Policy Brief: What Steps Are Countries Taking To Implement Pro-Poor Universal Health Coverage?

The June 6–10, 2015 workshop at the Rockefeller Foundation Bellagio Center in Italy on implementing pro-poor universal
health coverage was supported by The Rockefeller Foundation and the United States Agency for International Development.
What Steps Are Countries
Taking To Implement
Pro-Poor Universal Health
Coverage?
Key messages from the literature
and expert interviews
POLICY
BRIEF

Prolicy Brief: What Steps Are Countries Taking To Implement Pro-Poor Universal Health Coverage? | 1
Background
Universal health coverage (UHC)—ensuring that everyone
has access to quality, affordable health services when
needed—can be a vehicle for improved equity, health,
financial well-being, and economic development. In its
2013 report, Global Health 2035: A World Converging within
a Generation, the Commission on Investing in Health made
the case that pro-poor pathways towards UHC, which
target the poor from the outset, are the most efficient way
to achieve both improved health outcomes and increased
financial protection (FP).i
Countries worldwide are now
embarking on health system changes to move closer to
achieving UHC, often with a clear pro-poor intent.
Much has been written about what steps countries have
taken and are currently taking to: (1) set and expand
guaranteed services, (2) develop health financing systems
to fund guaranteed services and ensure FP, (3) ensure
high-quality service availability and delivery, (4) improve
governance and management of the health sector, and (5)
strengthen other aspects of health systems to move closer
to UHC.ii
As background for a meeting on UHC implemen-
tation, held at the Rockefeller Foundation’s Bellagio Center,
Italy, from 7–9 July 2015, we reviewed this body of literature,
and conducted interviews with global UHC implementers
and researchers.iii
In this short policy brief,iv
we synthesize
the key messages from the literature and interviews.
1. What countries are doing to set and expand
guaranteed services
As countries move towards UHC, they are taking a number
of different approaches to setting and expanding popula-
tion coverage and service packages. In setting pathways to
expand coverage, countries should consider the ability of
i See globalhealth2035.org
ii These five buckets categorizing the steps that countries are taking in
the path towards UHC closely align with WHO’s health system build-
ing blocks, namely: delivery of high quality, effective health services; a
solid health financing system; strong leadership and governance; and
a well-functioning and well-performing health system (where inputs
such as human resources and medical products, vaccines, and tech-
nologies are available and of high quality and where a strong health
information system is available and used).
iii In contrast to the large amount of literature on what steps countries
are taking to implement UHC, there is less information published or
otherwise easily accessible about the “how” of UHC—how to max-
imize the chances of successful implementation. “How” questions
were the focus of the Bellagio meeting: participants shared their ex-
periences in, and discussed the limited amount of empirical evidence
on, tackling a set of key “how” questions. The Bellagio meeting report,
and a short practice brief summarizing the main discussion points,
are available at globalhealth2035.org.
iv The full background report, which expands on the topics in this brief,
is available at http://globalhealth2035.org/sites/default/files/bellagio/
background-paper-pro-poor-uhc-evidence.pdf.
selected strategies to meet the health needs of the
population, to meet the equity and FP goals of UHC, and to
ensure value for money.
• Determining which populations to cover. Many countries
have begun their path to UHC by offering targeted
coverage to a subset of the population. Common
strategies used to determine coverage include targeting
by employment status (e.g. social health insurance for
formal sector employees), and targeting specific popu-
lation groups, such as by geographic location (Lagarde
et al, 2012) or health priority (e.g. pregnant women and/
or children under 5 years of age) (Yates 2010). These
approaches vary in their ability to provide coverage to
poor populations at the outset, and in response, some
countries have chosen to gradually expand coverage to
poorer populations as more resources become available.
A major challenge that several countries face is that of a
“coverage wall:” for example, coverage rates stubbornly
remain at 60–70% in Indonesia, the Philippines, and
Vietnam, and are considerably lower in Ghana (35%)
and Nigeria (5%), despite efforts to expand towards
universality (Nicholson et al, 2015).
There are a number of challenges associated with
targeted approaches, including concerns about quality
of care, fragmentation, and lack of coverage for the
informal sector and middle-income populations. To
address these, Nicholson and colleagues (2015) suggest
that achieving full population coverage from the outset,
with a smaller package of services, is preferable
to “covering selected population groups with more
generous packages of services and leaving some
people relatively uncovered.”
• Defining which services to guarantee. The World
Health Organization (2014) outlines three elements to
consider when deciding which services to cover: cost-
effectiveness, priority for the worst-off, and FP. Nicholson
and colleagues (2015) also highlight the importance of
reducing inequality when determining service packages,
while the World Bank (2014) includes a strong emphasis
on public health program investment and primary
health care principles. The Global Health 2035 report
made the case that infectious disease control,
maternal and child health services, and “best buys” for
non-communicable diseases should be prioritized first
in pro-poor pathways to UHC because the poor are
disproportionately affected by these conditions. There
is a growing emphasis on the need for research
evidence and country-specific contexts to be taken into
consideration in determining service packages,
something that many countries are starting to do
(Nakhimovsky et al, 2015).

Such fragmented systems may be more costly, and can
be inequitable. Nonetheless, providing the poor with
coverage through at least one mechanism is a move
towards improving equity, enabling them to access
essential services with out-of-pocket payments (OOPs)
even if they do not have access to as extensive a service
package as wealthier populations.
Some countries have a longer-term vision to reduce
or eliminate fragmentation, and with it, inequality.
Thailand, for example, has a goal of merging its three
existing health insurance schemes—the social securi-
ty scheme, the civil servants’ medical benefit scheme,
and the universal coverage scheme (Evans et al, 2012).
However, to date this has been politically challenging. It
is also possible for governments to play a risk-equaliza-
tion role between the different schemes, effectively
ensuring greater government subsidies go to the
scheme covering the poor.
2. What countries are doing to develop health
financing systems
To achieve UHC, countries must develop health financing
strategies and systems that (i) provide adequate resources
to guarantee and expand coverage over time and (ii) in-
centivize the efficient use of resources, provision of high
quality care, and equitable distribution of health coverage
across populations.
• Raising funds: Countries have many options for raising
additional domestic funds for health (see Box 1). In se-
lecting among these options, it is important to evaluate
the ability of these fund sources to provide sustainable
finance, and to ensure the FP of poor populations.
There is broad agreement that the poor should have free
or very low cost payments for services. In most low-
income countries (LICs) and middle-income countries
(MICs), where a priority is to increase FP, OOPs should
not be used as the main mechanism for revenue
generation as they are regressive and inequitable, they
deter use of health services, and they are a common
cause of impoverishment. Decreasing the reliance on
forms of direct payments, including OOPs, requires
increasing the amount of revenue from forms of pre-
payment, such as through insurance premiums. Cur-
rently, no national health insurance system relies solely
on wage-related deductions or contributions; even in
high-income countries, general government revenue is
required to supplement the cost of assuring coverage.
• Ensuring value for money using cost-effectiveness
analysis (CEA) and extended CEA. As countries expand
coverage, it is increasingly important to ensure the im-
pact and cost-effectiveness of UHC programs. There is
general consensus that good value for money can
be achieved by emphasizing primary care and
community-based services, as well as some district
hospital services (Jamison et al, 2013; Nicholson et
al, 2015). Examples of the former include Ethiopia’s
community-health worker scheme (Crowe, 2013), and
China’s barefoot doctors (Weiyuan, 2008), both of which
contributed to impressive population health gains at
relatively low cost.
Cost-effectiveness analysis—which compares the costs
and outcomes of alternative interventions—is one
important tool for improving the efficiency of health
service delivery, although it should not be used in isola-
tion from considerations about priority for the poor and
equity. However CEA does not assess an intervention’s
impact on FP. A newer tool, extended cost-effectiveness
analysis (ECEA), measures both the health and FP ben-
efits of alternative interventions (Jamison et al, 2013)
and can help decision-makers by showing the financial
versus mortality trade-offs between investing in differ-
ent interventions. While many countries are beginning
to use CEA and ECEA in determining service packages
(Nakhimovsky et al, 2015), this information is not always
incorporated into decision-making where there is politi-
cal pressure to the contrary (Giedion et al, 2014; Kapiriri,
2012). In addition to focusing on specific interventions,
new information on the cost-effectiveness of different
types of delivery platforms, such as clinic-, hospital-,
community- or outreach-based strategies, will be need-
ed to help countries determine which service delivery
strategies are likely to have the greatest reach and
impact at the lowest cost.
