Economic growth and development are usually accompanied by significant changes in how health systems are financed, a process which is increasingly being referred to as the health financing transition: the tendency for the levels of health expenditure to increase, accompanied by an increase in the domestic publicly-financed share of health spending; the flip side being a decline in the external- and out-of-pocket (OOP)-financed share of health spending as national incomes rise. These empirical trends are driven by a range of factors: institutional development, medical technological advancements, ageing, changing population preferences, etc. If and how countries undergo their health financing transition – especially in terms of the willingness and ability of countries to increase the level and progressivity of public financing for health – will determine the rate of progress toward UHC for decades to come. Hence, improving an understanding of factors that can help countries optimally navigate their health financing transition is key from a policy perspective: to sustain gains made under externally-financed programs, to address remaining challenges, and to meet new and emerging challenges.
Countries do not undergo their health financing transitions in isolation. Many low and middle-income counties are facing twin challenges of transiting towards more sustainable domestic financing but in a context of partial epidemiological shifts that place new pressures on service delivery. Whereas there has been significant attention paid towards the former the challenges of providing services for populations with multiple morbidities and risks remain daunting. Despite an overall reduction in the share of communicable diseases in the disease burden, significant pockets of unimmunized children and populations suffering from malaria, tuberculosis, and HIV/AIDS remain. At other end of the spectrum countries are also experiencing increases in non-communicable diseases, multi-morbidities and chronicity. This necessitates a reorientation of services, such that the provision of care is proactive rather than reactive, comprehensive and continuous rather than episodic and disease-specific and founded on lasting patient-provider relationships rather than incidental, provider-led care. Focused and sustained investments are urgently required to build the capacity of the service delivery side of the health system. Many lower- and middle-income countries are therefore facing a triple challenge – still facing unfinished agenda of MCH and infectious diseases challenges, rapidly advancing NCD challenges, and all at the time when external financing is getting less.
In addition to the need for mobilizing more domestic resources to sustain and expand coverage achieved with the support of external financing, an equally important challenge has emerged - integrating single disease program management into the country front line service delivery models, including information management, governance, financing and purchasing, outreach and community health. And, keeping in mind the triple challenge referred to above – to it so that the country’s health system is readied and strengthened to face also the NCDs.
At its core, integrated care addresses fragmentation in patient services by improving coordination and emphasizing provision of more continuous and frontline-focused health care as opposed to episodic and hospital-centric care. And provision of more frontline-focused integrated care requires going beyond health financing to strength and orient other pillars such as how health systems are governed and how service delivery is managed and organized.
At the Global Health Systems Research symposium in Liverpool in October 2018, the UHC2030 launched a statement on sustainability and transition from external financing. Estimated 58 lower and upper middle-income countries will face this transition to smaller or larger extent over the next 5 years. Some of the key 10 principles outlined in the statement call for developing transition policies in the context of UHC, adopt the perspective of health system over singular focus on specific individual health programs, ensure that health system and disease-specific programs work closely towards overcoming health system barriers for progress towards UHC.