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Most developed countries provide publicly-financed insurance for many health services for their populations although there is considerable variation across countries in the types of services covered, eligible population groups and whether co-payments are levied. The Irish healthcare system, with a complex mix of public and private financing of healthcare services, offers a useful case study for an examination of the impact of type of health insurance cover on population health. In this paper, we investigate the extent to which type of health insurance cover is associated with all-cause, cause-specific, and amenable mortality using data on a representative survey of the population aged 50+ from the Irish Longitudinal Study on Ageing (TILDA) matched to administrative data on death registrations. The results show that those without public or private health insurance have a higher risk of all-cause and cancer mortality. However, there is no evidence that type of health insurance cover affects mortality risk from causes that are considered amenable to healthcare intervention, although this analysis was based on a much smaller sample size. This analysis provides important evidence for a country that is implementing reforms to its financing and delivery structures in order to move towards a system of universal healthcare.

The COVID-19 pandemic triggered an economic shock just ten years after the shock of the 2008 global financial crisis. Economic shocks are a challenge for health systems because they reduce government revenue at the same time as they increase the need for publicly financed health care. This article explores the resilience of health financing policy to economic shocks by reviewing policy responses to the financial crisis and COVID-19 in Europe. It finds that some health systems were weakened by responses to the 2008 crisis. Responses to the pandemic show evidence of lessons learnt from the earlier crisis but also reveal weaknesses in health financing policy that limit national preparedness to face economic shocks, particularly in countries with social health insurance schemes. These weaknesses highlight where permanent changes are needed to strengthen resilience in future: countries will have to find ways to reduce cyclicality in coverage policy and revenue-raising; increase the priority given to health in allocating public spending; and ensure that resources are used to meet equity and efficiency goals. Although many health systems are likely to face budgetary pressure in the years ahead, the experience of the 2008 crisis shows that austerity is not an option because it undermines resilience and progress towards universal health coverage.

Summary Background Childhood immunisation is one of the most cost-effective health interventions. However, despite its known value, global access to vaccines remains far from complete. Although supply-side constraints lead to inadequate vaccine coverage in many health systems, there is no comprehensive analysis of the funding for immunisation. We aimed to fill this gap by generating estimates of funding for immunisation disaggregated by the source of funding and the type of activities in order to highlight the funding landscape for immunisation and inform policy making. Methods For this financial modelling study, we estimated annual spending on immunisations for 135 low-income and middle-income countries (as determined by the World Bank) from 2000 to 2017, with a focus on government, donor, and out-of-pocket spending, and disaggregated spending for vaccines and delivery costs, and routine schedules and supplementary campaigns. To generate these estimates, we extracted data from National Health Accounts, the WHO–UNICEF Joint Reporting Forms, comprehensive multi-year plans, databases from Gavi, the Vaccine Alliance, and the Institute for Health Metrics and Evaluation's 2019 development assistance for health database. We estimated total spending on immunisation by aggregating the government, donor, prepaid private, and household spending estimates. Findings Between 2000 and 2017, funding for immunisation totalled US$112·4 billion (95% uncertainty interval 108·5–118·5). Aggregated across all low-income and middle-income countries, government spending consistently remained the largest source of funding, providing between 60·0% (57·7–61·9) and 79·3% (73·8–81·4) of total immunisation spending each year (corresponding to between $2·5 billion [2·3–2·8] and $6·4 billion [6·0–7·0] each year). Across income groups, immunisation spending per surviving infant was similar in low-income and lower-middle-income countries and territories, with average spending of $40 (38–42) in low-income countries and $42 (39–46) in lower-middle-income countries, in 2017. In low-income countries and territories, development assistance made up the largest share of total immunisation spending (69·4% [64·6–72·0]; $630·2 million) in 2017. Across the 135 countries, we observed higher vaccine coverage and increased government spending on immunisation over time, although in some countries, predominantly in Latin America and the Caribbean and in sub-Saharan Africa, vaccine coverage decreased over time, while spending increased. Interpretation These estimates highlight the progress over the past two decades in increasing spending on immunisation. However, many challenges still remain and will require dedication and commitment to ensure that the progress made in the previous decade is sustained and advanced in the next decade for the Immunization Agenda 2030. Funding Bill & Melinda Gates Foundation.

