different mechanisms apply to the national public health delivery system, public insurance schemes and social security. There is a need to analyse and implement the most efficient payment mechanisms in order to achieve strategic purchasing in support of universal health coverage.

In assessing progress towards universal health coverage, the most direct indicators of financial protection are the extent of catastrophic health expenditure and impoverishment due to health care spending. Both indicators for Bolivia are relatively low compared to other countries, suggesting improvements in financial protection. This result is consistent with decreasing levels of out-of-pocket payments. However, these indicators do not capture those people who cannot afford to pay for any care (even subsidised health care in public health facilities) and are still not covered by public insurance.

The question of who pays for health care is addressed through a progressivity analysis of multiple financing mechanisms. There is evidence that resources from general taxation are regressive, as well as employers’ contributions to mandatory social security. By contrast, there is evidence that out-of-pocket payments in Bolivia, which constitute the largest fraction of private spending, are progressive, as it is the more affluent population groups that incur higher payments. The net effect is probably a slightly regressive health financing system, however.

The analysis of equity in health care utilisation relative to need is important for the assessment of the health system in relation to the goal of universal health coverage. In Bolivia, the positive value of the concentration index for overall health service utilisation indicates that utilisation is still concentrated amongst the better-off. Although services provided in public facilities seem to be equally distributed across socioeconomic groups, those provided by social security and private for-profit facilities are highly pro-rich. Hospital health services, regardless of type of provider, tend to be more concentrated among the higher socioeconomic groups.

In terms of coverage, Bolivia still faces important challenges to securing financial protection for its whole population. Overall, health insurance coverage is still low. Public health insurance is heavily concentrated on specific vulnerable populations, and social security only reaches around one third of the population. It is a big challenge to find ways to expand financial protection to the self-employed and those in the informal sector using innovative schemes.

Another key challenge is equalising or universalising the benefits covered by all of these schemes. Only a small fraction of the population has access to a comprehensive set of services and is partially protected from severe financial risk (that is, those people belonging to social security affiliates). Services covered by public health insurance are limited in terms of scope, with only partial coverage for catastrophic conditions.

Finally, another main challenge that lies ahead is improving the overall efficiency and quality of the health service network, including expanding and improving health infrastructure to make services available to all. Distributing human resources efficiently and equitably is part of this challenge.

Further analysis is required to monitor and assess the health financing system in Bolivia comprehensively, to explore catastrophic health spending and impoverishment in vulnerable populations, and to evaluate the progressivity of health expenditure. For this task, updated National Health Accounts information and timely micro-level data from household surveys are a priority.


Fuertes, CV. 2016. Universal health coverage: Bolivia. Global Network for Health Equity (GNHE). Available at:

Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

WHO health financing country diagnostic

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This website presents assessments of the extent to which countries and other territories have progressed towards universal health coverage (UHC).

These assessments were written by members of the GNHE network, according to a template developed by the coordinators.

The template, in turn, was based on an early version of McIntyre D, Kutzin J. 2016. Health financing country diagnostic: a foundation for national strategy development. Geneva: World Health Organisation.

Check out the final version of this document here.


Lower-middle-income countries South-East Asia

Achieving universal health coverage in Pakistan

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To celebrate the start of a new year, GNHE has published an assessment of progress towards universal health coverage in another country – Pakistan.

You can read the full assessment here.


The author is Muhammad Ashar Malik and his main conclusions are:

In Pakistan, the health system is dominated by private financing (in the form of out-of-pocket payments) and private provision of health services. Apart from government spending there are very few prepayment mechanisms. Consequently cross-subsidisation is limited, especially as the better off have access to their own provider networks as well as government facilities.

Pakistan is now ranked as a lower-middle income country so it should increasingly be able to rely on domestic resources to finance health care. On many occasions the government has documented universal health coverage as its prime agenda for the health sector. However, to make progress, more serious efforts are required to reform health policy, revenue collection, resource pooling, resource allocation, purchasing and health care provision.

There are a number of dimensions that need the particular attention of policy-makers in Pakistan:

  1. Health care is now a provincial function and the four provincial governments can set their own priorities in their respective provinces. Although there is a new Ministry at federal level, consensus between the four provincial governments on financing and the scope of services would be essential to pursue the agenda of universal health coverage.
  2. Considering the currently constrained fiscal space it is unlikely that the government will be able to enhance allocations to the health sector substantially, without expanding the tax base and improving tax collection. Other sustainable modes of health financing should be explored besides general taxes.
  3. It is essential to set up a health system that offers comprehensive care and where the primary health care level has a strong gatekeeping function. From the universal health coverage perspective, a controlled referral system needs to be implemented.
  4. Medical practice in the country is alarmingly unregulated. Moreover, it is costly at the point of service delivery. For universal health coverage to materialise, an appropriate skills mix is a key policy instrument to save costs, while provider behaviour needs to be regulated for the provision of standardised, quality care.

Malik MA. 2015. Universal health coverage assessment: Pakistan. Global Network for Health Equity (GNHE). Available at:

Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

Measuring progress towards UHC

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If you missed our posts last year, remember to read GNHE’s perspective on practical approaches countries can take to measuring their progress towards UHC.

A summary of key messages on this topic is available here.

Two policy briefs that provide more details on how to measure progress towards access and financial risk protection, respectively, are available here.

Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

Key messages on UHC measurement

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With the inclusion of universal health coverage (UHC) in the Sustainable Development Goals (SDGs), there is considerable discussion on how best to measure progress to UHC. This note summarises the perspective of the Global Network for Health Equity (GNHE), a network that brings together the views and experience of a diverse network of researchers based at country level in Africa, Asia and Latin America.


Guiding principles

  • Our concern is with UHC as defined according to outcomes, namely access to needed health services of sufficient quality to be effective, and financial risk protection for all. Within this context, measurement of these outcomes must be independent of the structure of financing and provision in a health system.
  • In order to allow comparison across all countries irrespective of their income level, UHC measures must use data that are likely to be available across a diverse range of health systems, or for which there are reasonable substitutes.
  • GNHE supports the use of a small number of key indicators rather than a single composite UHC indicator, which obscures the multi-dimensionality of UHC as a concept. However, indicators of the two key elements of UHC should be assessed and interpreted together.
  • Monitoring of progress towards UHC should not only be measured in terms of each indicator’s overall average, but also the narrowing of differentials across socio-economic groups to take account of equity.


UHC goal of access to health services for all

  • Due to the complexity of measuring access directly, we propose measuring actual use of services.
  • Instead of focusing on a few services (such as antenatal care and immunisations), GNHE proposes assessing the adequacy and equity of overall service utilisation.
  • We recommend a minimum average utilisation rate of 4 outpatient visits per person per year; utilisation rates below this threshold suggest that a country is unlikely to have adequate access to services.
  • For inpatient services, a minimum threshold of 100 inpatient discharges per 1,000 population per year is recommended.
  • To assess equity, these minimum thresholds should be achieved in all socio-economic groups. Given that service utilisation should be according to need, the difficulty of accurately measuring need for health care and the generally greater burden of ill health among lower-income groups, utilisation rates should be at least equal across socio-economic groups.
  • Further work is required to develop an appropriate means of assessing quality and effectiveness of services used.