• Differing populations may be guaranteed different
services. We use the term “universalism” somewhat
loosely to mean “everyone covered.” This does not
necessarily mean that all people are in the same pool,
paying the same premiums and co-payments, and ac-
cessing the same services. Instead, the reality in several
countries that have made great progress towards UHC,
including Mexico and Thailand, is “fragmentation.” For
historical reasons, different populations are covered by
different schemes, contribute different amounts
(nothing for the poor except through general taxation),
and are guaranteed a different set of health services.

of inefficiency (WHO, 2010). Countries seeking to reduce
this inefficiency use two primary strategies: (i) conduct-
ing active or “strategic” purchasing, and (ii) introducing
forms of results- or outputs-based payments. Strategic
purchasing requires that countries explicitly consider:
the costs and benefits of alternative packages of health
services; where services should be made available; who
delivers them; and the costs and incentives for effi-
ciency and quality that exist in the alternative payment
mechanisms potentially available. Changing payment
from historical line item budgets that do nothing to en-
courage efficiency to forms of paying for results or out-
puts can be difficult and requires good administrative
capacities, but is a strategy that is increasingly being
pursued in several countries around the world.
• Considering equity in health finance arrangements:
Countries must explicitly consider the equity impli-
cations of decisions about all three health financing
functions—raising funds, pooling them, and using them
to provide or purchase services. Decisions about raising
funds impact who pays and how much they pay. With
pooling, critical questions such as who is eligible to
receive benefits emerge. For example, should it only
be individuals (i.e. the policyholder)? Or should it be
individuals and their families (and what is the limit on
the number of family members who can be covered)? In
terms of purchasing, equity considerations are related to
the question of what services are purchased or provided,
and if these services meet the health needs of poor and
vulnerable populations.
3. What countries are doing to ensure
high-quality service availability and delivery
• Ensuring service availability and use. There are many
steps that countries can take to improve service avail-
ability and use, such as (i) seeking to involve all of the
“vertical” health programs in development, review, and
modification of national health plans and policies, and
(ii) using planning tools, such as the OneHealth Cost
and Impact Tool, which estimates costs and impacts of
scaling up disease-specific programs and health
systems. It is important that countries engage a variety
of actors in these discussions, from external partners to
civil society. Countries should also ensure that plans to
improve FP go hand-in-hand with plans to improve the
availability and quality of needed health services.
• Ensuring continuity of care. Countries are developing
strategies to provide and link services across the con-
tinuum of health needs, from promotion and prevention,
to treatment, rehabilitation and palliation; throughout
the life course; and across the various levels of care (e.g.
Box 1. Sources of domestic funds for health
Out-of-pocket payments
Payment for service delivery by individuals at the
point of care
Health insurance premiums
Paid by individuals directly or through wage
deductions, by companies through employer
contributions, or by governments
Taxes and charges
Options include income and company taxes, indirect
taxes such as value added tax (VAT), and taxes on
specific items such as alcohol, tobacco, imports,
and exports.
Contributions from charitable organizations and
external development partners
There are many options for raising additional govern-
ment revenues, including various tax strategies, at
least some of which can be used for health. However,
ensuring the earmarking or allocation of these revenue
sources towards health, and UHC specifically, remains a
challenge in many countries. Many counties could also
increase the share of government funding currently
allocated to health. While there is no clear evidence on
exactly what proportion of government spending should
be directed to health, in 2001 the heads of state of the
African Union in the Abuja Declaration determined
that 15% was an appropriate level. However, in most
LICs and lower MICs, government allocations to health
remain well below this target.
