WHO and many other commentators have called for countries to take concrete steps towards the achievement of universal health coverage, which in its simplest formulation means providing all people with access to needed health services of sufficient quality to be effective, without their use imposing financial hardship.1, 2, 3 Stronger reliance on prepaid health spending and risk pooling mechanisms are regarded as key indicators of progress towards universal coverage (panel). One fundamental objective is to reduce the financial barriers that people face to gain access to necessary health care. High reliance on out-of-pocket payments in health financing is associated with an increased risk of households being affected by financial catastrophe, being pushed into poverty (or further into poverty) because of health-care payments, or forgoing needed treatment because of inability to pay.1, 5, 6
Key messages
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A greater reliance on prepaid health spending and financial risk pooling is regarded as a key sign of progress towards universal health coverage
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The direction and strength of the links between pooled prepayment, insurance mechanisms, and population outcomes can be affected by many factors
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State-of-the-art quantitative methods provide evidence on the causal effect of broader health coverage on population outcomes
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Broader health coverage generally leads to better access to necessary care and improved population health, with the largest gains accruing to poorer people
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The health gains derived from broader coverage are likely to depend on factors such as institutional framework and governance arrangements
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Countries with enough resources should regard progress towards universal health coverage as a key investment target
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Donors have an important role in ensuring that the poorest countries have the sustained ability to invest adequate resources in the enhancement of coverage
Even though financial protection is in itself regarded as a valuable objective in many societies, expanded coverage is also justified on the grounds that it leads to health improvements, particularly for poor people.1, 7 This reasoning often lies behind efforts to expand access to health services through pooled prepayment mechanisms that have an insurance function. The logic is that such pooling mechanisms will increase access to care by enhancing the availability and affordability of needed services, and thereby improve health.8
The figure illustrates the underlying argument by showing, in a simplified way, the potential causal chain from pooled prepayment (publicly or privately funded) to coverage (effective access to care and financial protection) to health outcomes. There can also be reverse causality in the chain if changes in population health status trigger changes in the amount of pooled funds available for health.
Although the causal pathway from pooled prepayment to universal coverage and health is often taken for granted in the international debate, findings from empirical research have not always shown that population health systematically improves in response to enhanced risk pooling and prepayment. There are theoretical reasons why those links might be weak or non-existent at the population level, since the relations in question could be affected by many other elements, represented by the vertical arrows in the figure. For example, a rise in government health spending—which usually takes the form of prepaid funds and amounted to 60% (IQR 45·4–75·6) of total health spending across 192 countries in 20089—might be accompanied by a matching reduction in prepaid private health expenditures. This situation could result in no changes in total prepaid spending, service use, or health status.
Even if extra government spending does increase the total amount of pooled resources devoted to health care, its effect on health might be disappointing if the targeting of funds is poorly aligned with population needs.10 Furthermore, the magnitude of any health gains is likely to depend on the identity of the beneficiaries. Poor people will usually stand to gain most from increased access to health services, so if access improves only for small groups of richer people, there could be few observable gains in aggregate.
Robust quantitative evidence is necessary to substantiate that the predicted causal pathway does occur in practice for populations, and to identify the main system-wide factors affecting the strength of the relation. Our aim is to synthesise the most rigorous, relevant empirical evidence produced so far, with a focus on system-level and cross-country statistical research.