Objectives, scope and principles

Universal Health Protection 39

4.2.1. Setting objectives and identifying gaps and barriers

National health protection policies should reflect historical and economic country contexts, social and cultural values, institutional settings, political commitment and leadership. However, there are some general principles that should be taken into account. They include universality and equity. Thus, countries should aim at improving access to health care for all citizens. In addition, objectives should be in line with globally agreed goals and objectives such as the Millennium Development Goals MDGs and international standards on social protection, particularly ILO Recommendation No. 202, the ILO Medical Care Recommendation, 1944 No. 69, the ILO Medical Care and Sickness Benefits Convention, 1969 No. 130 and the ILO Social Security Minimum Standards Convention, 1952 No. 102. When setting objectives for SPFs, it is also important to balance potential trade-offs between different principles, such as: Universality and equity : To what extent can the principle of universality be modified to meet individual needs? Should there be a priority, e.g. for the poorest? Should high-income earners pay higher co-payments, premiums, etc.? Universality, equity and essentiality of benefits : Should the same services be provided to all, or specific needs such as for the most vulnerable, women and the elderly be addressed in specific benefit packages? Universality, equity and quality levels – medical and non-medical – that are acceptable in constrained financial contexts. Universality, equity and the extent of financial protection with a view to OOP caused by the cost of treatments, medicaments or transport, loss of income due to sickness, and others Scheil-Adlung, ISSA, 2013a. Following the setting of objectives, gaps in and barriers to access to health care should be identified. A comprehensive evaluation of all dimensions relevant to achieving universal and effective access to health care should be carried out. Thus, in addition to closing gaps in legislation, the availability, affordability and quality of health care, as well as financial protection, should be assessed. Special attention should be devoted to deprivation in some Key aspect 4.3 Formulating and implementing SPFs in health 1. Set objectives reflecting national priorities. 2. Identify gaps in, and barriers to, protection. 3. Seek to close gaps in protection through appropriate and effectively coordinated schemes. 4. Complement social security with active labour market policies. 5. Specify financial requirements and resources as well as the timeframe and sequencing for progressive achievement of the objectives. 6. Coordinate developmental, economic, social and health policies with a view to achieving universal health coverage. 40 Universal Health Protection or all of these dimensions for vulnerable groups such as the elderly, women, persons with special needs and ethnic minoritiesmigrants. The analysis of gaps and deficits can be facilitated by developing a coverage map. A suggestion of how such a map could be structured is provided in figure 4.1. If applicable and feasible, it is recommended to include detailed information on aspects such as deficits related to gender or ethnicity. Apart from the quantitative data, qualitative information is required for a comprehensive overview. Figure 4.1. Identifying gaps and deficits using a coverage map

4.2.2. Selecting and improving health financing mechanisms

Developing financing mechanisms that provide adequate funds is a key to progress towards universal health coverage. When selecting financing mechanisms there is no one- size-fits-all model; the criteria for selection will depend on specific national contexts. Most countries have chosen a mix of financing mechanisms to provide social protection in health through different systems, subsystems and schemes: national health services, social health insurance, community-based insurance and mandated private health insurance. It is important that such a financing mix be coordinated to avoid fragmentation and operate within a clearly defined scope. Characteristics of population to be covered, e.g. Civil service Employees Self-employed Self-employed in agriculture Familiy members Unemployed of active age Informal sector workers Medically vulnerable groups such as elderly, disabled, persons with special needs. Affiliation Population coverage in e.g. Government health system Social health insurance fund National health insurance fund Occupational health schemes Micro health insurance Private health insurance Source of funding General tax revenues Social national private health care funds Employer-based initiatives Out-of-pocket Disaggregated e.g. by - Gender; - Workers and families - Age - Place of residence - Ethnicity; - Migrant status Disaggregated by, for example: - Gender - Workers and families - Age - Place of residence - Ethnicity Universal Health Protection 41 In order to arrive at an optimal combination of financing mechanisms for a specific country, the applicability and performance of the different mechanisms needs to be assessed on the basis of their capacity to mobilize funds and their efficiency in targeting vulnerable groups. In addition, it is important to consider the power structures impacting on both the supply and demand side in health-care delivery, accountability and quality of budgeting. Key aspect 4.4 lists important criteria for the selection of financing mechanisms. Key aspect 4.4 Criteria for selecting financing mechanisms - Political, economic and cultural context - Burden of disease - Poverty rate - Size of the informal economy - Number, structure and performance of existing schemes - Size of the tax base - Capacity to collect taxescontributionspremiums - Managerial capacity - Availability of infrastructure - Possibility of enforcing the legislation - Regulation and related impacts on equity The financing mechanisms selected should be based on the principle of solidarity, and thus need to reflect the individual’s capacity to pay, and large risk pooling. An optimal balance of the responsibilities and interests of those who finance and benefit from health protection should be achieved, as stated in Recommendation No. 202 para. I. 3h. Furthermore, financing mechanisms should be selected with regard to financial, fiscal and economic sustainability. Table 4.1 lists the pros and cons of core financing mechanisms: tax-based health protection, contribution-based social health insurance, premium-based community health insurance and private health insurance. The table does not include social assistance- type financing mechanisms in the form of vouchers or cash transfers.