Form and functioning: contextualising the start of the global financing facility policy processes in Burkina Faso.

BACKGROUND: Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally. OBJECTIVE: This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso. METHODS: We conducted an exploratory qualitative policy analysis. Data collection included document review (N = 74) and in-depth semi-structured interviews (N = 23). Data were analysed based on the components of the health policy triangle. RESULTS: There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective. CONCLUSIONS: Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.

Main findings: There was a high level of political commitment to the Global Financing Facility in Burkina Faso, but its implementation has been hindered by policy fragmentation, competing interests, weak institutional anchoring, and misunderstandings.Added knowledge: This study documents the initiation of a global health initiative, specifically the Global Financing Facility, including the development and implementation of its planning documents, namely the Investment Case and Project Appraisal Document.Global health impact for policy and action: An understanding of the factors that facilitated or impeded the policy processes of developing and implementing the Global Financing Facility can inform the design and implementation of future initiatives.

Health financing and access to medicines in the Caribbean

For millions of people, including those in the Caribbean region, accessing affordable and high-quality medicines poses significant challenges. These include affordability issues, concerns over the quality and safety of medicines, and inadequate financing for health care, as well as the inappropriate use of essential medicines, weak or limited regulatory systems, and complex procurement and supply chain management processes. The Caribbean region also faces a unique set of challenges, including high levels of public debt and significant informal economies. These factors constrain the capacity of governments to invest in social programs and agendas, including the provision of universal health coverage. At present, public spending on health care in the region is only 3.9% of gross domestic product, well below the 6% target. Consequently, many people must rely on out-of-pocket payments for health care, including medicines. This financial burden creates barriers to accessing health care and can lead to the irrational use of prescription drugs and other medicines. This report offers an initial and concise evaluation of certain health financing aspects that are crucial for accessing medicines in the Caribbean. It also provides a preliminary set of recommendations to guide national and regional efforts to improve the region’s current organization, financing, and provision of medicines. These recommendations aim to tackle the significant challenges highlighted in the report, including those related to system financing, barriers to access, and the financial burden of out-of-pocket costs. Envisioned as an integral part of a broader series of initiatives, this study aims to promote equitable, affordable, and sustainable access to medicines and health technologies by strengthening regulatory frameworks and production capacities, as well as by promoting the rational use of medicines. The publication also aims to be a useful resource for policymakers, health professionals, and other stakeholders in the region and beyond, as they work toward ensuring that everyone in the Caribbean has access to the medicines they need to lead healthy and productive lives, and that the region can achieve sustainable and equitable health financing.

[Main characteristics and historical evolution of China' s health financing transition].

OBJECTIVE: To comprehend the main characteristics and historical evolution of health financing transition in China. METHODS: Data were collected from various sources, including the Global Health Expenditure Database (GHED), China Health Statistics Yearbook, National Health Finance Annual Report, China ' s Total Health Expenditure Research Report, et al. Descriptive statistics and literature study was conducted. RESULTS: Since the beginning of the 21st century, most countries in the world had witnessed a transition of health financing, characterized by the expansion of health financing scale and the strengthening of public financing responsibility. Notably, China ' s health financing transition exhibited distinctive features. Firstly, there had been a more rapid expansion in health financing scale compared with global averages. Between 2000 and 2019, total health expenditure per capita experienced a remarkable increase of 816.6% at comparable prices, significantly surpassing average growth rates observed among other countries worldwide (102.1%). Secondly, greater efforts had been made to strengthen the responsibilities of public financing. From 2000 to 2019, there was a substantial decrease of 30.6 percentage points in the proportion of out-of-pocket health expenditure as a share of total health expenditure. This decline was significantly larger than the average reduction observed among other countries worldwide (5.6 percentage points). Thirdly, there had been a significant shift in government health expenditure allocation patterns, with an increased emphasis on "demand-side subsidies" surpassing "supply-side subsidies". Within the realm of "supply-side subsidies", funding directed towards hospitals had notably increased and surpassed that allocated to primary healthcare institutions and public health institutions. Based on these distinctive characteristics, this paper expanded China ' s health financing transition into three dimensions: Scale dimension, structure dimension and flow dimension. Using a comprehensive analytical framework, the history of China ' s health financing transition was roughly divided into four stages: The planned economy stage, the economic transition stage, the post-SARS stage and the new health system reform stage. The main features and evolutionary logic associated with each stage were analyzed. CONCLUSION: Above all, the health financing system should be enhanced in terms of vertical "embeddedness" and horizontal "complementarity". Moreover, the significance of health financing transition in preserving hidden value and mitigating public risk should be emphasized, and there is a need for an improved two-way trade-off mechanism that balances value and risk. Additionally, the ethical principles associated with health financing transition should be considered comprehensively, while optimizing budget decision-making within the government ' s actual governance model. Lastly, it is crucial to recognize the overall and profound impact of modern medicine development and explore long-term strategies and pathways for health financing transition in China.

Digital technologies for health financing in low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: Universal health coverage (UHC) is a global priority, ensuring equitable access to quality healthcare services without financial hardship. Many countries face challenges in progressing towards UHC. Health financing is pivotal for advancing UHC by raising revenues, enabling risk-sharing through pooling of funds and allocating resources. Digital technologies in the healthcare sector offer promising opportunities for health systems. In low-income and middle-income countries (LMICs), digital technologies for health financing (DTHF) have gained traction, supporting these three main functions of health financing for UHC. As existing information on DTHF in LMICs is limited, our scoping review aims to provide a comprehensive overview of DTHF in LMICs. Our objectives include identifying and describing existing DTHF, exploring evaluation approaches, examining their positive and negative effects, and investigating facilitating factors and barriers to implementation at the national level. METHODS AND ANALYSIS: Our scoping review follows the six stages proposed by Arksey and O'Malley, further developed by Levac et al and the Joanna Briggs Institute. The reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework. Eligibility criteria for studies reflect the three core elements of the search: (1) health financing, (2) digital technologies and (3) LMICs. We search multiple databases, including Medline via PubMed, EMBASE via Ovid, the Web of Science Core Collection, CENTRAL via Cochrane and the Global Index Medicus by the WHO. The extracted information is synthesised from both quantitative and qualitative studies. ETHICS AND DISSEMINATION: As our scoping review is based solely on information gathered from previously published studies, documents and publicly available scientific literature, ethical clearance is not required for its conduct. The findings are presented and discussed in a peer-reviewed article, as well as shared at conferences relevant to the topic.

Denmark: Health System Review.

This analysis of the Danish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Population health in Denmark is good and improving, with life expectancy above the European Union (EU) average but is, however, lagging behind the other Nordic countries. Denmark has a universal and tax-financed health system, providing coverage for a comprehensive package of health services. Notable exclusions to the benefits package include outpatient prescription drugs and adult dental care, which require co-payment and are the main causes of out-of-pocket spending. The hospital sector has been transformed during the past 15 years through a process of consolidating hospitals and the centralization of medical specialties. However, in recent years, there has been a move towards decentralization to increase the volume and quality of care provided outside hospitals in primary and local care settings. The Danish health care system is, to a very high degree, based on digital solutions that health care providers, citizens and institutions all use. Ensuring the availability of health care in all parts of Denmark is increasingly seen as a priority issue. Ensuring sufficient health workers, especially nurses, poses a significant challenge to the Danish health system's sustainability and resilience. While a comprehensive package of policies has been put in place to increase the number of nurses being trained and retain those already working in the system, such measures need time to work. Addressing staffing shortages requires long-term action. Profound changes in working practices and working environments will be required to ensure the sustainability of the health workforce and, by extension, the health system into the future.

Improving access to primary health care through financial innovation in rural China: a quasi-experimental synthetic difference-in-differences approach.

BACKGROUND: Inadequate financing constrains primary healthcare (PHC) capacity in many low- and middle-income countries, particularly in rural areas. This study evaluates an innovative PHC financing reform in rural China that aimed to improve access to healthcare services through supply-side integration and the establishment of a designated PHC fund. METHODS: We employed a quasi-experimental synthetic difference-in-differences (SDID) approach to analyze county-level panel data from Chongqing Province, China, spanning from 2009 to 2018. The study compared the impact of the reform on PHC access and per capita health expenditures in Pengshui County with 37 other control counties (districts). We assessed the reform's impact on two key outcomes: the share of outpatient visits at PHC facilities and per capita total PHC expenditure. RESULTS: The reform led to a significant increase in the share of outpatient visits at PHC facilities (14.92% points; 95% CI: 6.59-23.24) and an increase in per capita total PHC expenditure (87.30 CNY; 95% CI: 3.71-170.88) in Pengshui County compared to the synthetic control. These effects were robust across alternative model specifications and increased in magnitude over time, highlighting the effectiveness of the integrated financing model in enhancing PHC capacity and access in rural China. CONCLUSIONS: This research presents compelling evidence demonstrating that horizontal integration in PHC financing significantly improved utilization and resource allocation in rural primary care settings in China. This reform serves as a pivotal model for resource-limited environments, demonstrating how supply-side financing integration can bolster PHC and facilitate progress toward universal health coverage. The findings underscore the importance of sustainable financing mechanisms and the need for policy commitment to achieve equitable healthcare access.

Bridging the gap or widening the divide? Exploring the dual role of social capital in healthcare financing in rural Uttar Pradesh, India.

Social capital, defined as the nature of the social relationship and the resources embedded within the social network of an individual or community, influences how individuals within a group interact and collaborate within their communities or organizations. While it is acknowledged that social capital can be drawn from as a coping strategy to mitigate financial stress, there is a notable absence of the lived experience in the literature on how social capital influences households to tap resources from their social network. We have investigated the role of social capital in healthcare financing in rural Uttar Pradesh, India, highlighting the challenges faced by households in managing healthcare expenses. We took a qualitative research approach, conducting in-depth interviews with 24 households in the Hardoi District of Uttar Pradesh in August 2017 to explore participants' lived experience of accruing support from their community during their healthcare crisis. Data analysis followed a thematic content analysis approach. The study finds that households leverage social capital for both financial and non-financial support during health crises. Social networks, trust, and community cohesion play critical roles in resource acquisition. However, overreliance on social capital can be coercive, leading to inequity, privacy invasion, and dependency. Though social capital serves as a crucial resource of support in healthcare emergencies, its unequal distribution and potential for misuse highlight the need for more structured health financing policies in India. The findings underscore the importance of integrating community-driven resources into broader health financing strategies, considering local social structures and community dynamics.

Financial protection and equity in the healthcare financing system in Iran: a cross-sectional study among slum dwellers with type 2 diabetes.

OBJECTIVES: This study was conducted to assess financial protection and equity in the healthcare financing system among slum dwellers with type 2 diabetes (T2D) in Iran in 2022. DESIGN: Cross-sectional study. SETTING: Primary care centres in Iran were selected from slums. PARTICIPANTS: Our study included 400 participants with T2D using a systematic random sampling method. Patients were included if they lived in slums for at least five consecutive years, were over 18 years old and did not have intellectual disabilities. PRIMARY AND SECONDARY MEASURES: A self-report questionnaire was used to assess cost-coping strategies vis-à-vis T2D expenditures and factors influencing them, as well as forgone care among slum dwellers. RESULTS: Of the 400 patients who participated, 53.8% were female. Among the participants, 27.8% were illiterate, but 30.3% could read and write. 75.8% had income below 40 million Rial. There was an association between age, education, income, basic insurance, supplemental insurance and cost-coping strategies (p<0.001). 88.2% of those with first university degree used health insurance and 34% of illiterate people used personal savings. 79.8% of people with income over 4 million Rial reported using insurance to cope with healthcare costs while 55% of those with income under 4 million Rial reported using personal savings and a combination of health insurance and personal savings to cope with healthcare costs. As a result of binary logistic regression, illiterate people (adjusted OR=16, 95% CI 3.65 to 70.17), individuals with low income (OR 5.024, 95% CI 2.42 to 10.41) and people without supplemental insurance (OR 1.885, 95% CI 0.03 to 0.37) are more likely to use other forms of cost-coping strategies than health insurance. CONCLUSIONS: As a result of insufficient use of insurance, cost-coping strategies used by slum dwellers vis-à-vis T2D expenditures do not protect them from financial risks. Expanding universal health coverage and providing supplemental insurance for those with T2D living in slums are recommended. Iran Health Insurance should adequately cover the costs of T2D care for slum dwellers so that they do not need to use alternative strategies.

Redefining Debt-to-Health, a triple-win health financing instrument in global health.

BACKGROUND: As a recognized win-win-win approach to international debt relief, Debt-to-Health(D2H)has successfully translated debt repayments into investments in health-related projects. Although D2H has experienced modifications and periodic suspension, it has been playing an increasingly important role in resource mobilization in public health, particularly for low-and middle-income countries deep in debt. MAIN TEXT: D2H, as a practical health financing instrument, is not fully evidenced and gauged by academic literature though. We employed a five-step scoping review methodology. After posing questions, we conducted comprehensive literature searches across three databases and one official website to identify relevant studies.We also supplemented our research with expert interviews. Through this review and interviews, we were able to define the concept and structure of D2H, identify stakeholders, and assess its current shortcomings. Finally, we proposed relevant countermeasures and suggestions. CONCLUSION: This paper examines the D2H project's implementation structure and influencing variables, as well as the current research plan's limitations, with a focus on the role health funding institutions have played during the project's whole life. Simultaneously, it examines the interdependencies between debtor nations, creditor nations, and health financing establishments, establishing the groundwork for augmenting and revamping D2H within the ever-changing worldwide context of health development assistance.

Can performance-based financing improve efficiency of health centers in Ethiopia? A Malmquist Productivity Index analysis.

INTRODUCTION: The Ethiopian government has introduced several healthcare financing reforms intending to improve efficiency. Piloting implementation of performance-based financing is one of these actions. The purpose of this research is to assess the efficiency of healthcare facilities that have implemented performance-based financing compared to those that have not. METHODS: Efficiency was measured using a nonparametric data envelopment analysis and the Malmquist Productivity Index technique. Total factor productivity change, technical change, and technological change are compared across eight sampled healthcare facilities that are implementing performance-based financing and eight that are not in Ethiopia. RESULTS: Health facilities implementing performance-based financing have a mean technical efficiency score of 64%, allowing for a potential 36% reduction in inputs without affecting outputs. Their scale efficiency is 88%, indicating a potential 12% increase in total outputs without expanding facilities. In contrast, facilities not implementing performance-based financing have a mean technical efficiency score of 62%, with a potential for 38% input reduction without affecting outputs. Their scale efficiency is 87%, suggesting a potential 13% increase in total outputs without scaling up facilities. Among the 16 healthcare facilities observed, seven experienced a decline in the mean total productivity, while one remained stagnant. The remaining eight facilities witnessed an increase in productivity. The healthcare facilities implementing performance-based financing showed a 1.3% decrease in mean total productivity during the observed period. Among them, five showed an increase and three showed a decrease in the total factor of productivity. The mean total factor of productivity of all healthcare facilities not implementing performance-based financing remained stagnant over the three-year period (2019-2021), with four showing an increase and four showing a decrease in total productivity. CONCLUSIONS: The study concludes that implementing performance-based financing did not improve productivity levels among healthcare facilities over three years. In fact, productivity decreased among the facilities implementing performance-based financing, while those not implementing it remained stagnant. This shows health facilities that implement performance-based financing tend to utilize more resources for similar outputs, contradicting the anticipated efficiency improvement.

Reconciling devolution with health financing and public financial management: challenges and policy options for the health sector.

The interplay between devolution, health financing and public financial management processes in health-or the lack of coherence between them-can have profound implications for a country's progress towards universal health coverage. This paper explores this relationship in seven Asian and African countries (Burkina Faso, Kenya, Mozambique, Nigeria, Uganda, Indonesia and the Philippines), highlighting challenges and suggesting policy solutions. First, subnational governments rely heavily on transfers from central governments, and most are not required to allocate a minimum share of their budget to health. Central governments channelling more funds to subnational governments through conditional grants is a promising way to increase public financing for health. Second, devolution makes it difficult to pool funding across populations by fragmenting them geographically. Greater fiscal equalisation through improved revenue sharing arrangements and, where applicable, using budgetary funds to subsidise the poor in government-financed health insurance schemes could bridge the gap. Third, weak budget planning across levels could be improved by aligning budget structures, building subnational budgeting capacity and strengthening coordination across levels. Fourth, delays in central transfers and complicated procedures for approvals and disbursements stymie expenditure management at subnational levels. Simplifying processes and enhancing visibility over funding flows, including through digitalised information systems, promise to improve expenditure management and oversight in health. Fifth, subnational governments purchase services primarily through line-item budgets. Shifting to practices that link financial allocations with population health needs and facility performance, combined with reforms to grant commensurate autonomy to facilities, has the potential to enable more strategic purchasing.

Opportunities and challenges for financing women's, children's and adolescents' health in the context of climate change.

Women, children and adolescents (WCA), especially in low-income and middle-income countries (LMICs), will bear the worst consequences of climate change during their lifetimes, despite contributing the least to global greenhouse gas emissions. Investing in WCA can address these inequities in climate risk, as well as generating large health, economic, social and environmental gains. However, women's, children's and adolescents' health (WCAH) is currently not mainstreamed in climate policies and financing. There is also a need to consider new and innovative financing arrangements that support WCAH alongside climate goals.We provide an overview of the threats climate change represents for WCA, including the most vulnerable communities, and where health and climate investments should focus. We draw on evidence to explore the opportunities and challenges for health financing, climate finance and co-financing schemes to enhance equity and protect WCAH while supporting climate goals.WCA face threats from the rising burden of ill-health and healthcare demand, coupled with constraints to healthcare provision, impacting access to essential WCAH services and rising out-of-pocket payments for healthcare. Climate change also impacts on the economic context and livelihoods of WCA, increasing the risk of displacement and migration. These impacts require additional resources to support WCAH service delivery, to ensure continuity of care and protect households from the costs of care and enhance resilience. We identify a range of financing solutions, including leveraging climate finance for WCAH, adaptive social protection for health and adaptations to purchasing to promote climate action and support WCAH care needs.

Financing for pandemic preparedness and response measures: a systematic scoping review.

Objective: To obtain insights into reducing the shortfall in financing for pandemic preparedness and response measures, and reducing the risk of another pandemic with social and economic costs comparable to those of the coronavirus disease. Methods: We conducted a systematic scoping review using the databases ScienceDirect, Scopus, JSTOR, PubMed® and EconLit. We included articles published in any language until 1 August 2023, and excluded grey literature and publications on epidemics. We categorized eligible studies according to the elements of a framework proposed by the World Health Organization Council on the Economy of Health for All: (i) root/structural causes; (ii) social position/foundations; (iii) infrastructure and systems; and (iv) communities, households and individuals. Findings: Of the 188 initially identified articles, we included 60 in our review. Most (53/60) were published after 2020, when academic interest had shifted towards global financing mechanisms. Most (37/60) addressed two or more of the council framework elements. The most frequently addressed element was infrastructure and systems (54/60), discussing topics such as health systems, financial markets and innovation ecosystems. The roots/structural causes were discussed in 25 articles; communities, households and individuals in 22 articles; and social positions/foundations in 11. Conclusion: Our review identified three important gaps: a formal definition of pandemic preparedness and response, impeding the accurate quantification of the financing shortfall; research on the extent to which financing for pandemic preparedness and response has been targeted at the most vulnerable households; and an analysis of specific financial instruments and an evaluation of the feasibility of their implementation.

[Effects of parliamentary amendments on municipal financing of primary health care in the Brazilian Unified National Health System]. / Efeitos das emendas parlamentares no financiamento municipal da atenção primária à saúde do Sistema Único de Saúde.

This study aims to analyze the effects of the expansion of the federal transfer of parliamentary amendments for municipal financing of primary health care (PHC) in the Brazilian Unified National Health System (SUS), from 2015 to 2020. A longitudinal study was conducted using secondary data on transfers of parliamentary amendments from the Brazilian Ministry of Health and expenditure of municipalities' own resources on public health actions and services and PHC. The effect of the transfer of parliamentary amendments on municipal financing was verified in a stratified way by population size of the municipalities, using generalized estimating equation models. The transfer of parliamentary amendments for PHC showed a large discrepancy in per capita values among municipalities of different population sizes. No correlation with municipal spending on public health actions and services was observed in municipalities with more than 10,000 inhabitants, and the association with spending on PHC (p < 0.050) was inverse in all municipalities. Therefore, the increase in the transfer of parliamentary amendments by the Brazilian Ministry of Health favored a reduction in the allocation of municipal revenues to PHC, which may have been directed to other spending purposes in the SUS. These changes seem to represent priorities established for municipal budget expenditure, which have repercussions on local conditions for guaranteeing stable funding for PHC in Brazil.

O objetivo deste artigo é analisar os efeitos da ampliação do repasse federal de emendas parlamentares no financiamento municipal da atenção primária à saúde (APS) do Sistema Único de Saúde (SUS), no período de 2015 a 2020. Foi realizado estudo longitudinal com dados secundários de transferências por emendas parlamentares do Ministério da Saúde e de despesas com recursos próprios dos municípios, aplicadas em ações e serviços públicos de saúde e na APS. O efeito do repasse de emendas parlamentares no financiamento municipal foi verificado de forma estratificada por porte populacional dos municípios, por meio de modelos de equações de estimativas generalizadas. O repasse de emendas parlamentares para a APS apresentou grande discrepância de valores per capita entre os municípios de diferentes portes populacionais. Observou-se inexistência de correlação com a despesa municipal em ações e serviços públicos de saúde nos municípios com mais de 10 mil habitantes e associação inversa com a despesa em APS (p < 0,050) em todos os grupos. Conclui-se que o aumento do repasse de emendas parlamentares pelo Ministério da Saúde favoreceu a redução da alocação de receitas municipais com APS, que podem ter sido direcionados para outras finalidades de gasto no SUS. Tais mudanças parecem refletir prioridades estabelecidas para a despesa orçamentária dos municípios, que repercutem sobre as condições locais para a garantia da estabilidade do financiamento da APS no Brasil.

El artículo tiene como objetivo analizar los efectos de la ampliación de la transferencia de recursos federal de enmiendas parlamentarias sobre el financiamiento municipal de la atención primaria de salud (APS) en el Sistema Único de Salud brasileño (SUS), en el período del 2015 al 2020. Se realizó un estudio longitudinal con datos secundarios de transferencias de recursos por enmiendas parlamentarias del Ministerio de Salud y de gastos con recursos propios de los municipios, aplicados a acciones y servicios públicos de salud y a la APS. El efecto de la transferencia de recursos de enmiendas parlamentarias sobre el financiamiento municipal se verificó de forma estratificada por tamaño de población de los municipios, utilizando modelos de ecuaciones de estimaciones generalizadas. La transferencia de recursos de enmiendas parlamentarias para la APS mostró una gran discrepancia en los valores per cápita entre municipios de diferente tamaño poblacional. No hubo correlación con el gasto municipal en acciones y servicios públicos de salud en aquellos con más de 10.000 habitantes y asociación inversa con el gasto en APS (p < 0,050) en todos los grupos de municipios. Se concluye que el aumento en la transferencia de recursos de enmiendas parlamentarias por parte del Ministerio de Salud favoreció la reducción de la asignación de ingresos municipales a la APS, que pueden haber sido dirigidos a otros fines de gasto en el SUS. Tales cambios parecen reflejar prioridades establecidas para el gasto presupuestario municipal, que repercuten en las condiciones locales para garantizar la estabilidad del financiamiento de la APS en Brasil.

Mitigating the regressivity of private mechanisms of financing healthcare: An Assessment of 29 countries.

Progressive financing of health care can help advance the equity and financial protection goals of health systems. All countries' health systems are financed in part through private mechanisms, including out-of-pocket payments and voluntary health insurance. Yet little is known about how these financing schemes are structured, and the extent to which policies in place mitigate regressivity. This study identifies the potential policies to mitigate regressivity in private financing, builds two qualitative tools to comparatively assess regressivity of these two sources of revenue, and applies this tool to a selection of 29 high-income countries. It provides new evidence on the variations in policy approaches taken, and resultant regressivity, of private mechanisms of financing health care. These results inform a comprehensive assessment of progressivity of health systems financing, considering all revenue streams, that appears in this special section of the journal.