Exploring the features of universal coverage.

Designing and implementing a health financing policy for universal coverage is relatively simple in principle but complex in practice. This issue of the Bulletin explores how it can be done, drawing lessons from several country experiences. Equity of access to health services of all types is key to universal coverage policy. High levels of out-of-pocket payments, including user fees, are still pervasive in many countries, limiting the ability of people to use services. Lagarde and Palmer (839–848) reinforce earlier evidence that removing or reducing user fees increases utilization, at least in the short term. Leive and Xu (849–856) illustrate another problem of out-of-pocket payments, showing that many households in 15 African countries cope by borrowing or by selling assets, i.e. they use their savings and go into debt, thereby restricting long-term economic survival. An important challenge therefore is to shift away from out-of-pocket payments through the development of pre-payment schemes. The development of such health financing schemes may take time and the overall country context matters; these two issues are discussed by Carrin et al. (857–863), who also address the importance of establishing appropriate rules and incentives for the organizations that are involved in implementing these policies. The development of strategies for universal coverage will vary according to country circumstances and constraints, illustrated by El-Idrissi et al. (902–904) for Algeria and Morocco. Prepayment schemes can take many forms on the road to universal coverage. In Mali, membership of community or mutual health insurance schemes has a positive effect on access to priority health services, shown by Miller Franco et al. (830–838). Moving towards prepayment is important but in many settings additional funds will also be critical. Prakongsai et al. (898–901) examine the advantages and disadvantages of earmarking revenues specifically for health, a mechanism often advocated by health professionals. Kaddar and Furrer (877–883) show that international debt relief initiatives can be used to supplement other sources of funding for health and that ministries of health can seek access to these resources. The role of external aid in expanding the funding for health in the African region is debated in the round table (889–895). Kirigia and Diarra-Nama propose several key strategies that would allow countries to eventually wean themselves off international donor funding , essentially involving the better use and management of domestic resources. Ooms and Van Damme highlight, however, the huge gaps between current health expenditures in most low-income settings and …