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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: