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Table 1 Institutional design features of state budget transfer/government subsidization arrangements

From: State budget transfers to health insurance funds: extending universal health coverage in low- and middle-income countries of the WHO European Region

Institutional design aspect Related policy choices Intermediate output indicators UHC related progress indicators
Eligibility and enrolment rules
 Groups eligible for exemption from  contributions/subsidization Definition of vulnerability (e.g. children, unemployed, pregnant women, informal sector workers, poor, near poor) Share of the eligible among the bottom two income quintiles and other vulnerable groups Total population coverage (i.e. enrolment in health insurance fund), differentiated along income quintiles
 Targeting method E.g. universal (based on a very broad criterion such as residence or no employment in the formal sector), indirect (based on socio-demographic, socio-economic or geographic characteristics usually correlated with poverty and vulnerability), direct (through a means assessment or proxy means testing); different targeting approaches can be in place at the same time for different groups Share of the exempted/subsidized within total (insured) population; Share of the exempted/subsidized among those being targeted for exemption/subsidization (targeting effectiveness of the system)
 Enrolment process Active enrolment by the beneficiary or automatic enrolment by the authorities
 Organization responsible for identification  of the exempted non-contributors/the  subsidized E.g., insurance company; central, regional, local government  
 Type of enrolment / membership Mandatory or voluntary  
Financing arrangements
 Degree of subsidization/co-contribution Full or partial (a co-contribution is required) Share of the exempted/subsidized within total (insured) population/those being targeted for subsidization (importance of government revenue)
 Type of transfer mechanism Individual-based (a specific amount is being paid for each exempted individual), or lump-sum (a lump sum transfer for the entire exempted population is made)   
 Calculation logic to determine the amount  of funds to be transferred E.g., based on regular contribution levels, minimum or average wages, specific percentage of the government budget, negotiated by the government Sufficient funding for a comprehensive benefit package Level of cross-subsidization from contributions Financial protection (incidence of catastrophica / impoverishing health expenditure), also differentiated along income quintiles and other aspects; Access to services
 Source of funding for state budget transfers E.g. general government revenues, earmarked government revenues, transfers from other health insurance funds or from contributors within the same pool (cross-subsidization), donor funding  
Pooling arrangements
 Type of pool(s) (general) Single pool, or multiple pools Degree of fragmentation, Size and composition of pools, Level of cross-subsidization Equity in access; Equity in financing; Financial protection
 Type of pool (exempted/subsidized) Exempted/subsidized integrated in the pool with contributors, or separate pool for the exempted/subsidized
 Type of health insurance affiliation/ membership of the contributors Voluntary or mandatory
Purchasing arrangements and benefit package design
 Range of services covered by the  benefit package E.g. comprehensive, inpatient focus, outpatient focus, pharmaceuticals, dental care, indirect costs (e.g. transportation) Different or same package as that for contributors   Financial protection; Access (utilization rates); Equity in access
 Degree of cost-sharing Cost-sharing mechanisms (e.g., co-insurance, co-payment, deductible) and rates
 Provider payment mechanisms Type of provider payment and rates Same or different rules around provider payment Efficiency  
  1. a As per the WHO definition, catastrophic expenditure “occurs when a household’s total out-of-pocket health payments equal or exceed 40 % of household’s capacity to pay” ([59], p. 4)
  2. Source:[11]