Methodological Critique from an Epidemiological Perspective on 'Transitions in Health Financing and Policies for Universal Health Coverage.'

Amitabha Sarkar*

*PhD Researcher
Centre for Social Medicine and Community Health
School of Social Sciences
Jawaharlal Nehru University
New Delhi, India
E mail-


Universal Health Coverage (UHC) is the single most policy priority agenda for many countries including India. The design and policy proposals of UHC have been mooted by the concept as well as findings of some initial research reports. This review does a methodological critique of one of such reports. The report is considered as a crucial guideline for the preparation of UHC framework by many Low and Middle Income countries. The critique is based on the epidemiological perspective to analyze its conceptualization, objectives, research questions and operational design. The analysis finds that the report is developed on the assumption of growth phenomenon and not on the reality of complex medical market. The epidemiological concerns are given less priority from design to findings. Selection of wrong indicators, limited research questions and weak assumptions dilute the advantage of having an ecological design to compare the data and analyze with exiting knowledge system. This report is unable to address the confusion currently UHC has over its design and application. UHC research is an epidemiological planning exercise, instead the report ponders over only with financing mechanisms.

‘Universal (Health) coverage is the single most powerful concept that public health has to offer’ (Margaret Chan, DG, WHO, 2012). The declaration of Director General, WHO (World Health Organization) to roll out UHC (Universal Health Coverage) is becoming the most priority public health topic for understanding and assessing in current time. Many researches are happening to understand the feasibility of achieving UHC for various countries. The report on 'Transitions in Health Financing and Policies for Universal Health Coverage: Final Report of the Transitions in Health Financing Project', hereafter the report, has been prepared under the aegis of the Result for Development Institute.(1) It has been officially published on August 24, 2012, and since then it has become one of the central guiding documents for designing UHC in many countries. The aim of this critique is to critically appraise the report and contribute to the knowledge of UHC discussion. The report has been published in 2012 but it is still a valuable technical paper in UHC discourse. Critical assessment of this report would help in understanding the theory behind the financial structure of UHC and how the very theoretical structure shapes the country’s health system for service provisioning purpose.

UHC and the debate

UHC is a scheme to offer health services to everyone in the society irrespective of their financial status. The mechanism of UHC is under process and there is no structured definition from where the technicality of the system can be determined. However, a range of WHO documents, scholarly works and other critical assessments have given a common meaning to UHC, i.e., equity and access. The 2005 World Health Assembly resolution says that "access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in accesses". Going by this notion, it is apparent that health care services (as the resolution mentioned promotive, preventive…) are not adequately accessible because of either service constraint and/or financial restriction, so achieving access to service lead towards achieving equity too.(2)

The two contradictory ideological thoughts are continuously debating with each other over the issue of conceptualization and thus the feasibility of UHC in particular in the low and middle income countries. The pro-UHC supporter has great belief on the impact of UHC as envisaged that it would also include the people from marginalized societies without experiencing any financial obligation thus both equity and access are possible.(3) One the other side, the contesting thought is that without political and social relevance (both historically and contextually) how far it is possible to go for ‘coverage’ based medical centric approach, that too in a resource challenged countries. Hence, the contesting argument is that the model of global north can not be replicated in global south. (4) The report appears to be neutral in this debate by maintaining that it does not offer any particular design of health care system to achieve ‘efficiency and equity’ (for UHC) instead giving a new perspective “…….on today’s health policies by setting them against long term trends in health financing and public policy” (pp. 3). However, the report professes the trajectory of health financing transitions to achieve UHC. In this trajectory, the said perspective illustrates how the different approaches of health financing mechanisms and public policy measures in opposition to the conventional practice may change health policy decisions to achieve UHC. The report’s perspective driven unconventional approaches knowingly or unknowingly set a standard guideline to achieve UHC.

The report at a glance

The report is an interesting review exercise under the context of above mentioned debate. This is a report of the project on transitions in health financing started in the year of 2009. The report acknowledges the transition phases of demography and epidemiology in various countries and argues that transitions in health financing are also much relevant in public health. The transitions in health care financing are generally marked by increase in health spending and rising of pooled financing as influenced under the economical (health spending), technological (medical advancement) and political (ideology, commitment) development. The literature review shows that the studies have been conducted on the areas of growth related health spending, pooled finance vs. out of pocket expenditure, rising income leads to improvement in health, but there is a dearth of need to analyze all theses relevant thematic areas together by reviewing the literatures, consulting the past trends, building the evidence to establish the relation between economics and health that mark down the transitions.

The report has five major sections, starting with the conceptual framework of health financing transition, measures of health financing in respect to coverage and outcomes, phenomena of rising health spending, the reason behind the growth of pooled financing and the strategies adopted by the countries for achieving UHC.

Conceptualization, objectives and research questions:

Two transitions are common for every country or region i.e., demographic and epidemiologic. The demographic transition is based on the decline in mortality and subsequent reduction in fertility, and the epidemiologic transition is processed by the decline in communicable diseases and followed by the decline in non-communicable diseases. Both the transitions give a pathway of population growth: reduce mortality from communicable disease, increase life expectancy and the growth of population, and the increase share of non-communicable diseases. According to the report, along with these two transitions there is another transition (health financing transition) also occurs as an implication of public health advancement. Health financing transition is characterized by increase both in health spending and share of pooled health expenditure. Like other two transitions, the health financing transition is also influenced by social processes and public policies. Though, it does not occur simultaneously as like the other two transitions.

Table: 1 : Types of financing

                                                          Finance Mechanism

                               Pooled Finance

            Non pooled Finance

Tax Based Finance

Social Insurance

Voluntary Insurance (Private insurance)

(out of pocket expenditure)

Medical Savings Account

The health financing transition describes the increase in pooled financing through subsidies provisions or insurance and its effect in expansion of health care services. Pooled financing is based on tax or insurance where most of the time govt. takes the responsibility to provide services to the people irrespective of their financial condition. This process is leading towards the minimization of OOP (out of pocket expenditure) which is by definition on the spot payment as per the service taken. The OOP is always a cause of concern for the state as it excludes the marginalized society from obtaining health services on financial ground. The pooled financing is a mechanism which gives protection to the citizen for health care need by collecting the money in advance and then mobilizing it as need be within the rich and poor as per the theory of risk pooling. So, the conceptualization is rooted in the shift of health care financing and institutional mechanism where poor (and all other sections) of any country is ideally to get health care services without any financial barriers (or comparatively less) unlike earlier era because of OOP, and that is possible because of the health financing transition. This conceptual framework has been finally designed as a project to explore the 'nexus' between economics and health that shapes the transition.

To understand the nexus, the project looks into the interrelationship between spending, expanded care and its impact on population health.

Two assumptions have been made

  1. Growth in health spending is attributed to the rising level of income and advancement of medical technology
  2. Increasing health spending is considered as a factor to expand the coverage area that further enhances the better health of the population.
To explore these assumptions, the following research questions are posed:
  1. What explains growth in health spending?
  2. Why has the pooled share of health spending grown?
  3. How are countries reforming health system today?

Operational design:

The design of the project is ecological that compare various countries over specific indicators to address the research questions. The project design has been made such a way so that it can build the causal pathway for UHC step by step. The health benefits of the population increase due to the expanded coverage and that coverage expansion is because of the health financing transition as processed by various social and political factors. The report makes the argument that the health financing transition is leading towards UHC. This chain of causality has been tried to establish in this report.

Causal framework

The entire report is in two parts, and these two parts altogether represent the five sections. The findings of the five sections are based on the different working papers as made by various research teams involved