UHC goal of financial risk protection

  • Indicators of catastrophic levels of out-of-pocket health expenditure and impoverishment from making out-of-pocket payments for health services should be used to assess financial risk protection.
  • Constraints on currently available data limit refinements to these existing measures. Priorities for improved data collection and future refinement of these measures include:
    • Including all direct costs related to using health services when needed (e.g. costs of transport to the health care provider) and possibly also health insurance contributions
    • Developing a common methodology to measure country-specific basic needs’ thresholds for use in impoverishment analyses instead of the global, minimalistic poverty lines (e.g. $1 per day)
  • It is important to recognise that these measures only reflect the proportion of the population who actually use health services and are impoverished or face financial catastrophe as a result. They do not take account of those who do not use health services due to a lack of financial resources. It is for this reason that measures of financial risk protection must be assessed together with measures of service utilisation; where utilisation rates are below the minimum threshold, this is likely to reflect the existence of unmet need.
Africa Lower-middle-income countries

Achieving universal health coverage in Ghana

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Bertha Garshong and James Akazili of the Research and Development Division, and the Navrongo Health Research Centre, of the Ghana Health Service respectively, have written an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:


  • Over the past few years there has been some improvement in access to health care in Ghana. However, there are still many challenges to the achievement of universal health coverage.
  • Ghana’s National Health Insurance Scheme (NHIS) is a pro-poor policy and offers a generous benefit package to its members. Yet many poor people find it difficult to pay registration fees as well as the premiums. The Scheme also has difficulties determining the socioeconomic status of applicants: flat-rate rather then income-related premiums therefore burden poorer members disproportionately. While there have been promises by policy-makers to improve the equity of the NHIS, not much progress has been made in this regard on the ground, and proposed premium reforms remain controversial. As a consequence, the NHIS still caters more for higher-income groups, leaving many poor families without any prepaid cover, despite contributing to the VAT-funded component of the Scheme. As a result, out-of-pocket expenditure remains relatively high.
  • For Ghana to move towards universal coverage, the country needs to find more money to replace the current out-of-pocket payment system. As the relative contributions of premiums is small, tax-based funding is the obvious source. However, increasing the fiscal space to fund the NHIS requires economic growth and improved tax collection.
  • For a modest increase in fiscal space for health for 3 to 5 years, Ghana needs to achieve a revenue collection rate of 20% of GDP by 2015. Currently the collection rate of tax revenue is below 13%. A World Bank report on the NHIS states that Ghana’s macroeconomic landscape is still fragile and any move must be done cautiously. With Ghana’s oil find the growth rate was modest but steady around 6% in 2013, and this gives some fiscal space for health in the next five years. However, this will depend on government spending and revenue collection efforts and priorities. Much as Ghana is not expected to get foreign aid because of its lower-middle-income status, it could benefit if it increases its credit rating and devises a clear exit strategy from aid. Lastly, Ghana has structural inefficiency in its health system as well as in the operations of the NHIS. Tackling these inefficiencies could release some additional fiscal space.
  • Apart from strengthening the financing and coverage of the NHIS, it is vital to expand access to health care services and raise the quality of care. This would include addressing the inequitable distribution of human resources and equipment, and improving the management and administrative capacity of the NHIS. The Community Health Planning Services programme, which is designed to provide a close-to-client service, needs to be expanded. Primary health care services are closer to the people and are within reach of the poor, but confidence in these facilities has dwindled due to lack of skilled staff, equipment and supplies and the poor quality of care, particularly in rural communities. These limitations necessitate referrals but, with the lack of transport and poor roads, many referred clients are unable to access higher levels of care.
  • Information barriers are another area that requires attention. There has not been a consistent and effective communication strategy for either providers or potential clients regarding the mechanisms of the NHIS, especially with respect to the poor.


Bertha Garshong and James. 2015. Universal health coverage assessment: Ghana. Global Network for Health Equity (GNHE). Available at:

Africa Lower-middle-income countries

Financing options for universal health coverage in Zambia

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Bona Chitah and Dick Jonsson, of the Department of Economics at the University of Zambia, have written an assessment of Zambia’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

