6в‰§ДЇor countries that have not yet implemented a formal sector scheme, alternatives exist. 5 For example, in most low- and middle-income countries that have initiated financing reforms with a health insurance scheme solely for the formal workforce, attention and resources are focused on already advantaged and well organized groups, which tends to exacerbate rather than redress inequalities and leads to locking into a two-tier system.

Fragmentation exists when there are barriers to this redistribution, with perhaps a worst-case scenario where there are different schemes for different social groups. Universal health coverage goals of equitable access with financial protection require pooling arrangements that redistribute prepaid resources to individuals with the greatest health service needs. Larger pools with more diverse populations This further implies that moving towards universal health coverage in such contexts means moving away from the idea of a purely or even a predominantly contributory basis for entitlement and coverage. value added tax) in most low- and middle-income contexts), and the relative need for this grows in proportion to the size of the so-called 'informal sector' of the population. Thus, increasing the size of the compulsory prepaid pool of funds requires transfers from general revenues (sourced predominantly from consumption taxes (e.g. For poorer countries, the structure of the economy, with a large share of the population outside salaried employment, makes it difficult to enforce either income taxes or payroll taxes on most citizens. Even the German government injects general revenues into the system to ensure coverage for those unable to contribute. While public funding can come from general government revenues or compulsory 'social health insurance' contributions (payroll taxes), general government revenues are essential for universal health coverage. And certainly, misplaced faith in voluntary prepayment should not provide an excuse for governments to direct public resources away from the health sector. 4 So while it is unfortunately the case that low- and middle-income countries with poor fiscal capacity may need to explore voluntary prepayment mechanisms as an alternative to out-of-pocket payments, this is not a long-term solution. Compulsion, with subsidization for the poor, is a necessary condition for universality. No country has attained universal population coverage by relying mainly on voluntary contributions to insurance schemes, whether they are run by nongovernmental organizations, commercial companies, 'communities', or governments. Predominant reliance on compulsory or public financing is essential for universal coverage. All systems, regardless of what they are called, have to address these functions and policy choices. Kyrgyzstan, Mexico, Rwanda, Thailand).Дeriving meaningful lessons from innovative reform experiences requires a deeper understanding of how countries have altered their funding sources, pooling arrangements, purchasing methods, and policies on benefits and patient cost-sharing. 3 Such labels hide more than they illuminate, as shown by emerging evidence on reforms that increase access and financial protection but are funded predominantly from general tax revenues (e.g. Interpretation of health financing reform experience requires getting beneath commonly used labels such as 'tax-funded systems' or 'social health insurance', or simply even 'health insurance', which was used as the basis for a systematic review published in the September issue of the Bulletin. 2 Theory and country experience yield important lessons on both promising directions and pitfalls to avoid.

Indeed, concerns have been raised that some reforms, often implemented in the name of expanding coverage, may actually compromise equity. However, this lack of a blueprint for health financing reforms was not meant to convey the message that 'anything goes' on the path to universal health coverage. to improve access to needed, effective services while protecting users from financial ruin. In its 2010 world health report, 1 the World Health Organization noted that there is no single, best path for reforming health financing arrangements to move systems closer to universal health coverage, i.e. World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland

Anything goes on the path to universal health coverage? No.

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