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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.
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:


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:

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:

Low-income countries South-East Asia

Achieving universal health coverage in Bangladesh

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Ahmed Mustafa and Tahmina Begum from Bangladesh 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:

  • Bangladesh faces a number of challenges from a financial protection perspective:
    • the country relies heavily on out-of-pocket payments that account for almost two-thirds of total health expenditure
    • there is evidence of a high incidence of catastrophic payments and impoverishment due to out-of-pocket spending
  • In Bangladesh, the better off:
    • pay more out of pocket for health care
    • spend proportionally more of their household resources on health care
    • receive more and better care
  • The poor pay less and receive less health care
  • The poorest of the poor simply cannot afford to pay and hence do not seek treatment
  • In most cases hospital care is pro-rich while non-hospital care is pro-poor
  • The pro-poor utilisation of outpatient services probably reflects the reliance of the poor on unqualified private informal providers
  • With the aim of achieving universal coverage, Bangladesh’s Ministry of Health and Family Welfare has developed a new 20-year health care financing strategy: the goal is to strengthen financial risk protection and extend health services and population coverage
  • The intention is to halve out-of-pocket payments for health care at the point of service delivery
  • The new strategy will combine funds from tax-based budgets, existing community-based and other prepayment schemes, and donor funding
  • Current low levels of health financing could be addressed through an increase in the level and efficiency of the government’s budget allocation as well as by creating a compulsory Social Health Protection Scheme
  • In order to increase access, tax-funded primary and preventive care services will remain free for all groups of the population.
  • The strategy envisages starting its health protection coverage with the poor and the formal sector. Then it will extend its coverage and benefit package to include the informal sector in order to achieve universal coverage


Read more in: Mustafa A, Begum T. 2014. Universal health coverage assessment: Bangladesh. Global Network for Health Equity (GNHE). Available at: