title: State budget transfers to health insurance funds: extending universal health coverage in low- and middle-income countries of the WHO European Region.
abstract: BACKGROUND
  Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups. This paper assesses the institutional design aspects of such financing arrangements and their performance with respect to universal health coverage progress in LMIC of the European region.
  
  
  METHODS
  The study is based on a literature review and review of secondary databases for the performance assessment.
  
  
  RESULTS
  Such financing arrangements currently exist in 13 LMIC of that region, with strong commonalities in institutional design: This includes a wide range of different eligible population groups, mostly mandatory membership, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. Performance is more varied. Enrolment rates range from about 65 % to above 95 %, and access to care and financial protection has improved in several countries. Yet, inequities between income quintiles persist.
  
  
  CONCLUSIONS
  Budget transfers to health insurance arrangements have helped to deepen UHC or maintain achievements with respect to UHC in these European LMICs by covering those outside formal sector work, and in particular vulnerable population groups. However, challenges remain: a comprehensive benefit package on paper is not enough as long as supply side constraints and quality gaps as well as informal payments prevail. A key policy question is how to reach those so far uncovered.
authors.affiliation: Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211, Geneva, Switzerland. mathaueri@who.int.
authors.forename: Inke
authors.identifier: http://orcid.org/0000-0002-9822-9262
authors.initials: I
authors.lastname: Mathauer
authors.affiliation: Health, Population Policy, Social Security Division, Federal Ministry for Economic Cooperation and Development, Bonn, Germany.
authors.forename: Mareike
authors.initials: M
authors.lastname: Theisling
authors.affiliation: Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211, Geneva, Switzerland.
authors.forename: Benoit
authors.initials: B
authors.lastname: Mathivet
authors.affiliation: Consultant with the World Health Organization at the time of writing from October 2014 to December 2015, Avenue Appia, 1211, Geneva, Switzerland.
authors.forename: Ileana
authors.initials: I
authors.lastname: Vilcu
mesh_terms: D005061:Europe, Eastern; D018166:Health Care Reform / Q000191:economics* / Q000379:methods; D005102:Health Expenditures / Q000639:trends*; D006801:Humans; D019472:Universal Health Insurance / Q000592:standards / Q000639:trends*; D014944:World Health Organization / Q000458:organization & administration
keywords: Financial protection; Government budget transfers; Health insurance; Informal sector; Universal health coverage; Vulnerable populations