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Competing Interests: Competing interests: None declared.

Abstract-Progress toward universal health coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the World Health Organization (WHO) Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases, and how should one adjudicate between them when their demands conflict? This article by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three key dimensions of progress toward UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to prepayment with pooling of funds. Our cases are simplified to highlight common trade-offs. Though we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC.

Background: Several developing countries, especially in Africa, have implemented performance-based financing (PBF) schemes with the aim of improving healthcare provision. PBF was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010., Objective: To enrich existing studies on Burundi in three ways. Firstly, by evaluating the effect of PBF on maternal care at primary and hospital levels; secondly, on the possession of maternity logbooks for maternal care records; and thirdly, how the amount of subsidies influences healthcare outputs., Design: We used data from repeated cross-sectional surveys in 500 households (intervention group: 225; control group: 275) conducted in 2006 and 2008. A total of 274 women, aged 15-49, who had recently given birth, were interviewed about the use of maternal healthcare and the possession of maternity logbooks. We performed a difference-in-differences analysis using pooled cross-sectional survey data from 2006 and 2008., Results: We found that PBF is associated with an increased institutional deliveries probability of 39.5 percentage points (p < 0.01) - a relative improvement of 81.8%. Institutional deliveries probability increased significantly only at health centre level by 33.6 percentage points (p < 0.01), a  relative rise of 80.6%. There is an indication of a positive spillover effect of PBF on the possession of maternity logbooks. We found no PBF effect on the number of antenatal care visits and anti-tetanus immunization., Conclusions: Our findings suggest that institutional delivery highly improved because it came from a low baseline and its unit payment was relatively high, leading health workers to promote its use. The fact that deliveries mainly increased in health centres and not in hospitals may be explained by the context of how health delivery is organized in Burundi. Health policymakers have to determine the appropriate financial incentives that best influence the improvement of each health service.

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC , the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting., Competing Interests: Competing interests: None declared.

Several governments in low- and middle-income countries have adopted performance-based financing to increase health care use and improve the quality of health services. We evaluated the effects of performance-based financing in the central African nation of Burundi by exploiting the staggered rollout of this financing across provinces during 2006-10. We found that performance-based financing increased the share of women delivering their babies in an institution by 22 percentage points, which reflects a relative increase of 36 percent, and the share of women using modern family planning services by 5 percentage points, a relative change of 55 percent. The overall quality score for health care facilities increased by 45 percent during the study period, but performance-based financing was found to have no effect on the quality of care as reported by patients. We did not find strong evidence of differential effects of performance-based financing across socioeconomic groups. The performance-based financing effects on the probability of using care when ill were found to be even smaller for the poor. Our findings suggest that a supply-side intervention such as performance-based financing without accompanying access incentives for poor people is unlikely to improve equity. More research into the cost-effectiveness of performance-based financing and how best to target vulnerable populations is warranted., (Project HOPE—The People-to-People Health Foundation, Inc.)

Introduction: Burundi introduced free healthcare for children under five and pregnant women in 2006. In 2010, this was linked to the Performance-Based Financing (PBF) approach. This article is designed to identify factors in these health financing reforms that have contributed to good governance in the health sector., Methods: Six criteria of good governance were used as an analytical framework. Results were derived from official reports and the international literature., Results: The main contributions of these reforms to good governance in Burundi were the separation of functions, transparency in management and a meticulous description of administrative procedures. Scrupulous monitoring resulted in several corrective measures., Discussion: Several unresolved questions remain, concerning the integration of vertical programmes and the sustainability of the system given the considerable costs, since funding is not yet fully ensured by the State and its partners.