  • Zambia is making continuous progress in all the key areas of its health system. However, there are gaps which need to be resolved for the country to be able to realise the goal of universal coverage, including universal financial protection and access to care.
  • A more equitable distribution of resources between urban and rural areas is required. Currently there is an urban bias in resource distribution. This is evidenced not only in the allocation of public health sector resources, but also in expenditures by the wealthy on private health care.
  • Resources need to be allocated to promote access to, and utilisation of, health care by the poorer socio-economic groups. The higher consumption of public inpatient health care services by wealthier groups is a striking example of inequitable utilisation, as is the relatively greater levels of government subsidy received by wealthier groups, even for primary health care.
  • The impoverishing effect of out-of-pocket payments exposes poorer households to financial risk, driving households into poverty or further into poverty. This requires reconsideration of public hospital user fees, both in terms of the level of fees and the application of bypass fees (which are charged when patients bypass primary health care facilities, including because of the severity of their conditions and their proximity to higher-level health facilities).
  • Finally, Zambia’s ambition to introduce social health insurance as a mechanism for improving the pooling and purchasing of services needs to be scrutinised for its possible impacts on equity. The proposed social health insurance scheme would require co-payments and perhaps other contributions, which would increase the financial burden on households. This means that the proposed scheme could effectively run counter to the ambition of attaining universal health coverage.
  • There should be a critical evaluation of the alternative option of simply continuing – and strengthening – the current tax-based financing system.

Chitah B, Jonsson D. 2015. Universal health coverage assessment: Zambia. Global Network for Health Equity (GNHE). Available at:

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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:


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:

Lower-middle-income countries South-East Asia

Achieving universal health coverage in Indonesia

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Trisnantoro, Marthias and Harbianto (from the Centre for Health Policy and Management, School of Medicine, Gadjah Mada University) in Indonesia, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.


The authors’ conclusions are:

  • The burden of health financing in Indonesia is mildly progressive
  • The distribution of utilisation is also mildly progressive, particularly for hospital inpatient care
  • Indonesia’s out-of-pocket payments are still at a very high rate because of user fees across the system and the large proportion of the population that remains uninsured
  • Catastrophic payments probably still burden many of the poor while utilisation by the poor is low relative to their need for health care
  • The complexity of the financial protection system has introduced distortions into funding flows and the provision of care
  • Risk pools have also been fragmented
  • To address these problems, the Indonesian government has initiated the implementation of its first universal health coverage program, National Health Insurance or BPJS
  • The intention is to unify all the old health schemes, creating one large risk pool
  • The coverage of the new scheme was almost 122 million people in 2012. The intention is to insure all 258 million Indonesians by 2019, including foreigners who work in the country for more than six months
  • The new scheme is funded through a mixture of government subsidies and premiums
  • There will be a nation-wide, single benefit package that is comprehensive, except for some limits and exclusions
  • The scheme will practise active purchasing with accredited providers (including capitation and Indonesian DRGs), negotiate with providers around cost control, and implement mechanisms to improve quality
  • Gate-keeping by primary care providers is an important strategy to improve health system efficiency
  • In conclusion, financial protection should be regarded as one aspect of universal health coverage and not the sole agenda for Indonesia. Intensive investment is required to ensure supply-side readiness, so that equitable health care utilization and health attainment can be achieved even in the currently under-developed regions of Indonesia.


Trisnantoro L, Marthias T, Harbianto D. 2014. Universal health coverage assessment: Indonesia. Global Network for Health Equity (GNHE). Available at:

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New GNHE website

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This is GNHE’s new website. We hope it will make it easier for you to access GNHE resources and interact with the GNHE coordinators. Here are some tips to help you find your way around:

  • The home page is a blog site where notices will be posted. Please click the Follow button so that notices are automatically sent to your e-mail address.
  • Depending on your screen viewing option, you will find a list of pages either in the left-hand column, or in a menu on the top right. These store information and useful resources. Click on the page name and the page will pop up.
  • You will also find a list of ‘Categories’ which will take you to any notices under the theme category. If you click on a category, all the notices under that theme will pop up. This way you will be able to find old notices that have already scrolled off the bottom of the screen.

If you have any suggestions on how we could improve the site, please let us know!