Targeted versus non-targeted strategies

For many low-income countries with dysfunctional public health systems and high dependence on the informal sector, universalism remains a long-term strategy. It is also likely that sustaining investment in universal coverage will be difficult in countries reliant on loans or donor aid. In the short-term, targeted strategies for reaching the poor will continue to be needed. In the meantime, more work on the cost implications of rolling out universal coverage in low-income countries is needed.

Free government health services: are they the best way to reach the poor? questions the benefits of concentrating on government health services. It is argued that the goal of equity via provision of universal free health care often remains elusive and that there are other ways for governments to ensure that the poor receive adequate, affordable services through alternative approaches to resource allocation and purchasing.

Targeting services towards the poor: A review of targeting mechanisms and their effectiveness assesses six different targeting mechanisms that have been applied in the health sector in a range of contexts with a single framework. The paper concludes program design and implementation issues are of paramount importance in targeting and its capacity to reach the poor. There is however a gap in knowledge on the “’how and why” issues in the literature. Cost of targeting may obviously be an issue. Further research is needed before we can start drawing a comparative analysis with the alternative of universal benefits.

Some countries that are committed to universal provision of free health care, such as Sri Lanka, Malaysia and Hong Kong, have proved to be high performers in relation to health equity. The ability of countries to reach and protect the poor depends on how health systems are organised and funded, rather than level of economic development, or levels of public spending.

The Sri Lanka health service, in particular, has strong pro-poor credentials. Universal free access to education, which has global support, sets a precedent for universal free health provision. It is important to note other pre-requisites that ensured the success of universal coverage in Sri Lanka, being strong policy and provider commitment to universalism; good geographical coverage of health facilities; investment in improving quality of care in the public sector; policy commitment to meeting increased demand via supply efficiencies; reliance on tax funding for the public sector.