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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. 

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.
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:

High-income countries South-East Asia

Achieving universal health coverage in Hong Kong

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Cheuk Nam Wong and Keith YK Tin, of the School of Public Health at the University of Hong Kong, have written an assessment of Hong Kong’s progress towards universal health coverage for GNHE.

You can read the full assessment here.


The authors’ main conclusions are:

  • Hong Kong is a good example of a progressive health financing system. This is because there is a relatively large tax-financed, public health system that shields those with low incomes from out-of-pocket payments. It also requires the rich to pay more tax, both in absolute terms and as a proportion of income. Equally importantly, almost no-one in Hong Kong lives in poverty and health outcomes are good across the various socio-economic quintiles.
  • These features account for why a relatively high level of out-of-pocket expenditure (around a third of total health care financing) does not have a negative equity impact on vertical and horizontal equity. These payments are mainly made by the rich who have the ability to purchase health care services in the private sector.
  • In terms of efficiency, over the last decade total health expenditure in Hong Kong was amongst the lowest as a percentage of GDP compared with OECD countries. Despite this low level of spending, Hong Kong’s health care system achieved service quality and health outcomes that are outstanding by global standards (including the longest life expectancies and lowest infant mortality rates).
  • Further, given its universally accessible public sector, adverse selection in Hong Kong is virtually non-existent. Moral hazard is limited to the private system. Thus, one study suggested that third-party coverage in Hong Kong, be it through public entitlement or private insurance, mostly facilitated access that met genuine health need rather than encouraged inappropriate overuse of services. A supply-driven public sector with an effective referral system, and high out-of-pocket co-payments for private services, probably explain these observations.
  • Hong Kong does not fare as well in terms of equitable access to health services, however. There is pro-rich inequity in the delivery of general outpatient care (but not specialist care) and very marginally for inpatient care, when utilisation is considered in relation to need.
  • With respect to future reforms, the setting up of a closely regulated voluntary private health insurance scheme is a priority on government’s agenda. The government is currently going through a public consultation process but will have to overcome public scepticism and clarify the need for such a scheme as part of a sustainable model of health financing. Should the voluntary health insurance scheme be implemented, it can be expected that personal contributions will play a more important role in the financing of the Hong Kong health system in future, and facilitate risk cross-subsidies so that access to health care is improved.
  • However, no country in the world has reached universal population coverage based mainly on voluntary prepayments. Voluntary prepayment for private health expenditure does not diminish people’s demands for more public spending on health, and compulsory prepayments are essential for health financing to be sustainable, be it in the form of various taxes or mandatory health insurance. Hong Kong is not likely to be an exception. It has taken time for citizens to realise that the current system is not financially sustainable without help from mandatory prepayment.
  • The most pressing question therefore seems to be whether the share of the gross domestic product going to taxes should be increased, thereby allowing greater budget allocations to the health sector. An argument against this would be that this might lead to under-funding of other social pillars such as education, housing, and social assistance. In addition, in the past Hong Kong has made the political choice for low tax regime and stringent controls on government expenditure. In fact, when scaled against the public revenue base, Hong Kong’s public spending on health is only slightly lower than other comparable economies.
  • Apart from these questions around financing, there are two other challenges to universal health coverage. First, an ageing population puts pressure not only on the provision of health care services but also the financing mechanism driven by tax revenue. In future years, less people will be working and thus paying tax to support a health system that will be taking care of more people.
  • Second, demographic issues are further complicated by the Hong Kong government’s lack of autonomy in immigration control. A continuous population influx from mainland China will exert pressure on Hong Kong’s health system. The number of immigrants from the mainland is difficult to forecast as it is subject to policy changes that are unpredictable and are out of the Hong Kong government’s control. It is difficult to devise long-term plans for the health system if population forecasts are not accurate.
  • Finally, the extent to which government health expenditure is accepted by the public hinges on the accountability of the government. As shown by recent protests, the government does not enjoy the support of the whole population. When citizens have little confidence in the government, every policy that the government tries to put forward prompts a reaction which is not always positive. As a result, attempts to implement health reforms in Hong Kong have been made over more than a decade, but changes that have the potential to improve the health system are yet to materialise.

Wong CN,  Tin KYK. 2015. Universal health coverage assessment: Hong Kong. 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:

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:

High-income countries South-East Asia

Single-payer, mandatory health insurance in Taiwan

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Jui-fen Rachel Lu, of Chang Gung University in Taiwan, wrote an assessment of her territory’s progress towards universal health coverage for GNHE.

You can read the full assessment here.


The author’s main conclusions are:

  • National Health Insurance (NHI) is one of the most highly rated social programmes in the history of Taiwan, with consistently more than 70% of the public expressing satisfaction with the programme in 2014
  • Since its inception in 1995, NHI has greatly improved access to care and successfully provided financial protection to all citizens of Taiwan
  • It has delivered broadly satisfactory results in terms of the equity of both the financing and delivery of care
  • In general, NHI has been able to shield needy patients from financial barriers to access and provided access to comprehensive care
  • To a great extent the public has enjoyed freedom of choice and convenient access to services
  • Despite its popularity, NHI has constantly been plagued by the threat of financial insolvency
  • The issue of financial sustainability is always top of the reform agenda and there have been numerous reform proposals
  • Unfortunately, unwieldy political processes have prevented the Ministry of Health and Welfare from undertaking reforms to tackle the deficiencies of the system
  • In its 18-year history, the National Health Insurance Administration has only succeeded in raising the premium contribution rate three times, and this came at a high political price, with a Minister of Health having to step down at one point
  • Without fundamental reforms to NHI’s financing mechanism, such as linking premiums to better measures of total household income, the rapidly ageing population and economic stagnation are likely to threaten the financial soundness of the programme
  • For the foreseeable future, financial sustainability will remain a formidable challenge to the single-payer health insurance program in Taiwan