Background Research output on global neurosurgery (GNS) has exponentially increased in recent years. As research efforts increase, we must first analyze how the current body of GNS literature fits into the macroscopic schema of systems-based policies. The aim of this study was to identify and categorize GNS research based on health system domains. Methods PubMed, CINAHL, and Embase were searched for GNS literature published from 1999 to 2019. Then, health system domains were defined and itemized based on publicly available documents from the Program in Global Surgery and Social Change. This items chart was subsequently used to categorize the GNS literature into health system domains. Results A total 63 articles were determined to focus on a health system domain. Of these articles, 6 focused on multiple domains, yielding an adjusted total of 70 articles. Overall, the most represented health system domain was service delivery (21 articles), followed by workforce (19), infrastructure (15), financing (12) and information management (3). A total of 30 low- and middle-income countries (LMICs) were represented across all articles. In addition, the first author was affiliated with an institution from a high-income country for 71.4% of the articles. Conclusions This review highlighted the pressing need for more research into information management in the context of GNS. In addition, health system–focused GNS literature represented only 20% of all LMICs (30/143). The trends in authorship should be noted, because many ethical (and practical) issues may arise if there is a disconnect in the objectives of the authors and the neurosurgeons in LMICs.

Introduction This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC. Materials and methods We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services. Results The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I–V Clavien-Dindo complications (p Conclusion The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

Objectives Currently, Malaysia faces great challenges in allocating adequate resources for healthcare services using a tax-based system. Therefore, Malaysia has no choice but to reform its healthcare financing system. The objective of this study is to assess Malaysian household willingness to pay and acceptance levels to the proposed National Health Financing Scheme. Study design This is a cross-sectional study. Methods In total, 774 households from four states in Malaysia completed face-to-face interviews. A validated structured questionnaire was used, which was composed of a combination of open-ended questions, bidding games and contingent valuation methods regarding the participants' willingness to pay. Results The study found that the majority of households supported the establishment of the National Health Financing Scheme, and half proposed that a government body should manage the scheme. Most (87.5%) of the households were willing to contribute 0.5–1% of their salaries to the scheme through monthly deductions. Over three-quarters (76.6%) were willing to contribute to a higher level scheme (1–2%) to gain access to both public and private healthcare basic services. Willingness to pay for the National Health Financing Scheme was significantly higher among younger persons, females, those located in rural areas, those with a higher income and those with an illness. Conclusion There is a high level of acceptance for the National Health Financing Scheme in the Malaysian community, and they are willing to pay for a scheme organised by a government body. However, acceptance and willingness to pay are strongly linked to household socio-economic status. Policymakers should initiate plans to establish the National Health Financing Scheme to provide the necessary financing for a sustainable health system.

In 2017, the Estonian government addressed the longstanding challenge of financial sustainability of the health system by expanding its revenue base. As a relatively low-spending country on health, Estonia relies predominantly on payroll contributions from the working population, which exposes the system to economic shocks and population ageing. In an effort to reduce these vulnerabilities, Estonia will gradually introduce a government transfer on behalf of pensioners, although long-term sustainability of the health system could still prove challenging as the overall health spending as a percentage of GDP is not expected to substantially increase. Estonia has rolled out the reform according to plan, but it has led to debate about the need to achieve universal population coverage (currently at about 95%). Moreover, the Estonian experience also holds important lessons for other countries looking to reform their health system. For example, policymakers should recognize that reforms require extensive preparation using consistent messaging over a long period of time, also to prevent prioritising short term and popular fixes over structural reforms. Additionally, collaboration between the health and financial ministries throughout the reform increases the buy-in for the reform and likelihood of adoption. Furthermore, health professionals play a significant role in advocacy, and seeking support from this group can smooth the path towards health system reform.

In the path to universal health coverage, policymakers discuss different alternative health system's financing schemes. Classical typologies have been posited, including models such as National Health Service, Social Health Insurance and Private Health Insurance. More recently, National Health Insurance (NHI) has been suggested as a separate model. Nevertheless, there are discrepancies regarding what defines an NHI model. The purpose of this article is to propose a comprehensive definition of an NHI model, aimed to disentangle the current discrepancies in the conceptualization and the scope of this type of arrangement. Based on the previous literature we identified some common characteristics across NHI definitions, namely universal coverage, pooling in a single fund and a purchasing function based on a single-payer financing mechanism. Areas of controversy were also identified. While some authors emphasized the importance of an effective separation between the purchaser and provider functions, others highlighted the relative importance of privately-owned provision to define a system like NHI-type. Based on empirical data, we suggest that the ownership is not a critical variable to distinguish an NHI from other models, and instead, suggest that a pivotal characteristic of the NHI is the single payer mechanism that is not integrated with the health providers.

Policy decisions regarding breast cancer screening and treatment programmes may be misplaced unless the decision process includes the appropriate utilities and disutilities of mammography screening and its sequelae. The objectives of this study were to critically review how economic evaluations have valued the health states associated with breast cancer screening, and appraise the primary evidence informing health state utility values (cardinal measures of quality of life). A systematic review was conducted up to September 2018 of studies that elicited or used utilities relevant to mammography screening. The methods used to elicit utilities and the quality of the reported values were tabulated and analysed narratively. 40 economic evaluations of breast cancer screening programmes and 10 primary studies measuring utilities for health states associated with mammography were reviewed in full. The economic evaluations made different assumptions about the measures used, duration applied and the sequalae included in each health state. 22 evaluations referenced utilities based on assumptions or used measures that were not methodologically appropriate. There was significant heterogeneity in the utilities generated by the 10 primary studies, including the methods and population used to derive them. No study asked women to explicitly consider the risk of overdiagnosis when valuing the health states described. Utilities informing breast screening policy are restricted in their ability to reflect the full benefits and harms. Evaluating the true cost-effectiveness of breast cancer screening will remain problematic, unless the methodological challenges associated with valuing the disutilities of screening are adequately addressed.

With Universal Health Coverage (UHC) now entrenched among the top global development priorities, questions arise as to the conditions under which politicians commit to UHC and why certain strategies for health financing and access are favoured over others. The Ethiopian government has been piloting and scaling-up Community-Based Health Insurance (CBHI) for the informal sector since 2010 and is establishing Social Health Insurance for formal sector workers as a means of achieving UHC. CBHI covers 11 million people making it one of the largest health insurance schemes in Africa. This paper employs a process tracing methodology to examine the political drivers of the adoption and evolution of state health insurance based on 28 key informant interviews conducted between 2015 and 2018 with politicians, policymakers and donor officials. The paper highlights the inadequacy of existing theories—focusing on interest group mobilisation, electoral competition and bureaucratic actors—for explaining the Ethiopian case. Instead the paper proposes an ‘Adapted Political Settlements’ framework that explains the state's push to expand CBHI and stalled progress on SHI. This framework highlights the interests and ideas of the ruling coalition as important drivers of reform. In a context of ruling party dominance and minimal threat from electoral competition, the ruling coalition has sought to build political legitimacy through the delivery of socioeconomic progress, including health services. The policy idea of health insurance, meanwhile, has secured elite commitment due to its fit with deeply held ideas within the ruling coalition concerning the importance of self-reliance and resource mobilisation for development. Finally, the centralisation of power within the ruling coalition prior to 2012 enabled the emergence of a long-term developmental vision and the marginalisation of opposition to health insurance, while fragmentation of the ruling coalition since 2012 has led SHI to stall.

Objective To determine whether crowdfunding of pharmacy-related products through popular online platforms is a viable means to attain funding and what factors influence success. Methods Kickstarter and Indiegogo were searched for projects related to pharmacy using select key words. Projects were included for analysis if they were a device or system relevant to pharmacy care and excluded if found to be nonrelevant to medication management purposes or were of an artistic nature. Projects were assessed for their success in reaching their primary funding goals and also whether they were still in business following completion of their crowdfunding phase. Results Subsequent to the application of the inclusion and exclusion criteria to the dataset, 40 projects were identified, of which 13 reached their desired crowdfunding funding amounts. The most commonly created crowdfunded projects were those involving medication adherence or storage tools. Anecdotal evidence points to media attention leading to continued success beyond the initial crowdfunding phase of the business. The presence of a medical professional on the project team or the inclusion of a product demonstration did not lead to a different rate of success. Conclusion The crowdfunding of pharmacy care–related products appear to have a low success rate, although Indiegogo might offer a higher success rate compared with Kickstarter in this niche product area. The products’ ability to garner media attention seems to be a primary driver in the business surviving past the crowdfunding stage and becoming a lasting success.

Background: The opiate crisis in Canada, among other causes, has led to increased demand and wait times for addiction-related services. One response to this situation has been for Canadians to seek crowdfunding support for services outside of the public system. However, little is known about how large this practice is, what addiction-related services Canadians seek, and what the implications of this practice are. Methods: We searched the crowdfunding platforms GoFundMe and YouCaring using keywords related to addiction. This search identified 129 crowdfunding campaigns by Canadian residents seeking addiction-related services. The authors recorded information from the campaigns and conducted a thematic analysis of their narrative content. Results: These campaigns requested $12,722,527 and were pledged $204,848 (1.6%). Thematic analysis revealed four core elements discussed in the pursuit of addiction-related crowdfunding: 1) affording treatment, including at private and/or perceived higher quality facilities; 2) surviving treatment by seeking living expenses during and before treatment; 3) life after treatment by addressing needs following receiving treatment for addiction; and 4) publicizing treatment where recipients often struggled with the need to reveal personal details as part of their campaigns. Conclusion: These findings confirm discussion in the academic and policy literature on Canadians seeking addiction-related services that wait times for public services are a significant issue for many. However, these findings also show that the costs of living expenses before and during treatment, as well as restarting lives following treatment, also create struggles for Canadians. These findings confirm and expand concerns in the literature on medical crowdfunding, where this practice is thought to raise issues around the equitable distribution of resources and the loss of personal privacy. While crowdfunding for addictionrelated services has helped some Canadians, the money raised was vastly less than that requested, came at a cost to personal privacy, and raises equity issues.

The World Bank Group is the largest global development organization working to end poverty and promote shared prosperity. Its 5 institutions play an essential role in the advancement of global health through innovative health financing, data collection and management, policy reform, and advocacy. Previously, the World Bank Group has supported global surgery through data collection and advocacy. As it grows, it must continue to focus on the importance of surgical care in promoting health and avoiding poverty in low- and middle-income countries. The house of surgery and its community should play an active role in advocating for the many ways in which the World Bank Group could facilitate the strengthening of surgical systems to improve access to surgical care worldwide.

Mental Health services in Victoria, Australia have seen major reform over the past 30 years. Rights based mental health legislation and major structural changes supported a reduction in bed based services and the development of a strong community mental health sector from the mid 1990's. Community Treatment Orders were established in the Mental Health Act (1986) and widely used across the State. Reformed legislation in 2014 brought greater emphasis on supported decision making and recovery orientation. Funding for mental health services did not keep pace with significant population growth, with consequent reduction in bed availability and intensity of community based services. This paper considers the impact of funding and service availability on the intended policy and practice directions of mental health legislation with particular consideration of the impact on the utilisation of Community Treatment Orders.

In this study, we present findings from an experimental evaluation of a mandatory employer-sponsored health insurance scheme in Bangladesh. We randomly introduced the scheme to female artisans to understand the impacts on healthcare utilisation, expenditure and subjective well-being using both survey and administrative data. Our findings suggest that the scheme broke even; however, it covered only six percent of the overall health expenditure and 16 percent of the hospitalisation costs. We find higher inpatient care utilisation, particularly among women, and in favour of empanelled hospitals causally associated with the intervention, consistent with the design of the scheme. We do not find significant healthcare savings or improvement in subjective well-being, consistent with low coverage. The findings suggest the scheme to be financially sustainable and it changes the healthcare seeking behaviours as the scheme incentivises. However, meaningful savings and protection against catastrophic health expenditures will require a higher level of coverage.

"Intrinsic motivation crowding out", the erosion of high-quality, sustainable motivation through the introduction of financial incentives, is one of the most frequently discussed but yet little researched potential unfavorable consequence of Performance-based Financing (PBF). We used the opportunity of the introduction of PBF in Malawi to investigate whether and how PBF affected intrinsic motivation, using a mixed-methods research design theoretically grounded in Self-Determination Theory (SDT). The quantitative component served to estimate the impact of PBF on intrinsic motivation, relying on a controlled pre- and post-test design, with data collected from health workers in 23 intervention and 10 comparison facilities before (March/April 2013; n = 70) and approximately two years after (June/July 2015; n = 71) the start of the intervention. The qualitative component, relying on in-depth interviews with health workers in selected intervention facilities one (April 2014; n = 21) and two (September 2015; n = 20) years after the start of PBF, served to understand how PBF did or did not bring about change in intrinsic motivation. Specifically, it allowed us to examine how the various motivation-relevant elements and consequences of PBF impacted health workers' basic psychological needs for autonomy, competence, and relatedness, which SDT postulates as central to intrinsic motivation. Our results suggest that PBF did not affect health workers' overall intrinsic motivation levels, with the intervention having had both positive and negative effects on psychological needs satisfaction. To maximize positive PBF effects on intrinsic motivation, our results underline the potential value of explicit strategies to mitigate unintended negative impact of unavoidable design, implementation, and contextual challenges, for instance by building autonomy support activities into PBF designs.

Singapore and Hong Kong, two high-income "Tiger economies" in Asia, were ranked as the top two most efficient health systems in the world. Despite remarkable similarities in history and socioeconomic development, both economies embraced rather different paths in health care reforms in the past decades, which reflect their respective sociopolitical dynamics. Rapidly ageing populations and the anxiety about future funding of health care have prompted them to embark on major health financing reforms in the recent three years. While Singapore has transitioned to universal health coverage with the implementation of MediShield Life (MSL), Hong Kong is about to introduce the Voluntary Health Insurance Scheme (VHIS) to supplement its health care financing. Based on secondary materials including policy documents, press releases, and anecdotal reports, this essay compares these two recent reforms on their political context, drivers of reforms, and policy contents, and assesses their prospects in terms of coverage, financial protection, and major implementation challenges. The preliminary assessment suggests that while both programs are associated with certain drawbacks, those of the VHIS may be more fatal and warrant close attention. This essay concludes with a central caveat that underscores the pivotal role of the state in managing health care reforms.

Sub-Saharan Africa’s health challenges are numerous and wide-ranging. Most sub-Saharan African countries face a double burden of traditional, persisting health challenges, such as infectious diseases, malnutrition, and child and maternal mortality, and emerging challenges from an increasing prevalence of chronic conditions, mental health disorders, injuries, and health problems related to climate change and environmental degradation. Although there has been real progress on many health indicators, life expectancy and most population health indicators remain behind most low-income and middle-income countries in other parts of the world. Our Commission was prompted by sub-Saharan Africa’s potential to improve health on its own terms, and largely with its own resources. The spirit of this Commission is one of evidence-based optimism, with caution. We recognise that major health inequities exist and that health outcomes are worst in fragile countries, rural areas, urban slums, and conflict zones, and among the poor, disabled, and marginalised. Moreover, sub- Saharan Africa is facing the challenges and opportunities of the largest cohort of young people in history, with the youth population aged under 25 years predicted to almost double from 230 million to 450 million by 2050. The future of health in Africa is bright, but only if no one is left behind.

China has made remarkable progress in strengthening its primary health-care system. Nevertheless, the system still faces challenges in structural characteristics, incentives and policies, and quality of care, all of which diminish its preparedness to care for a fifth of the world's population, which is ageing and which has a growing prevalence of chronic non-communicable disease. These challenges include inadequate education and qualifications of its workforce, ageing and turnover of village doctors, fragmented health information technology systems, a paucity of digital data on everyday clinical practice, financial subsidies and incentives that do not encourage cost savings and good performance, insurance policies that hamper the efficiency of care delivery, an insufficient quality measurement and improvement system, and poor performance in the control of risk factors (such as hypertension and diabetes). As China deepens its health-care reform, it has the opportunity to build an integrated, cooperative primary health-care system, generating knowledge from practice that can support improvements, and bolstered by evidence-based performance indicators and incentives.

The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.

Financial support for children's medical expenses has been introduced in many countries. Limited work has been done on price elasticity in children's healthcare demand, especially in countries other than the United States. Moreover, it remains unclear how the effects of a change in the cost sharing rate on healthcare demand would differ by medical condition. We investigated the impact of an increase in the cost sharing rate on medical service utilization among school children as a whole and for each of nine common conditions, applying a difference-in-differences approach. The study period ranged from April 1, 2012, to March 30, 2014. Participants were elementary school children in an urban area who were eligible for National Health Insurance (a community-based public insurance) during the study period and who were enrolled in the 2nd, 3rd, or 4th grade in April 2013. We collected observations from 2896 persons and 69,504 (2896 × 24 months) person-months. When elementary school children were promoted to the 4th grade, they became disqualified for a municipal medical subsidy. The control group was the children promoted to the 2nd or the 3rd grade, who remained eligible for the subsidy. All data were obtained from health insurance claims. We identified the nine most common medical conditions among the subject children, and stratified the analyses by the condition diagnosed. We found that an increase in the cost sharing rate reduced outpatient service utilization as a whole. Also, we observed an increase in inpatient service utilization, not because of worsened health conditions, but rather due to substitution of inpatient service for outpatient service. The reductions in outpatient service were heterogeneous across medical conditions; declines were sharper for mild or chronic conditions. These findings may help to characterize how a change in cost sharing rate affects health outcomes in children.

Crowdfunding is an expanding form of alternative financing that is gaining traction in the health sector. This article presents a typology for crowdfunded health projects and a review of the main economic benefits and risks of crowdfunding in the health market. We use evidence from a literature review, complimented by expert interviews, to extend the fundamental principles and established theories of crowdfunding to a health market context. Crowdfunded health projects can be classified into four types according to the venture's purpose and funding method. These are projects covering health expenses, fundraising health initiatives, supporting health research, or financing commercial health innovation. Crowdfunding could economically benefit the health sector by expanding market participation, drawing money and awareness to neglected health issues, improving access to funding, and fostering project accountability and social engagement. However, the economic risks of health-related crowdfunding include inefficient priority setting, heightened financial risk, inconsistent regulatory policies, intellectual property rights concerns, and fraud. Theorized crowdfunding behaviours such as signalling and herding can be observed in the market for health-related crowdfunding. Broader threats of market failure stemming from adverse selection and moral hazard also apply. Many of the discussed economic benefits and risks of crowdfunding health campaigns are shared more broadly with those of crowdfunding projects in other sectors. Where crowdfunding health care appears to diverge from theory is the negative externality inefficient priority setting may have towards achieving broader public health goals. Therefore, the market for crowdfunding health care must be economically stable, as well as designed to optimally and equitably improve public health.

Summary Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC. Funding Bill & Melinda Gates Foundation.

The experience of adversity and toxic stress in childhood is associated with the development of chronic health and behavioral health problems. These problems contribute substantially to health care expenditures and the overall burden of disease. Although a strong scientific literature documents the effectiveness of primary prevention in reducing childhood adversity, promoting well-being and lessening the incidence of negative outcomes, funding for these interventions is highly fragmented across multiple government agencies as well as private and philanthropic sectors. It is becoming increasingly clear that improving population health will require a concentrated public health effort to improve access to and the accountability of these interventions as well as the development of novel financing schemes. In this perspective we review existing financing mechanisms for funding interventions known to reduce adverse childhood experiences and discuss innovative financing approaches that use insurance as well as pay-for-success funding mechanisms. The latter require that cost savings associated with primary prevention be quantified and that these savings be used to offset program costs, sometimes with a return on investment for private investors. We provide a series of recommendations regarding better coordination and strategic oversight of existing resources as well as the need to further develop and validate methodologies for estimating the societal costs and benefits associated with the varying social policies that are designed to ameliorate the effects of adversity and to build resilience.

Summary The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.

Summary Development assistance for health (DAH), the value of which peaked in 2013 and fell in 2015, is unlikely to rise substantially in the near future, increasing reliance on domestic and innovative financing sources to sustain health programmes in low-income and middle-income countries. We examined innovative financing instruments (IFIs)—financing schemes that generate and mobilise funds—to estimate the quantum of financing mobilised from 2002 to 2015. We identified ten IFIs, which mobilised US$8·9 billion (2·3% of overall DAH) in 2002–15. The funds generated by IFIs were channelled mostly through GAVI and the Global Fund, and used for programmes for new and underused vaccines, HIV/AIDS, malaria, tuberculosis, and maternal and child health. Vaccination programmes received the largest amount of funding ($2·6 billion), followed by HIV/AIDS ($1080·7 million) and malaria ($1028·9 million), with no discernible funding targeted to non-communicable diseases.

European Structural and Investment Funds (ESIF) are a major source of investments in the newer EU member states. In Lithuania's health sector, the amount for the 2007-2013 funding period reached more than �400 million. In this paper we aim to (i) identify the key areas in the health sector which were supported by ESIF, (ii) determine the extent to which ESIF assisted the implementation of the ongoing health system reform; and (iii) assess whether the use of funds has led to expected improvements in healthcare. We review the national strategic documents and legislation, and perform calculations to determine funding allocations by specific area, based on the available data. We analyse changes according to a set of selected indicators. We find that implementation of programmes funded by the ESIF lacks formal evaluation. Existing evidence suggests that some improvement has been achieved by 2013. However, there are persisting challenges, including failure to reach a broad agreement on selection of health and healthcare indicators, lack of transparency in allocations, and absence of coherent assessment measures of healthcare quality and accessibility.

Background With the launch of very highly priced therapies and sudden price increases of generics, pressures on health systems have drastically increased. Objectives We aimed to elicit opinions of key decision makers responsible for national assessment and funding decisions on their experiences to adapt to these new realities. Methods/setting Through interviews with decision makers of pharmaceutical assessment and/or funding agencies, we describe the challenges systems are currently facing, systems’ responses and systems’ characteristics facilitating or hindering responses to changes and overarching topics for the future. Results Among the most common challenges are increased funding pressures, increased uncertainty and lack of transparency in decision-making. Systems’ responses include utilization management, changing of assessment processes, stakeholder engagement and a focus on outcomes and on coordinated negotiations. Integrated delivery systems, fixed health care budgets and geographic and historical characteristics facilitate or sometimes hinder responses to change. Future policy emphasis lays on expanding data structures, managing the exit of drugs funded early, and implementing processes for communications with patients and the public. Conclusions Going forward emphasis has to be given to structured communications with all stakeholders with a specific emphasis on the broader public and patients about financial limits and priority setting in health care.

Improving financial access to services is an essential part of extending universal health coverage in low resource settings. In Cambodia, high out of pocket spending and low levels of utilisation have impeded the expansion of coverage and improvement in health outcomes. For twenty years a series of health financing policies have focused on mitigating costs to increase access particularly by vulnerable groups. Demand side financing policies including health equity funds, vouchers and community health insurance have been complemented by supply side measures to improve service delivery incentives through contracting. Multiple rounds of the Cambodia Socio-Economic Survey are used to investigate the impact of financing policies on health service utilisation and out of pocket payments both over time using commune panel data from 1997 to 2011 and across groups using individual data from 2004 and 2009. Policy combinations including areas with multiple interventions were examined against controls using difference-in-difference and panel estimation. Widespread roll-out of financing policies combined with user charge formalisation has led to a general reduction in health spending by the poor. Equity funds are associated with a reduction in out of pocket payments although the effect of donor schemes is larger than those financed by government. Vouchers, which are aimed only at reproductive health services, has a more modest impact that is enhanced when combined with other schemes. At the aggregate level changes are less pronounced although there is evidence that policies take a number of years to have substantial effect. Health financing policies and the supportive systems that they require provide a foundation for more radical extension of coverage already envisaged by a proposed social insurance system. A policy challenge is how disparate mechanisms can be integrated to ensure that vulnerable groups remain protected.

Crowdfunding involves raising money from large groups of individuals, often through the use of websites dedicated to this purpose. Crowdfunding campaigns aimed at raising money to pay for expenses related to receiving medical treatment are receiving increased media attention and there is evidence that medical crowdfunding websites are heavily used. Nonetheless, virtually no scholarly attention has been paid to these medical crowdfunding campaigns and there is no systematic evidence about how widely they are used and for what reasons, and what effects they have on the provision of medical care and individuals' relationships to their health systems. Ethical concerns have been raised in relation to these campaigns, focusing on issues for campaigners and donors such as exposure to fraudulent campaigns, loss of privacy, and fairness in how medical crowdfunding funds are distributed. Medical crowdfunding websites themselves have not been systematically studied, despite their significant influence on how these campaigns are developed and promoted. In this paper, we identify three very broad and pressing ethical questions regarding medical crowdfunding for social scientists to address and offer some preliminary insights into key issues informing future answers to each: Who benefits the most from medical crowdfunding and how does medical crowdfunding affect access to medical care; How does medical crowdfunding affect our understanding of the causes of inadequate access to medical care; and How are campaigner and donor privacy affected by website design? Our observations indicate the need for increased scholarly attention to the ethical and practical effects of medical crowdfunding for campaigners, recipients, donors, and the health system as a whole.

Performance-based financing (PBF) is a common health system reform approach in low and middle income countries at present. Although increasing evidence on the effectiveness of PBF and knowledge of principles of good design are available, research is still lacking in regards to other aspects. Among these are a yet limited understanding of the complex role of health worker motivation in PBF and of potential side effects, for instance on intrinsic motivation. Our article aims to support meaningful future research by advancing the theoretical discussion around health worker motivation and PBF. We argue that an in-depth understanding of the motivational mechanisms and consequences of PBF at health worker level are of high practical relevance and should be at the heart of the PBF research agenda, and that predominant unidimensional conceptualizations of health worker motivation and descriptive rather than explanatory research approaches are insufficient to fully understand whether, how, and why PBF schemes alter health workers' motivational structures, mindsets, affect, and behavior. We introduce and apply Self-Determination Theory to the context of PBF as a valuable theoretical framework for future empirical exploration. From this, we conclude that PBF interventions are unlikely to have a generally adverse effect on intrinsic motivation as feared by parts of the PBF community. Rather, we posit that PBF can have positive and negative effects on both intrinsic and extrinsic motivation, to varying degrees depending on the specific design, implementation, and results of a particular intervention and on health workers' perceptions and evaluations of it.

BACKGROUND: Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. METHODS: We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health. FINDINGS: Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89-4·12) annually, although it grew slower in per capita terms (2·72% [2·61-2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55% [5·18-5·95]), mainly due to growth in government health spending, and in lower-middle-income countries (3·71% [3·10-4·34]), mainly from DAH. Health spending globally reached $8·0 trillion (7·8-8·1) in 2016 (comprising 8·6% [8·4-8·7] of the global economy and $10·3 trillion [10·1-10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184-5319) in high-income countries, $491 (461-524) in upper-middle-income countries, $81 (74-89) in lower-middle-income countries, and $40 (38-43) in low-income countries. In 2016, 0·4% (0·3-0·4) of health spending globally was in low-income countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to $15·0 trillion (14·0-16·0) by 2050 (reaching 9·4% [7·6-11·3] of the global economy and $21·3 trillion [19·8-23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68-2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6-0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9-136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7-138·1]). The decomposition analysis identified governments' increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending. INTERPRETATION: Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets. FUNDING: Bill & Melinda Gates Foundation.

Summary Background In 2009, Gavi, the World Bank, and donors launched the pneumococcal Advance Market Commitment, which helped countries access more affordable pneumococcal vaccines. As many low-income countries begin to reach the threshold at which countries transition from Gavi support to self-financing (3-year average gross national income per capita of US$1580), they will need to consider whether to continue pneumococcal conjugate vaccine (PCV) use at full cost or to discontinue PCV in their childhood immunisation programmes. Using Kenya as a case study, we assessed the incremental cost-effectiveness of continuing PCV use. Methods In this modelling and cost-effectiveness study, we fitted a dynamic compartmental model of pneumococcal carriage to annual carriage prevalence surveys and invasive pneumococcal disease (IPD) incidence in Kilifi, Kenya. We predicted disease incidence and related mortality for either continuing PCV use beyond 2022, the start of Kenya's transition from Gavi support, or its discontinuation. We calculated the costs per disability-adjusted life-year (DALY) averted and associated 95% prediction intervals (PI). Findings We predicted that if PCV use is discontinued in Kenya in 2022, overall IPD incidence will increase from 8·5 per 100 000 in 2022, to 16·2 per 100 000 per year in 2032. Continuing vaccination would prevent 14 329 (95% PI 6130–25 256) deaths and 101 513 (4386–196 674) disease cases during that time. Continuing PCV after 2022 will require an estimated additional US$15·8 million annually compared with discontinuing vaccination. We predicted that the incremental cost per DALY averted of continuing PCV would be $153 (95% PI 70–411) in 2032. Interpretation Continuing PCV use is essential to sustain its health gains. Based on the Kenyan GDP per capita of $1445, and in comparison to other vaccines, continued PCV use at full costs is cost-effective (on the basis of the assumption that any reduction in disease will translate to a reduction in mortality). Although affordability is likely to be a concern, our findings support an expansion of the vaccine budget in Kenya. Funding Wellcome Trust and Gavi, the Vaccine Alliance.

For healthcare financing to remain profitable and to continue to function, the care system must be innovative in terms of patient care. Work organisation has changed with the pricing system for medical acts. The system of enhanced recovery after surgery helps to reduce hospitalisation times and to reflect on organisation. Nurses are on the front line.

This article addresses the issue of the classification of healthcare systems, with the intent to take a step further than the previously analysed models of healthcare organisation. As concerns the financing of healthcare services, the standard tripartite classification (according to which healthcare systems are divided into three groups: voluntary insurance, social health insurance and universal coverage) is enriched with two additional types: compulsory national health insurance and residual programs. With respect to the provision of services and the relationship between insurers and providers, it is important to distinguish between vertically integrated and separated systems. What differentiates this analysis from the majority of previous studies is its underlying logic. Assuming that all systems are hybrid, the article proposes to put aside the classic logic for classifying healthcare systems (according to which individual countries are pigeonholed into different classes depending on the prevailing system) in favour of the identikit logic. The concept of segmentation (of healthcare services or population) proves to be remarkably useful to this purpose.

Summary In recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences with UHC, the Government of Japan and the World Bank collaborated on a 2-year multicountry research programme to analyse the processes of moving towards UHC. The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam), representing diverse geographical, economic, and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The study showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls—but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context.

Congenital anomalies once considered fatal, are now surgically correctable conditions that now allow children to live a normal life. Pediatric surgery, traditionally thought of as a privilege of the rich, as being too expensive and impractical, and which has previously been overlooked and excluded in resource-poor settings, is now being reexamined as a cost-effective strategy to reduce the global burden of disease-particularly in low, and middle-income countries (LMICs). However, to date, global pediatric surgical financing suffers from an alarming paucity of data. To leverage valuable resources and prioritize pediatric surgical services, timely, accurate and detailed global health spending and financing for pediatric surgical care is needed to inform policy making, strategic health-sector budgeting and resource allocation. This discussions aims to characterize and highlight the evidence gaps that currently exist in global financing and funding flow for pediatric surgical care in LMICs.

Background: This study focuses on out-of-pocket payments for health care in Serbia. In contrast to previous studies, we distinguish three types of out-of-pocket patient payments: official co-payments, informal (under-the-table) payments and payments for "bought and brought goods" (i.e. payments for health care goods brought by the patient to the health care facility).Methods: We analyse the probability and intensity of three different types of out-of-pocket patient payments in the public health care sector in Serbia and their distribution among different population groups. We use data from the Serbian Living Standard Measures Study carried out in 2007. Out-of-pocket patients payments for both outpatient and inpatient health care are included. The data are analysed using regression analysis.Results: The majority of health care users report official co-payments (84.7%) and payments for "bought and brought goods" (61.1%), whereas only 5.7% health care users declare that they have paid informally. Regarding the regression results, users with an income below the poverty line, those from rural areas and who are not married are more likely to report payments for "bought and brought goods, while young and more educated users are more likely to report informal patient payments.Conclusion: Overall, the three types of out-of-pocket payments are not correlated. Payments for "bought and brought goods" take the highest share of the total annual household budget. Serbian policymakers need to consider different strategies to deal with informal payments and to eliminate the practice of "bought and brought goods".

Fragmentation in social health insurance schemes is an important factor for inequitable access to health care and financial protection for people covered by different health insurance schemes in China. To fulfil its commitment of universal health coverage by 2020, the Chinese Government needs to prioritise addressing this issue. After analysing the situation of fragmentation, this Review summarises efforts to consolidate health insurance schemes both in China and internationally. Rural migrants, elderly people, and those with non-communicable diseases in China will greatly benefit from consolidation of the existing health insurance schemes with extended funding pools, thereby narrowing the disparities among health insurance schemes in fund level and benefit package. Political commitments, institutional innovations, and a feasible implementation plan are the major elements needed for success in consolidation. Achievement of universal health coverage in China needs systemic strategies including consolidation of the social health insurance schemes.