Transitions in Health Financing

The Challenge
Universal health coverage is taking off in countries as varied as South Africa, India, Rwanda, Indonesia, and the United States, with governments around the world engaging in serious political and technical discussions on how to expand health coverage. Still others are considering such reforms, but are struggling to navigate the legal, financial, and political frameworks of their countries to determine the best path toward reform.

The Opportunity   
The Transitions in Health Financing research initiative is part of the Rockefeller Foundation’s strategy on Transforming Health Systems. In the context of that strategy, the goal of this research initiative is to foster greater understanding of the factors influencing health spending in low and middle income countries, in an effort to assess further the economic feasibility of and imperative for universal health coverage (UHC).

Our Work
The research supported and synthesized evidence and research findings on a pre-identified set of key issues, culminating in the publication of a summary paper and six background studies concerning: (1) the determinants of health spending, (2) case studies of countries that have achieved UHC, (3) the relationship between health spending and health outcomes, (4) the relationship between health expenditure, UHC and health outcomes, (5) case studies of countries that are currently trying to achieve UHC, and (6) an overview of evidence on the political and economic trends that lead to universal health coverage.

A more in-depth description of each paper and links to each are below:

  • Transitions in Health Financing and Policies for Universal Health Coverage: This summary paper of the Transitions in Health Financing project seeks to provide a fresh perspective on today’s health policies by setting them against long-term trends in health financing and public policy. It accomplishes this by summarizing the findings of the Transitions in Health Financing project related to the impact of health coverage on outcomes, the determinants of health spending and the declining share of out-of-pocket spending, the evolution of institutional arrangements for expanding health care access, and the diversity of health reforms and performance today.
  • The determinants of health spending: This paper analyzes how total health spending and its components (public vs. private, out of pocket vs. prepaid or insured) depend on income (level, composition and distribution), demographic factors, government revenues and other causes. It shows that, in addition to income, many factors contribute to the wide variations in health spending across countries, ranging from demographic factors to health system characteristics. It also reveals differences between the paths of government health expenditure and out-of-pocket payments.
  • Progress toward universal health coverage: This paper shows how universal health coverage has emerged from a range of policies within the context of particular economic, political, institutional and technological trends. It suggests how these policies influence the pace and shape of universal health coverage particularly with reference to critical choices regarding the breadth and depth of coverage and institutions created to finance and provide health care.
  • Health spending and health outcomes: This paper investigates health outcomes across countries in relation to health spending and the structure of health coverage. It tests the hypothesis that higher spending and broader coverage lead to better population health outcomes by untangling a number of confounding factors. It concludes that public policies that expand health system coverage lead to improved general population health.
  • Efficiency of health service coverage and access: This paper explores methods for assessing the efficiency with which the elements of universal health coverage yield better population health. It explains the different methods available for measuring efficiency and provides an illustration with new data.
  • The universal coverage financing challenge: This paper analyzes the financing sources and strategies for achieving UHC in 4 countries from Africa, Asia, and Latin America. It assesses the stability of trends toward UHC through economic and political cycles. It also investigates the implications of these different strategies for equity. It shows how similar strategies can lead to differing outcomes in terms of the health system’s overall costs, service accessibility, equity, and financial protection.
  • The health financing transition: This paper describes the health financing transition as a conceptual framework for understanding shorter term analyses of health markets and public policy. It reviews the literature to show that health spending growth is a consequence of rising income and expanding medical technologies, while declining shares of out-of-pocket spending are a consequence of policies driven by political movements and social change.

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