• Pooling to spread risk: Pooling mechanisms enable
costs to be subsidized across populations, while also
minimizing the financial risk of the insurers. Contribu-
tions from a larger population (either by households
directly or through third-party government or employer
contributions) effectively enable the healthy to subsi-
dize the costs for the sick. Most pooling schemes also
develop progressive contribution systems such that the
rich subsidize the poor. Government revenues, some of
which are used to provide or fund health services, and
health insurance funds serve the same purpose as
prepayment and pooling.
• Using funds more efficiently: The 2010 World Health
Report estimated that between 20% and 40% of health
resources were typically wasted through various forms

Common governance challenges that governments face in
moving towards UHC include: (1) identifying an appropriate
role for the private sector and regulating this sector ac-
cordingly; (2) establishing adequate leadership and techni-
cal capacity within the health system; (3) instituting mech-
anisms for accountability and transparency in financing
and delivery decisions; (4) ensuring participation in these
decisions; (5) controlling corruption; and (6) maintaining
regulatory strength and enforcement capacity for financers
and providers of health services.
• Strengthening governance: Strategies used to improve
the governance function of health systems include
methods of control (e.g. laws and contracts), coordi-
nation (e.g. joint strategic planning, cost-sharing or
resource pooling), collaboration (e.g. partnerships with
civil society, inter-ministerial committees), and commu-
nication (e.g. satisfaction surveys, and publicly available
budgetary information) (Barbazza and Tello, 2014). In
some cases, strong leadership has translated into pub-
licly-announced commitments to moving towards UHC.
Tools that support the development and maintenance
of strategic direction in policy development (such as
creation of a national health plan), and implementation
(such as operational guidelines and protocols) can be
very helpful in improving transparency. Tools can also
support knowledge generation (such as periodic audits
or public expenditure performance reviews), improved
accountability (such as performance-based payment,
licensing, and accreditation) and monitoring and con-
trolling corruption (such as through routine auditing).
Finally, a handful of tools—such as open meetings, pub-
lic workshops and national fora—can increase public
engagement and collaboration across stakeholders.
• Measuring governance: Governments and health
system leaders require information about governance
in order to improve governance systems and ensure
the desired outcomes of quality, equity, and efficiency.
Governance evaluation tools and indicators are
commonly divided into four areas:v
(i) governance inputs
or determinants (existence of policies and institutions
that make up and influence the health system), (ii) gover-
nance processes and performance (implementation of the
policies and systems in place to understand the gaps
between expected and actual practice), (iii) governance
outcomes (determining how well health system policies
result in the desired health system goals), and (iv) con-
textual factors (external factors that impact the type of
governance structures that need to be in place and
their enforcement).
v See Baez-Camargo and Jacobs, 2011 and Savedoff, 2011.
primary care to tertiary hospitals, and between public
and private providers). Organized provider networks
with clear and appropriate referral systems are
important, as are decisions about integration across
delivery platforms.
• Overcoming barriers to service access. It can be very
helpful for countries to conduct reviews to determine
population service access barriers. Financial barriers
are common, including those linked to OOPs, transport,
accommodation, food, and lost work time. Barriers can
also be linked to gender, ethnicity, and social or edu-
cational status. Countries should develop appropriate
responses based on the best available international
experiences, adapted to the local setting. If health ser-
vices are already known to be of such poor quality that
people avoid them except when absolutely necessary,
improving quality is an important first step.
• Balancing the role and integration of non-governmen-
tal sector service provision. Countries must balance
the appropriate role for the public sector and non-gov-
ernmental sectors (NGOs, faith-based organizations,
private non-profits, and private for-profits) in service
delivery, including in health promotion and non-per-
sonal services such as laboratories, medical products,
and cleaning and catering services. Quality in the
non-government sector ranges widely, from state of the
art facilities to unlicensed medicine vendors. In many
settings government regulatory capacity is weak. Many
governments must expand their capacity to legislate,
regulate, and set and enforce quality standards with-
in the non-government sector, which has commonly
expanded more rapidly than government’s capacity to
oversee and monitor. Countries that have moved most
successfully towards UHC have taken a pragmatic
approach to expanding service availability by assessing
what mix of government and non-government services
makes most sense in their settings, and ensuring
government has the capacity to set, incentivize, and
enforce quality standards everywhere.
4. How countries are improving health sector
governance and management
Governance includes the process and rules through which
health systems are administered and managed, including
policy formulation and implementation, how responsibility
and accountability are assigned to actors, and the incentive
structures that shape the relationships between these
actors (Brinkerhoff and Bossert, 2008; Kaufmann and
Kraay, 2008; Savedoff, 2011; Barbazza and Tello, 2014).

• Seek quality improvement. Health service quality is a
key objective of a health system and is often considered
a third goal of UHC (alongside improved health outcomes
and increased FP) (Kruk, 2013). Nonetheless, the
quality of care in many LICs and MICs remains very low
(Berendes et al, 2011). It is critical that services are safe
and of good quality—and perceived by the population
to be so. Strategies that countries are using to improve
quality of care include: (i) approaches at the policy and/
or regulatory level (e.g. setting licensing and accredi-
tation standards or implementing performance-based
financial incentives); (ii) facility and/or provider level
strategies to motivate better practices (e.g. educational
inputs, or audit and feedback); and (iii) demand-side
strategies that seek to change social norms and
care-seeking behavior (e.g. vouchers and other
demand-side performance-based financial incentives)
(Mate et al, 2013).
6. Moving forward
As countries continue forward on the path towards UHC,
it is critical to continue to capture and document their
different experiences—both positive and those that are
less positive. The expanding evidence base on what works
best with regards to service definition, financing, and
delivery, and on ensuring effective health sector
governance and strengthened health systems, is a rich
resource for country leaders, researchers, and donors
alike. These stakeholders can learn from this resource,
and take it into consideration when considering possible
next steps forward.
This Practice Brief was written by Alix Beith, Independent
Global Health Consultant, Naomi Beyeler, Policy Program
Manager, Global Health Group, UCSF, and David Evans,
Scientific Project Leader, Swiss Tropical and Public Health
Institute, Switzerland (and Chair of the Bellagio workshop).
The authors declare that there are no competing interests.
5. Other health system strengthening steps that
countries are taking to move closer to UHC
• Strengthening human resources. The primary strategy
countries are using to strengthen human resources is
health workforce training. Pre-service training essen-
tially increases the numbers (and quality) of providers
while in-service training either increases provider skills
or prevents these from deteriorating over time. Training
efforts can target expansion into (i) particular service
areas (such as building a primary care workforce
through the use of community health worker programs
to expand access in rural and underserved areas), or (ii)
geographic areas (such as expanding the rural health
workforce by increasing the recruitment of rural popula-
tions into the health professions). Other strategies being
used are (i) development and review of comprehensive
national health plans and strategies to strengthen
in-service training, and (ii) task sharing that enables
existing cadres of health workers to take on new ser-
vice areas or creates new cadres of health workers that
require less training, which can expand the accessibility
of high need services in underserved areas.
Countries are also implementing recruitment and
retention policies—including the use of financial and
educational incentives and regulatory policies—that
seek to improve the motivation, skills mix, and
geographic distribution of the health workforce. At
the global level, the international community is working
to support health worker retention through policies to
discourage health worker migration from countries
with health workforce shortages.
• Ensure essential infrastructure, medicines, and health
technologies. In addition to human resources, health
systems require additional inputs—such as high-quality
diagnostics, medicines, health technologies, and health
delivery infrastructure—to ensure effective and efficient
health care delivery. Countries worldwide are imple-
menting strategies to improve the selection, procure-
ment, distribution, and use of medicines, to ensure that
populations access and appropriately use high-quality
appropriate low-price quality medicines and technolo-
gies (such as diagnostics).

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The Bellagio workshop was funded by The Rockefeller
Foundation and the United States Agency for International
Development (USAID).
This work is in the public domain. The user is
granted the right to use this work under the terms
of the Creative Commons CC0 1.0 Universal Public
Domain Declaration.
(read CC0 1.0 legal code at creativecommons.org/
publicdomain/zero/1.0/legalcode).
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