Lu JR. 2014. Universal health coverage assessment: Taiwan. Global Network for Health Equity (GNHE). Available at:

Africa Low-income countries

Achieving universal health coverage in Uganda

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Zikusooka , Kwesiga, Lagony and Abewe, of HealthNet Consult in Uganda, wrote 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:

  • Tax-based funds contribute a relatively small share of total health financing in Uganda
  • The public sector is heavily constrained in providing an adequate range and quality of services
  • The Uganda population reverts to seeking care from the large private sector, which is perceived to have better quality services
  • The fact that patients have to pay on an out-of-pocket basis for private care intensifies the exposure to financial risk across the population
  • With very limited financial protection and highly fragmented risk pools, there is very little income and risk cross-subsidisation in Uganda
  • As a consequence, utilisation of health care services is largely dependent on the ability to pay rather than need
  • Furthermore, purchasing arrangements do not encourage efficient, high-quality service provision or the provision of services that meet patients’ needs
  • To address some of these problems, the country needs to utilise the current mechanisms put in place to ensure donor assistance is more useful by increasing its effectiveness and equity.
  • The prospects of increasing health resources through the budget seem to be dwindling as the health sector has been crowded out by other government priorities, particularly infrastructural development and the education sector
  • Leveraging other sector-specific resources through implementing mandatory health insurance is thus an area where Uganda should look to increase public sector health resources (Uganda is still considering this policy option)
  • As has been done in other countries in Africa, Uganda could also look at tax levies earmarked for the health sector
  • Finally, wastage is a major issue in use of health sector resources. Making better use of existing resources would require government to institute mechanisms for monitoring and incentivising efficient performance



Zikusooka CM , Kwesiga B, Lagony S, Abewe C. 2014. Universal health coverage assessment: Uganda. Global Network for Health Equity (GNHE). Available at:


Low-income countries South-East Asia

GNHE launches new UHC assessment for Nepal

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Shiva Adhikari, from the Patan Multiple Campus at Tribhuvan University and Health Economics Association in Nepal, has just written an assessment of his country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.


The author’s main conclusions are:

  • Nepal’s health financing and expenditure indicators are slightly better than those of the average low-income country, but out-of-pocket expenditure is still extremely high
  • This means that financial protection is not adequate for large numbers of people
  • Despite the provision of free essential services to the poor, geographic access to quality services is still pro-rich
  • There is growing pressure on the government of Nepal to expand the benefits covered under the free essential health package, as well as to expand coverage to all Nepalese
  • There is also growing pressure to increase government expenditure on health and improve the efficiency of the health system.
  • Proposals for new financing mechanisms, such as health insurance, are being debated.
  • Meeting these demands will be difficult for Nepal, given its low-income status.
  • In relation to expanding the fiscal space for health, a first consideration is economic growth, as higher growth rates would broaden the tax base and increase government revenue, especially if tax administration could be improved as well. Unfortunately, in recent years real GDP growth has been quite low.
  • Another option for government is to expand its domestic borrowing although there are arguments that this could affect the economy. Increasing donor funding, or international loans, also does not seem a very viable option, given that Nepal already receives considerable funding from these sources.
  • From a macro-fiscal perspective, therefore, the prospects of finding additional public resources for health are relatively low, unless health can increase its share of the government budget. Some consider that this would be difficult to argue for, as Nepal already spends a relatively large share of its budget on the health sector.
  • After analysing all these potential sources, a report produced by World Bank suggested that the only realistic option for Nepal is improving the efficiency of existing health expenditure.
  • However, more thinking may need to be done on how to increase tax-based financing – through widening the tax base, improving tax administration and ear-marking certain taxes – given the remaining problems with financial protection and inequities in access in Nepal.


Adhikari S. 2015. Universal health coverage assessment: Nepal. Global Network for Health Equity (GNHE). Available at:

Low-income countries

Achieving universal health coverage in Tanzania

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Gemini Mtei and Suzan Makawia, of the Ifakara Health Institute in Tanzania, 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:

  • Despite the significant contribution of public and donor resources in Tanzania, benefit distribution is still pro-rich, even for some public providers (especially hospitals).
  • Benefits are pro-poor only in primary care facilities, which in many cases are characterized by poor quality and unavailability of certain services.
  • Out-of-pocket payments are inequitable.
  • Impoverishment due to catastrophic payments for health care translated into about 480,000 people falling into poverty in 2007.
  • The Tanzanian government has committed itself to attaining universal coverage through the expansion of health insurance coverage to 30% of the population by 2015 and increased government allocations to the health sector.
  • A challenge to the achievement of this target, though, is the high dependency on donor funding, especially as some donors are pulling out of health sector basket funding due to concerns about value for money.
  • Catastrophic health care payments and impoverishment might increase as long as donor funds remain unsustainable and if general tax allocations to the health sector do not increase.
  • More attention also has to be paid to extending coverage among the poor.
  • The range and quality of public sector services also need to be improved as this where most poor households access the health system.


Read more in: Mtei G, Makawia S. 2014. Universal health coverage assessment: Tanzania. Global Network for Health Equity (GNHE). Available at: