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Universal Health Coverage (UHC) as a health policy goal is gaining added currency in the policy agendas of many Low and Middle-Income Countries (LMIC) following the onslaught of the coronavirus (COVID-19) pandemic. The goal of UHC is to ensure that every citizen has access to quality healthcare services that they need without suffering financial hardship. Whereas most industrialised countries have achieved UHC through the implementation of various traditional health financing mechanisms, most LMIC have not made significant progress in providing financial protection against the costs of illness for majority of the population due to limited fiscal space and or lack of political commitment to raise government revenues and increase fiscal space for health. While the onslaught of COVID-19 refreshes the call for reform of countries' health financing policies to reflect the healthcare needs of the population, the debate about the type or combination of health financing models to employ in LMIC has yet to reach a consensus. This review critically analyses five health financing models to ascertain their appropriateness in providing financial risk protection against the cost of illness, especially in this era of COVID-19. Given the limited fiscal space for health in LMICs, we argue that one viable pathway towards achieving UHC is the adoption of an adaptive mix of diverse pooling mechanisms. Moreover, because the creation of fiscal space is context-specific, and UHC is a political issue rather than technical, securing strong political support is necessary for improving the governance and institutional frameworks for health and ensuring sustained economic growth to respond to the fiscal demands of health systems.

The COVID-19 pandemic has exposed health system funding challenges across many developing countries. The needed infrastructure to effectively respond to the pandemic was absent in many developing countries. This has resulted in policymakers resorting to various strategies to mobilise sufficient resources in response to the pandemic, especially in the early stages. This paper reviewed Ghana's efforts to mobilise domestic and external resources for the health sector in response to the pandemic. The paper also assessed lessons from these strategies and highlights how these lessons could be leveraged to sustain financing for the health sector. Using evidence from desk reviews, we demonstrate the existence of fiscal space through external sources, partnership with non-state actors, and effective public financial management (budget space). We also show that the COVID-19 pandemic presents an important momentum to drive future investment in health infrastructure across developing countries.

OBJECTIVES To explore contextual factors associated with overall dental service use, and investigate whether these factors influenced choice of the type of service according to the healthcare financing alternatives (public services; out-of-pocket services; and private health insurance), by adults and older individuals, based on the most recent Andersen's behavioural model. METHODS Cross-sectional study with individual data on 17,305 adults from 177 Brazilian municipalities in the National Oral Health Survey (SBBrasil 2010). Municipal-level information was obtained from health information systems and census data. Multilevel multinomial logistic regression was carried out for multivariable analysis. RESULTS In the previous year, 38.2% of the individuals visited the dentist; of which 21.4% used out-of-pocket spending, 11.6% used public services and 5.2% private dental insurance. Municipalities with population coverage of public primary dental care >80% had higher chances of using public services (OR = 1.28, 95%CI:1.00-1.64) than those with ≤60%, but lower chances of using private insurance (OR = 0.56, 95%CI:0.38-0.83). Municipalities with population coverage of private dental insurance > 5% had lower chances of using public services (OR = 0.62, 95%CI:0.47-0.81) than those with

In this paper we adopt a growth accounting projection model to estimate and characterize health-financing needs in Brazil as well as to assess the extent to which financing needs may diverge from spending capacity in the future. We estimate an annual increase of 0.71% in the share of projected financing needs relative to GDP, with excess growth rates being 0.74% and 0.69% for the public and private health sectors, respectively. Institutional reforms and public spending restrictions may leverage public-private segmentation in health financing throughout the next decades, thus potentially leading to losses of equity in the system. Our projections contribute to a scant empirical literature on health financing sustainability in low- and middle-income countries and shed light on the role of spending capacity and institutional constraints over the path towards universal health coverage.

INTRODUCTION AND AIMS Governments across the globe invest considerable amounts in funding alcohol and other drug (AOD) treatment. Little attention however has been paid to the ways AOD service providers are chosen and how they are paid. This study sought to examine the perceptions of Australian AOD treatment purchasers and providers regarding different purchasing and payment mechanisms. DESIGN AND METHODS Qualitative interviews with AOD treatment providers and purchasers (N = 197) were undertaken across the eight Australian states/territories and the Commonwealth. Data were collated against six main AOD treatment purchasing and payment mechanisms (as identified in the literature), then an inductive, comparative analysis to assign codes was conducted, followed by interpretive analysis to explore emergent themes. RESULTS Five main themes were identified in relation to AOD treatment payment and purchasing mechanisms: (i) applying private sector principles to purchasing; (ii) innovation, sector stability and addressing client needs; (iii) performance monitoring and measuring outcomes; (iv) the threat to designated funding for AOD treatment; and (v) the costs and benefits of having multiple funding sources. DISCUSSION AND CONCLUSIONS In many countries reforms are taking place in the health sector consistent with New Public Management principles. These principles, when applied to AOD treatment, have included introducing competition, output and outcomes-based funding models, standards and accountability. Purchaser and providers identified both strengths and weaknesses and highlighted the overarching concern that implementation of any (mix) of these mechanisms should always be underpinned by a client-centred and not a finance-centred approach.

A universal health care system has been a source of both identity and pride for Canadians for the last 6 decades. Currently, Canada actively negotiates the prices of cancer drugs but is not immune to their overwhelming financial toxicities. Prices of cancer drugs are set to ensure maximal profit based on what the market will bear rather than by the value they offer or solely because of the cost of research and development, as often is claimed by the manufacturers. The pan-Canadian Oncology Drug Review (pCODR) is mandated to provide funding recommendations to Canada's provinces and territories. For the most part, the pCODR has been crucial in assessing the cost-effectiveness and feasibility of new drugs in the Canadian context but it could assist more in safeguarding payers against extreme drug costs. Herein, the author suggests a few strategies by which national efforts such as the pCODR and its partners can help Canada to become a leader in facilitating value-based sustainable cancer care.

The impact of diagnosis-related group (DRG)-based funding has been analyzed along a wide range of dimensions. Its effects on hospital specialization, however, have been investigated only sparsely. This paper examines such effects in the context of the Italian National Health Service, where decentralization has produced a significant degree of variation in funding arrangements. To this end, a 9-year panel data set covering 762 Italian public and private hospitals was analyzed using a finite mixture model approach. Hospital specialization was measured by the internal Herfindahl-Hirschman Index. Three variables were introduced as proxies for the choices made by Italian Regions with respect to the development and use of their DRG systems. The best finite mixture model identified three groups of hospitals, two of which sizeable. Of these, one included nearly all public hospitals, while the other was composed almost exclusively of small and medium-sized investor-owned hospitals. Averagely, private and smaller hospitals showed a stronger tendency to specialize over time. The positive impact of DRG funding on the hospitals' propensity to specialize found only limited empirical support. Moreover, it emerged as comparatively much smaller for public hospitals vis à vis private ones.

Summary Most developing countries with weak economies and low GDPs strive to invest an optimal amount of budget to health sector. Compounding on this state of affairs is their inherent inefficiency to spend even that meager amount on the welfare of the patients, improving service delivery, motivating their workforce and making their health systems responsive to the needs of the people they serve. With weak fiscal base and inelasticity in budget spending, when these countries face a catastrophe like COVID‐19, there is a whole situation of havoc and lack of finances emerges as the biggest issue in such crises. Pakistan has been no exception to this kind of situation. Government funds allocated to other public sector development schemes are diverted to deal with the health emergency. Hence, the result is an overall socioeconomic shock that a country has to face. Amid such crises, other international commitments also face a state of uncertainty. With the changing disease patterns all over the world, the public financial management system for health sector needs to be revisited to devise a more sustainable and resilient mechanism not only to absorb shocks like COVID‐19 but also to meet the international health commitments.

In response to the poor performance of its public health care provision, Burkina Faso decided, to implement results-based financing (RBF). This strategy relies on a strategic purchase of the quantity and quality of services provided by health workers, monitored by a set of indicators. However, there is a lack of evidence on its effects. The objective of this article is to appreciate the effect of RBF on a set of maternal and child health (MCH) indicators in Burkina Faso. The study design is quasi-experimental comparative with a control group before and after the implementation of the RBF. To estimate the effect of RBF, we used two methods of analysis: (1) the segmented regression to measure the effect of RBF in the health districts (HD) implementing RBF (RBF HD) and (2) the difference-in-difference test to estimate the effect of RBF considering the differences in mean between RBF HD and HD that did not implement RBF (non-RBF HD). We found among five indicators studied that only the postnatal consultation coverage in RBF HD was significantly higher (7.68%; P = 0.04) than in the non-RBF HD. Overall, our findings do not clearly demonstrate the effectiveness of RBF in improving MCH indicators in Burkina Faso.

We study the differential impacts of public and private sources of health spending on health outcomes using a triple difference approach. We find that private health spending has on average a higher health-promoting effect than public health spending. This result is robust with respect to the choice of outcome measure and covariates in the regression and driven primarily by the countries with ineffective governments. Once we restrict our sample to countries with effective governments, private health spending is found to be no better than public health spending in improving the health outcome.

Background Nigeria is considering adopting Universal Health Coverage (UHC) as an official policy target to ensure access to quality health care services for her population without financial hardship. To facilitate discussion on the topic, the President of Nigeria convened a UHC summit in March 2014 to discuss Nigeria's options and strategies to achieve UHC. A strategy for achieving UHC requires analysis of the available infrastructure to deliver the services. We review the geographic and sectoral distribution of health facilities in Nigeria and discuss implications on the UHC strategy selected. Methods Secondary analysis of data from the Federal Ministry of Health's facility register was performed to assess the geographic and sectoral distribution of health facilities in Nigeria. Additionally, an extensive literature review was conducted to understand UHC strategies used by various countries and the associated health facility requirements. Results Primary health facilities make up 88% of health facilities in Nigeria while secondary and tertiary health facilities make up 12% and 0.25%, respectively. There are more government-owned health facilities than privately owned health facilities (67% vs 33%). Secondary health facilities are predominantly privately owned. The ratio of public to private health facilities is much higher in the northern part of the country than in the southern part. Conclusions The distribution of health facilities across Nigeria is nonuniform. As such, a UHC strategy must be responsive to the variation in health facility distribution across the country. Additional investments are needed in some parts of the country to improve access to tertiary health facilities and leverage private sector capacity.

Typically, healthcare financing for an ageing population requires projections on healthcare demand and cost. However, projecting healthcare demand based on projected elderly does not consider changes in population health state over time. This paper proposes a new approach to forecast health variables using a stochastic health state function and the well‐established Lee–Carter stochastic mortality model. With the estimated health state at each age over time, we project the hospitalization rate, healthcare demand, and financing cost for Singapore using historical life tables and hospital admission data. Our findings show that while hospital insurance claims increase owing to an aging population, improving health state could save costs from hospital insurance claims. This has policy implications: more attention should be given to preventive healthcare such as health screening to improve the overall health state of the population.

The MJA-Lancet Countdown on health and climate change was established in 2017 and produced its first Australian national assessment in 2018. It examined 41 indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. It found that, overall, Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In this report we present the 2019 update. We track progress on health and climate change in Australia across the same five broad domains and many of the same indicators as in 2018. A number of new indicators are introduced this year, including one focused on wildfire exposure, and another on engagement in health and climate change in the corporate sector. Several of the previously reported indicators are not included this year, either due to their discontinuation by the parent project, the Lancet Countdown, or because insufficient new data were available for us to meaningfully provide an update to the indicator. In a year marked by an Australian federal election in which climate change featured prominently, we find mixed progress on health and climate change in this country. There has been progress in renewable energy generation, including substantial employment increases in this sector. There has also been some progress at state and local government level. However, there continues to be no engagement on health and climate change in the Australian federal Parliament, and Australia performs poorly across many of the indicators in comparison to other developed countries; for example, it is one of the world's largest net exporters of coal and its electricity generation from low carbon sources is low. We also find significantly increasing exposure of Australians to heatwaves and, in most states and territories, continuing elevated suicide rates at higher temperatures. We conclude that Australia remains at significant risk of declines in health due to climate change, and that substantial and sustained national action is urgently required in order to prevent this.

While decentralisation of health systems has dominated political arena in the low-income and middle-income countries since the 1970s, there is scarcity of studies on how organisational capacities influence the ability of the decentralised local-level officials to use the available decision space. Using qualitative approach through in-depth interviews and focus group discussions in 4 districts in Tanzania, this study explored how organisational capacities influence the use of decision space available in the 5 broad categories namely planning, finance, human resources, service organisation, and governance. The findings of the study indicated that while the district health managers had authority in many health system functional areas, limited capacity of the local government in financial resources highly affected their capacity to make use of the available decision space. In addition, while the district health managers had skills, knowledge, and experiences in preparing district health plans, health facilities and community representatives had limited capacity. Most of the health facilities had critical shortage of skilled health providers. Similarly, health committees had limited capacity in knowledge and skills. This study concludes that decentralisation will only improve delivery of health services when an appropriate degree of discretion is combined with adequate institutional capacities to enable exercise of those authorities. The district councils and the Ministry of Health should strengthen the capacities of health service providers and members of health committees and boards.

We study the factors that influence willingness to pay to improve public health care in 29 post-communist countries, Eastern and Southern Europe, and Eurasia using 2 up-to-date cross-sectional surveys conducted in 2010 and 2016 (N = 34 768). Three hypotheses received full degree of support through empirical analysis: increase in satisfaction with health care, university education, and higher level of wealth positively associated with willingness to pay in all regions. In comparison, having a higher level social trust and adhering to left-leaning ideological position strengthens support for public health care in Southern Europe and Eurasia only, while having a higher level of institutional trust strengthens support for public health care in Eastern Europe and Eurasia only.

Attempts to study the determinants of health insurance enrollment in resource-poor settings have often given less consideration to the potential influence of informal risk-sharing systems on individuals and households' decisions about health insurance. This paper contributes to existing discussions in this area by examining the effect of informal financial support for health care, an example of informal risk-sharing arrangement, on enrollment in the Ghana National Health Insurance Scheme (NHIS). It is based on a mixed-methods research in Tamale metropolis of northern Ghana. The study found widespread availability and reliance on informal support among low-income households to finance out-of-pocket health-care expenditure. Informal financial support for enrollment into the NHIS was noted to be less available. The study further found less strong but suggestive evidence that the perceived availability of informal financial support for health care by individuals diminishes their enrollment in the NHIS. The paper emphasizes the need for theory and policy on health insurance uptake in resource-constrained settings to consider existing informal risk-sharing arrangements as much as other known determinants of enrollment.

Home parenteral nutrition (HPN) has been considered a lifesaving intervention since the late 1960s for patients with gastrointestinal (GI) failure and other conditions that affect the GI tract who are well enough to be at home. Payment for this therapy under federal programs requires significant documentation and complex processes to qualify. Medicare parenteral nutrition policy, qualification processes and challenges, and advocacy supported by the American Society for Parenteral and Enteral Nutrition are reviewed with the goal of increasing clinician awareness of the complexity surrounding Medicare HPN reimbursement.

To improve health services' quantity and quality, African countries are increasingly engaging in performance‐based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post‐launch in late 2014. The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents. Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community‐based audits had yet been done. Distribution of bonuses varied from one centre to another. This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.

The need to understand how an intervention is received by the beneficiary community is well recognised and particularly neglected in the micro-health insurance (MHI) domain. This study explored the views and reactions of the beneficiary community of the redesigned Community Health Fund (CHF) implemented in the Dodoma region of Tanzania. We collected data from focus group discussions with 24 groups of villagers (CHF members and nonmembers) and in-depth interviews with 12 key informants (enrolment officers and health care workers). The transcribed material was analysed thematically. We found that participants highly appreciate the scheme, but to be resolved are the challenges posed by the implementation strategies adopted. The responses of the community were nested within a complex pathway relating to their interaction with the implementation strategies and their ongoing reflections regarding the benefits of the scheme. Community reactions ranged from accepting to rejecting the scheme, demanding the right to receive benefit packages once enrolled, and dropping out of the scheme when it failed to meet their expectations. Reported drivers of the responses included intensity of CHF communication activities, management of enrolment procedures, delivery of benefit packages, critical features of the scheme, and contextual factors (health system and socio-political context). This study highlights that scheme design and implementation strategies that address people's needs, voices, and values can improve uptake of MHI interventions. The study adds to the knowledge base on implementing MHI initiatives and could promote interests in assessing the response to interventions within the MHI domain and beyond.

Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a "strong health system." We highlight that current findings on "what works" are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to rethink evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks, and methods can support more coherent HSS investment.

Background Our paper presents experiences and perceptions of beneficiaries, health service providers, and community members about a conditional cash transfer (CCT) programme piloted in Nigeria from April 2013 to May 2015 to boost demand for maternal, newborn, and child health services. Methods We conducted a descriptive cross-sectional retrospective study using both qualitative and quantitative methods. Personal interviews and focus group discussions (FGDs) were conducted between June and July 2015 for 314 CCT beneficiaries, 72 ward development committee (WDC) members, and 60 service providers (midwives, community health extension workers [CHEWs], and village health workers [VHWs]) including 29 officers-in-charge as key informants. Content analysis was applied to qualitative findings and grouped into themes of attitude, practices, CCT operations, payout, and perceived impact. Results Over 97% of beneficiaries affirmed that the cash incentive was very helpful and almost 70% opined that the free supply-side services were the real benefit. Majority of service providers applauded the programme though, with complaints about the increased workload. Community members applauded the scheme, with mixed feelings over some operational processes. Conclusion Beneficiaries, service providers, and community members expressed deep satisfaction with the CCT programme and opined that antenatal care (ANC) and skilled birth delivery service utilization increased. Insights into some programmatic challenges are provided to enrich future CCT design and implementation.

The study aims to explore the perceived satisfaction of insured clients in financing health services through National Health Insurance in Ghana. A quantitative method was used to recruit 380 respondents, selected by multistage cluster sampling. Data were collected through the administration of questionnaires. More than half, 57.9%, of respondents were males, and the average age was 34 years. Most respondents, 74.3%, were insured. Overall, 53.12% of insured clients were dissatisfied with the services of providers. Factors, such as benefit package of insurance, willingness to pay higher premium, and perceived discrimination were significantly associated with poor satisfaction with health services. The current advocacy for and awareness about the use of health insurance as a prepayment plan should be prioritised in policy initiatives. The benefit package for the insurance should be increased in order to cover all disease conditions that afflict the Ghanaian population.

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.

Nearly half of the countries in the world are in the process of reforming and strengthening their health care systems. More recently, even low-income and middle-income countries such as Mongolia have focused increasing attention on achieving universal health coverage (UHC). At this critical point, it is necessary to track recent progress and adjust health care strategies and planning. Therefore, this study analyzed changes in the health sector toward achieving UHC based on relevant literature, government documents, and framework analysis. We also investigated how basic principles of UHC were incorporated and reflected in Mongolia's Health Sector Strategic Master Plan. This study clarified the achievements of and challenges facing the health sector that remain or emerged during the plan's implementation over the last decade. Furthermore, all of the reviewed Master Plan strategies were underpinned by basic principles of UHC. However, strategies set out in the next Master Plan will require adjustments and innovative measures to respond to current challenges. This study may be used as a reference for other developing countries to track UHC achievements and serve as a guide to establishing a nation-wide strategic plan.

Background: Governments use a variety of processes to incorporate public perspectives into policymaking, but few studies have evaluated these processes from participants' point of view. Objective: The objective of this study was twofold: to understand the perspectives of selected stakeholders with regard to involvement processes used by Australian Advisory Committees to engage the public and patients; and to identify barriers and facilitators to participation. Design: Twelve semi‐structured interviews were conducted with representatives of different stakeholder groups involved in health technology funding decisions in Australia. Data were collected and analysed using a theoretical framework created by Rowe and Frewer, but adapted to more fully acknowledge issues of power and influence. Results: Stakeholder groups disagreed as to what constitutes effective and inclusive patient involvement. Barriers reported by interviewees included poor communication, a lack of transparency, unworkable deadlines, and inadequate representativeness. Also described were problems associated with defining the task for patients and their advocates and with the timing of patient input in the decision‐making process. Interviewees suggested that patient participation could be improved by increasing the number of patient organizations engaged in processes and including those organizations at different stages of decision making, especially earlier. Conclusions: The different evaluations made by stakeholder groups appear to be underpinned by contrasting conceptions of public involvement and its value, in line with Graham Martin's work which distinguishes between ‘technocratic’ and ‘democratic’ public involvement. Understanding stakeholders' perspectives and the contrasting conceptions of public involvement could foster future agreement on which processes should be used to involve the public in decision making. Refereed/Peer-reviewed

Infants who suffer hypoxic-ischaemic encephalopathy (HIE) at term are at risk of dying or developing severe cerebral palsy (CP). Children with severe CP often have other neurodevelopmental disabilities, which may affect their quality of life as much as the CP itself. New treatments for HIE, such as cooling, may improve motor outcomes, but affected infants may still have significant cognitive or communication problems. Infants who have experienced HIE and develop CP will require significant medical input throughout childhood and adult life. The costs of this medical input are high, but the indirect costs to the child, his or her family, and the relevant social services and education systems are many times greater. When demonstrating the cost-effectiveness of interventions aimed at preventing or treating HIE, these additional costs should be taken into account.

Risk coping strategies adopted by the households in the event of illness depends on the accessibility to healthcare financing mechanisms including health insurance. The empirical evidence on the effect of microhealth insurance (MHI) on the risk coping strategies of the households is scarce. This paper evaluates the impact of Sampoorna Suraksha Program, a nongovernmental organization-initiated MHI scheme and the risk coping strategies of households faced with medical illness in Karnataka state, India. In this descriptive cross-sectional study, we collected data from 416 insured households, 366 newly insured households and 364 uninsured households in randomly selected 10 taluks in three districts of Karnataka state, India. We hypothesized that insured individuals rely less on ex post risk coping strategies (borrowing, use of savings and sale of assets) compared with uninsured and newly insured individuals. Our hypothesis was tested using logistic and linear regression analysis. A significant difference among insured, uninsured and newly insured individuals was found for borrowing but not in the use of savings or sale of assets. A positive impact of MHI on illness-induced borrowing (both incidence and amount) was evident. The evidence from this study reinforces the role of MHI as a pivotal financing alternative to out-of-pocket expenditure in India.

SUMMARY Objective This paper aims to present a review of published evidence of barriers to emergency care, with attention towards both financial and other barriers. Method With the keywords (financial) accessibility, barriers and emergency care services, citations in PubMeb were searched and further selected in the context of the objective of this article. Results Forty articles, published over a period of 15 years, showed evidence of significant barriers to emergency care. These barriers often tend to persist, despite the fact that the evidence was published many years ago. Several publications stressed the importance of the financial barriers in foregoing or delaying potentially life-saving emergency services, both in poor and rich countries. Other publications report non-financial barriers that prevent patients in need of emergency care (pre-hospital and in-patient care) from seeking care, from arriving in the proper emergency department without undue delay or from receiving proper treatment when they do arrive in these departments. Conclusion It is clear that timely access to life-saving and disability-preventing emergency care is problematic in many settings. Yet, low-cost measures can likely be taken to significantly reduce these barriers. It is time to make an inventory of these measures and to implement the most cost-effective ones worldwide. Copyright © 2011 John Wiley & Sons, Ltd.

This paper assesses Singapore's healthcare financing arrangements in terms of their efficiency, fairness, and adequacy. Singapore represents an interesting case study because it is perhaps the only high-income, rapidly ageing country to rely on mandatory savings to finance healthcare, thus eschewing extensive risk-pooling arrangements, generally regarded as efficient and equitable. The paper argues that parametric reforms, i.e. relatively minor changes in the parameters of current schemes which preserve the existing philosophy and system design, will not be sufficient to meet healthcare financing objectives. Systemic reforms, which will bring Singapore into the mainstream of health financing arrangements found in the OECD countries, are urgently needed. Their design and timing should be based on good quality, timely and relevant data, and an environment conducive to vigorous debate.

Social security in Singapore is met by a compulsory personal savings scheme under the Central Provident Fund. Part of these savings go towards the individual's healthcare needs which are met through a spectrum of three schemes – Medisave, Medishield and Medifund, or the ‘3Ms’. This study examines the effectiveness of the ‘3Ms’ in making healthcare services affordable to families with cancer-stricken children. The extent to which the ‘3Ms’ support costly cancer treatment is an indication of the healthcare financing system's ability to meet diverse healthcare needs. Literature research and interviews with medical social workers and families with cancer-stricken children indicate that the ‘3Ms’ are unable to support these families’ medical needs without the help of voluntary welfare organisations. This suggests that there is a need to question a rigid adherence to financial prudence and consider a more flexible healthcare system that is responsive to varied needs.