Category Archives: Upper-middle-income countries

Latin America Upper-middle-income countries

Achieving universal health coverage in Costa Rica

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The last of GNHE’s country assessments was published today. Written by Pablo Slon, it examines the progress of Costa Rica towards universal health coverage.

As Pablo Slon writes, one of the main features of the Costa Rican health system is the existence of a single health insurance fund, just as in the United Kingdom, France and Canada. Prepayment is mandatory for the whole working population and employers, and health insurance coverage in 2011 was 86%. Health services are provided mainly by this health insurance fund, with the coexistence of private sector provision. Health services are free at the point of access.

There is equal access to public health services because there is high coverage in terms of provision. There is also equality of financial risk protection.. The factors explaining these achievements include various institutional factors and health system characteristics.

One of the explanatory factors is the fact that Costa Rica ‘started small’ with an early political agreement to develop a Bismarck-style insurance system for the working class. A gradual process of including progressively more groups into this insurance system played a major role.

The existence of a tripartite financing scheme – involving employers, employees and the state in contributing to a common fund – creates cross-subsidies that allow access to health care across different population groups. Having a single risk pool is also a key factor. The existence of a private sector that complements the public sector allows those who do not want to use public services to reduce the demand on the public system. Last, but not least, low income-inequality and poverty within the country helps to reduce economic barriers to accessing health services. Democratic institutions and the rule of law support the performance of the health system through accountability, supervision, law enforcement and regulation.

However, the fact that the public health insurance fund is the main revenue collector, purchaser and provider creates some conflict of interests from the perspective of regulation. This is because the lack of separation of functions weakens the allocation process and oversight of performance. It also gives the fund enormous economic and political power, constraining the stewardship role that should be played by the Ministry of Health.

A future challenge is to ensure the financial sustainability of the National Health System in the face of demographic changes, with the proportion of elderly people growing. There is also an epidemiological challenge because chronic diseases are becoming more prevalent. Finally, there is a portion (14%) of the population that is not insured. Although they can access care if they require services, they have to pay fees for these services, which can impoverish them as they could incur into catastrophic expenditures. An additional problem is that this segment of the population mainly accesses emergency services, and they are not able to get appointments for outpatient services. Insuring this remaining portion of the population and charging for services properly after they have been used are important challenges.

Finally, more data are needed to understand whether the Costa Rican health care system is closing the gap between health care needs and health care provision, especially across all socio-economic groups. There are some indications that there are remaining differentials in actual and perceived health status across different income quintiles, and that waiting lists prevent some patients receiving prompt attention.


Pablo Slon. 2017. Universal health coverage assessment: Costa Rica. Global Network for Health Equity. 

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.


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.
South-East Asia Upper-middle-income countries

Public financing for universal health coverage in Malaysia

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Chiu-Wan Ng, of the Julius Centre for Clinical Epidemiology and Evidence-based Medicine in the Department of Social and Preventive Medicine at the Faculty of Medicine of the University of Malaya, has written an assessment of Malaysia’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

  • The claim that Malaysia has achieved universal health coverage appears to be supported by the findings of the assessment of the country’s health system.
  • Financing of health care has a progressive distribution and average household out-of-pocket payments are relatively small, especially for poorer households. Overall, the population enjoys high levels of financial risk protection and the use of public health care services is equitably distributed.
  • The fact that the poor are spared a high burden of out-of-pocket payments can be partially attributed to the extensive network of public health facilities: this provides a wide range of very cheap health care services to those in need. Direct household out-of-pocket health payments in Malaysia are in fact almost exclusively for the purchase of private care. Out-of-pocket payment distributions favouring richer households indicate that, in general, private care is mainly purchased and consumed by the rich, a finding which should not be surprising since these households are more likely to be able to afford such care.
  • Increasing public demand for better quality care, as well as changing demographics and disease burdens, are putting the Malaysian public health system under tremendous strain. Major health reforms are being discussed within government although very few details have been released to the public. It is likely that a future system would involve social health insurance, a single purchaser and both public and private provision.

Ng C-W. 2015. Universal health coverage assessment: Malaysia. 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:


Latin America Upper-middle-income countries

Important strides to universal health coverage in Colombia

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Ramiro Guerrero, and others from the Centro de Estudios en Protección Social y Economía de la Salud in Colombia, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

Colombia has made big efforts to fulfil the goal of universal health coverage:

  • since 2000, health expenditure as a percentage of GDP has been around 6.8%
  • government health expenditure as a percentage of total health expenditure is almost 80%
  • in 2010 all health system financial sources were progressive, meaning that higher-income individuals contributed relatively more towards the health system
  • in 2013 the contributory and subsidised regimes covered approximately 96% of Colombia’s population, and more than half the population was completely subsidised
  • there is a common mandatory benefit package
  • The Colombian health system has two major health insurance schemes:
    • the contributory regime is mandatory for formal workers and other people with the capacity to pay
    • the subsidised regime is for the unemployed, informal sector workers and the poor
  • The structure of the health system pools all resources into a common fund that is distributed on a risk-adjusted, capitation basis to a range of public and private health maintenance organisations. People are allowed to choose their health maintenance organisation, and health maintenance organisations are able to choose the providers with which they contract.
  • However, 4.6% of households in 2010 incurred catastrophic expenditure (measured using a 40% threshold of non-food household expenditure). Although this was an improvement from 2008, the intensity of catastrophic expenditures is still concentrated in low-income people. Data also suggest that the households that became poor after a financial shock were predominantly those in the subsidized regime and the uninsured.
  • In summary, Colombia has made important progress towards universal health coverage but attention still needs to be paid to the differences in access to health care for those with lower incomes and living in rural areas.


Read more in: Guerrero R et al. 2015. Universal health coverage assessment: Colombia. Global Network for Health Equity (GNHE). Available at:



Africa Upper-middle-income countries

Achieving universal health coverage in South Africa

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Di Mcintyre, Jane Doherty and John Ataguba, from the Health Economics Unit at the University of Cape Town in South Africa, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

In South Africa, everyone without voluntary health insurance is able to use public sector services that provide a relatively comprehensive range of care.

Although most public sector users must pay fees for hospital care, these are income-related and, more importantly, the poorest, young children and pregnant women are eligible for fee waivers.

However, the South African health system falls short of the goal of universal coverage, both in relation to some aspects of financial protection and equity in financing but particularly in terms of equitable access to needed, effective and good quality health care.

There is a six-fold difference in health care spending between voluntary health insurance members and those entirely dependent on public sector services.

There are a number of causes of these problems:

  • An onerous burden of out-of-pocket payments on some individuals due to the uneven implementation of user fee exemptions at public hospitals and for those not eligible for exemption from user fees, yet with limited ability to cover these fees on an out-of-pocket basis
  • A range of barriers to health service access other than user fees, including an under-supply and a maldistribution of health workers relative to the distribution of the population with the greatest need for health care
  • A relatively low share of mandatory pre-payment funding
  • Fragmented funding and risk pools, which limit the potential for income and risk cross-subsidies
  • Weak purchasing including a poor incentive environment

Within the context of considerable income inequalities (where the richest 10% of the population account for 51% of income and the poorest 10% for only 0.2% of income) and a far greater burden of ill-health and hence risk of needing health care on lower socio-economic groups, the importance of creating an integrated pool of mandatory pre-payment funds in order to pursue universal coverage is indisputable.

While the South African government has published a draft policy on National Health Insurance, many of the details are yet to be finalised.

Read more in: McIntyre D, Doherty J, Ataguba J. 2014. Universal health coverage assessment: South Africa. Global Network for Health Equity (GNHE). Available at:



Upper-middle-income countries

Achieving universal health coverage in Peru

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Janice Seinfeld and Nicolas Besich, of Videnza Consultores in Peru, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ concluding points are:

  • The health sector in Peru is fragmented, consisting of a non-integrated set of sub-systems aimed at serving different segments of the population.
  • Over a third of the population remains uncovered and out-of-pocket payments account for over a third of health care financing.
  • More than 75,000 households are impoverished annually as a result of health care payments.
  • One of the most neglected segments of the population in terms of health insurance is the one including lower-middle and low-income individuals. This segment is not classified as poor and thus cannot access subsidized insurance through the publicly financed SIS. At the same time, they mostly work in the informal sector and therefore are not able to access the mandatory insurance scheme for formal sector workers, EsSalud.
  • There are several problems that account for this state of affairs:
    • the large informal labour market
    • the fragmentation of the health system
    • fragmented and inadequate funding for the public sector
    • the poor responsiveness of health services (especially in the public sector)
    • bottlenecks associated with the integration of the purchasing and provision functions of EsSalud
    • difficulties in implementing strategic purchasing
    • the absence of a risk-pooling mechanism for different insurance plans
    • the inefficient and inequitable distribution of human resources
  • In response to these problems, in 2013 the Ministry of Health announced a comprehensive reform of the public health sector:
    • reorganisation of the sector and public agencies
    • strengthening the funding of SIS and EsSalud
    • the modernisation of the management of public investments in the sector
    • the modernisation of the national health system (e.g. to shift the focus to promotion, prevention and early detection)
    • a comprehensive reimbursement policy
  • The impact of these reforms is not yet known.
  • Some important areas that need attention with respect to promoting financial protection are:
    • the definition of an explicit benefit package and actuarial projections about its costs
    • improving the efficiency of available resource use
  • Any budgetary increase must be justified by the increased ability of the government to attain its health objectives.


Read more in: Seinfeld J, Besich N. 2014. Universal health coverage assessment: Peru. 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!