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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


  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]