Health Financing and Financial Protection
in the Americas
Working Paper prepared by the WHO Regional Office for the Americas
AMRO/PAHO
Production: Phoenix Design Aid A/S, Denmark
Design: FFW Ltd
1 This paper is a summary of the Chapter 1, Section 6, of Health in the Americas 2017, with some updates and modifications. The new contribution is focused in financial protection and the analysis of new information about this issue.
Conference copy for consultation
WHO/HIS/HGF/HFWorkingPaper/17.9
© World Health Organization, 2017 All rights reserved.
This is a working paper prepared for the Universal Health Coverage Forum,
Tokyo, Japan, 2017. This document may not be reviewed, abstracted, quot-
ed, reproduced, transmitted, distributed, translated or adapted, in part or
in whole, in any form or by any means without the permission of the World
Health Organization.
The designations employed and the presentation of the material in this pub-
lication do not imply the expression of any opinion whatsoever on the part
of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Dotted lines on maps represent approximate border
lines, for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products
does not imply that they are endorsed or recommended by the World Health
Organization in preference to others of a similar nature that are not men-
tioned. Errors and omissions excepted, the names of proprietary products are
distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization
to verify the information contained in this publication. However, the published
material is being distributed without warranty of any kind, either express or
implied. The responsibility for the interpretation and use of the material lies
with the reader. In no event shall the World Health Organization be liable for
damages arising from its use.
The views expressed by authors, editors, or expert groups do not necessarily
represent the decisions or the stated policy of the World Health Organization.
Health Financing and Financial Protection
in the Americas1
AMRO/PAHO
Working Paper prepared by the WHO Regional Office for the Americas
Health Financing and Financial Protection in the Americas
ii
Acknowledgements
The paper was developed by Camilo Cid (regional advisor and focal point in health
economics and financing) , Claudia Pescetto (regional advisor in health economics
and financing), Juan Pablo Pagano (Consultant, health economics and financing),
Amalia Del Riego (unit chief health services and access unit), and James Fitzgerald
(Department Director) from the Department of Health Systems and Services of the
Pan American Health Organization/World Health Organization.
Valuable comments have been received from Gabriela Flores, Matthew Jowett and
Joseph Kutzin (WHO).
CONFERENCE PAPER
iii
1. INTRODUCTION .....................................................................................................1
2. FINANCING HEALTH IN THE AMERICAS .......................................................... 3
2.1 Public expenditure in health.................................................................................4
2.2 Out-of-pocket health expenditure .....................................................................7
2.3 Financial protection ...............................................................................................10
3. DISCUSSION AND CHALLENGES .....................................................................15
3.1 increasing public investment: a priority need ............................................. 15
3.2 more efficiency: necessary, but not enough ................................................ 17
3.3 improving financial protection through pooled funding ......................... 18
4. CONCLUSION .................................................................................................... 20
REFERENCES ...........................................................................................................21
Table of contents
CONFERENCE PAPER1. InTRODuCTIOn
1
Despite the progress in addressing health in the
Americas, exclusion and lack of access to quality
services persist for large sectors of the population.
An estimated 30% of the population has no access
to health care for financial reasons, and 21% is kept
from seeking by geographic barriers (1). At the
global level, In 2010 an estimated 103 million people
incurred out-of-pocket payments exceeding 10% of
households total consumption or income (11.1% of the
population in the region) and 17.5 million incurred it
at the 25% threshold (1.9% of the population). (2)
The prevailing models of care, based more on hospi-
tal care for episodes of acute illness than on compre-
hensive health care, including disease prevention and
health promotion, often with excessive use of tech-
nologies, weak primary care services, and poor distri-
bution of human resources (physicians, nurses, and
others), do not necessarily meet the health needs of
people and communities As an example, data shows
sustained high rates of total hospitalizations for am-
bulatory care-sensitive conditions in some countries
of the Region like Argentina (18%) and Colombia
(22%) (3). Investments to reform and improve health
systems have not always been designed to deal with
new challenges related largely to the demographic
and epidemiological transition, social and economic
changes, or the evolving expectations of the popula-
tion.
Lack of universality and equity in access to quality
services and appropriate coverage, entails a substan-
tial social cost and increases the risk of impoverish-
ment of population groups in highest conditions of
vulnerability. The evidence shows that when there
are access barriers to services (whether economic,
geographic, cultural, demographic, gender, ethnic or
age related, or other), deterioration in health implies
not only greater expenditure but a loss of income as
well. The absence of mechanisms to protect against
the financial risk of ill health creates and perpetuates
a vicious cycle of disease and poverty.
Insufficient financing and inefficient allocation and
use of the available resources for health are major
obstacles to progress toward equity and financial
protection. For example, if we take life expectancy as
an overall indicator of health status and take public
expenditure in health as one of its determinants, as
seen in other studies (4) in the Region of the Amer-
icas two countries like Chile and the United States
can reach similar levels of life expectancy (79.5
years) with very different levels of public expenditure
in health as a percentage of the GDP (3.9 and 8.3
respectively) indicating potential sources of inef-
ficiencies in public expenditure (3). Indeed, aver-
age public health expenditure in the Region of the
Americas is very low compared with the countries
of the Organisation for Economic Co operation and
Development (OECD) (5, 6). Still, the largest share of
available resources is highly concentrated in hospital
curative and specialized care rather than in preven-
tive and promotion activities at the first level of care.
Direct payment or out-of-pocket expenditure (OOP)
at the point of service, the most inefficient and re-
gressive form of financing, yields an unstable flow of
financial resources and constitutes an access barrier
that impedes or delays care and makes it more ex-
pensive for both users and the health system (7, 8).
Furthermore, it has a relatively greater impact on the
poor, as even the smallest payment can represent a
substantial portion of their budget, making it highly
regressive and inequitable. (12)
The strategy for universal access to health and
universal health coverage (1) of the Pan American
Health Organization (PAHO) redefined the concept
of coverage and access to health and stressed the
values of the right to health, equity and solidarity;
it also recognized financing as a necessary, though
insufficient, factor in reducing inequities and increas-
ing financial protection for the population.
1. Introduction
Health Financing and Financial Protection in the Americas
2
The core value in the strategy’s definition of “access,” embraced as a priority for
society as a whole, is “the right to health,” which requires adequate, allocated, and
efficiently managed financing.
This vision stands in sharp contrast to the traditional view, in which access to cer-
tain services depended on an individual’s and household’s ability to pay and went
hand in hand with the proposals to adopt direct payments and the promotion of
policies that had led to the fragmentation of health systems in previous decades.
At least part of these policies stemmed from recommendations found in reports
from multilateral agencies (9). At the same time, the strategy acknowledges the
need to foster the necessary changes through political and social action that puts
health squarely at the center of the policy agenda.
Strategic Line 3 of the strategy calls for “Increasing and improving financing, with
equity and efficiency, and advancing toward the elimination of direct payment that
constitutes a barrier to access at the point of service.” Three interrelated lines of
action flow from this:
• Increase financial protection by eliminating direct payment, which constitutes an
access barrier, thus preventing exposure to catastrophic expenditures or those
that lead to or exacerbate poverty. The replacement of direct payment as a
financial mechanism should be planned and progressively achieved through pre-
paid pooling mechanisms, using sources of funding that guarantee their stability
and sustainability.
• Increase public health expenditure to the benchmark of 6% of GDP, which im-
plies a commitment by society as a whole to increase the fiscal space for health
in terms of new public sources of financing, with the search for equity as the
main objective.
• Boost efficiency in the health system by adopting a series of measures that spe-
cifically impact its financing and organization, such as aligning payment mech-
anisms with health system objectives, deploying human resources accordingly
and with the right skills-mix and rationalizing the introduction of new medicines
and other health technologies that contribute significantly to rising health ex-
penditures.
Countries in the Region of the Americas have not remained indifferent to the chal-
lenges they face and have adopted different policies to address them. The commit-
ments made in 2015 with the launching of the UN Sustainable Development Goals,
among which the goal of universal access and the measure of financial protection
as one of its indicators, reinforce these efforts.
This paper shows an overview of the health system financing situation in the Re-
gion and the advances and challenges they still face under the lens of Universal
health objectives. Following this introduction, health financing in the Region will
be examined in a conceptual and descriptive section, with special attention to
financial protection. The third and final section discusses the immediate challeng-
es facing the countries in terms of the need to equitably and efficiently increase
financing with financial protection.
CONFERENCE PAPER2. FInAnCIng HeAlTH In THe AMeRICAS
3
The financing of health systems in the Americas rely on a variety of revenue sources
linked to the nature of the different arrangements to cover and improve access to health
services for the overall population. In general, there is a clear predominance of pub-
lic funding sources mirroring the prevailing mix of models linked to employment (e.g.
social health insurance) and entitlement based on legal residence (e.g. national health
services) along with specific schemes put in place to cover and financially protect the
most vulnerable, the unemployed and the informally employed.
General government and social security funds prevail as the main financing agents
through both specific budget-line allocations and transfers out of general revenues, and
social (employer/employees) contributions respectively, with some exceptions where
external and direct payments at the time of service play the biggest role.
Figure 1: Segmented health systems reflected in the financing
2. Financing health in the Americas
Social security funds General government revenue
Out-of-pocket expenditure Private insurance Other private
An
tig
ua
and
Bar
bu
da
Arg
enti
na
Bah
amas
Bar
bad
os
Bel
ize
Bo
livia
Bra
zil
Can
ada
Ch
ile
Co
lom
bia
Co
sta
Ric
a
Cu
ba
Do
min
ica
Do
min
ican
Rep
.
Ecu
ado
r
El S
alva
do
r
Gre
nad
a
Gu
atem
ala
Gu
yan
a
Hai
ti
Ho
nd
ura
s
Jam
aica
Mex
ico
Nic
arag
ua
Pan
ama
Par
agu
ay
Per
u
St.
Kit
ts a
nd
Nev
is
St.
Lu
cia
St.
Vin
cen
t &
th
e G
ren
adin
es
Su
rin
ame
Tri
nid
ad &
Tab
ago
Un
ited
Sta
tes
of
Am
eric
a
Uru
gu
ay
Ven
ezu
ela
Sources: PAHO/WHO 2017, Health in the Americas. (13)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Health Financing and Financial Protection in the Americas
4
External funding (from international agencies, donors, foundations, etc.) and
other private sources are only relevant in few countries and mainly linked to the
funding of priority programs (i.e. HIV/AIDS, Tuberculosis, malaria and vaccina-
tion), whose long-term financial sustainability is at stake.
Pooled resource arrangements, in turn, are usually long-term and have also taken
shape during the historical development of the systems. The Region is largely
characterized separate sub-systems built around specific population groups with
little or no solidarity across these.
On the other hand, the purchase of services as a resource allocation mechanism
takes many forms, with historical budgets in the public sector and fee-for-service
payments in the private sector predominating (10).
In the majority of the countries, operational financing decisions are made year-
to-year by the ministries of finance and health as part of a planning process in
which the democratic political system is involved, since in most cases, the main
source of funding (or a significant part of it) – the budget – is approved by the
parliament or congress. Other sources of financing are determined by the market
through private expenditure.
Total per capita health expenditure in the Region averages 1,320 international dol-
lars (Intl$) per year (adjusted by purchasing power parity) and ranges from Intl$
160 in Haiti to Intl$ 9,145 in the United States. Factoring out the United States
and Canada, the value falls to Intl$ 1,113. This absolute level of expenditure can
be compared with the average for the OECD countries, which is three times that
of the Region and far less scattered. Furthermore, in each country the different
segments present very different per capita expenditures, one of the most relevant
signs of inequity and segmentation. For example, in El Salvador, per capita health
expenditure in affiliates to the Institute of Magisterial Welfare 2 was four times
that of users of general public health services through the Ministry of Health, with
per capita expenditure in the general regime of social security standing almost
exactly in the middle of both extremes, at least until 2011 (11). However, in the last
years the country is advancing towards closing these gaps in an effort to reduce
inequities. Other countries are also making efforts in the same direction, but
slowly, as seen in Colombia and Chile. With the reform of 2008, Uruguay’s transi-
tion was faster in closing this gap, leading to a drop in the difference between the
per capita expenditure of mutual private providers and the main public provider
from 2.3 times greater in 2007 to just 25% greater in 2012.
2.1 Public expenditure in health Considering the universal health strategy’s public health expenditure benchmark
of at least 6% of GDP 3, Figure 2 shows that only 5 of the 34 countries that pro-
vided information are above that threshold: Canada, Costa Rica, Cuba, the United
States, and Uruguay. The countries below the threshold include three with public
health expenditure above 5% of GDP: Colombia (5.4%), Nicaragua (5.1%), and
Panama (5.9%).
2 Translation from Spanish “Instituto Salvadoreño de Bienestar Magisterial”3 While this indicator is very important because it is a significant measurement of country efforts in health and because of its acceptance as a prerequisite and useful benchmark in the regional strategy for universal health, it cannot be interpreted in isolation, since individual variations can reflect movements within a country’s economic cycle (variations in GDP), for example, regardless of the resources allocated to the health sector.
$76
5
COnFeRenCe PAPeR2. FInAnCIng HeAlTH In THe AMeRICAS
Observing what happens with total health expenditure and its public-private mix, we discov-
er that in countries that exceed the 6% benchmark, public health expenditure accounts for
more than 70% of total health expenditure, except in the United States.
Furthermore, in the case of Bolivia, Canada, Colombia, Costa Rica, Panama, and Uruguay, this
balance is similar to the average for the OECD member countries (73%). At 17%, total health
expenditure in relation to GDP in the United States is known to be the highest in the world,
without proportionally better health outcomes (14). This indicates the need not only for more
resources but greater efficiency in their use.
At the opposite extreme, countries with lower public health expenditure are also those in
which the composition of total health expenditure is more skewed toward the private com-
ponent: Guatemala (private expenditure of 62%), Haiti (79%), Saint Kitts and Nevis (58%),
and Venezuela (71%).
However, Peru and the Dominican Republic are examples of the opposite, with low public
health expenditure (3.3% and 2.9% of GDP, respectively) and a high share of public health
expenditure in total health expenditure (61% and 67%, respectively). Added to this is the case
of the United States, with high public health expenditure (8.3%), but health expenditure that
is predominantly private (52%).
Figure 2. Health expenditure as a percentage of GDP and composition public-private, as a percentage of total expenditure, 2014
Figure 3 presents data on fiscal capacity in the Americas, and the average for EU countries.
The median for the Region, around 30% of GDP, stands in marked contrast to the average
of 48% of GDP for total public expenditure in the EU countries. Fiscal capacity (understood
as total public-sector resource mobilization) should be a potential source of fiscal space for
health in the Region. Furthermore, the combination of a low tax burden and weaknesses in
tax collection—manifested, for example, in tax evasion, elusion and tax fraud—create a sce-
nario not uncommon in the Region that must be considered in the specific analyses.
General government Private
Ven
ezu
ela
Hai
ti
St.
Kit
ts a
nd
Nev
is
Gu
atem
ala
Arg
enti
na
Jam
aica
Gre
nad
a
Do
min
can
Rep
.
Su
rin
ame
Gu
yan
a
Tri
nid
ad a
nd
Tab
ago
Mex
ico
Per
u
Bah
amas
St.
Lu
cia
Do
min
ica
An
tig
ua
and
Bar
bu
da
Bra
zil
Ch
ile
Bel
ize
St.
Vin
cen
t an
d t
he
…
Ho
nd
ura
s
El S
alva
do
r
Par
agu
ay
Ecu
ado
r
Bo
livia
Bar
bad
os
Nic
arag
ua
Co
lom
bia
Pan
ama
Uru
gu
ay
OE
CD
Co
sta
Ric
a
Can
ada
Un
ited
Sta
tes
of
…
Cu
ba
18
16
14
12
10
8
6
4
2
0
Sources: PAHO/WHO 2017, Health in the Americas.
71 7958 62 45 48 54
3348 41 46 48 39
54 4631 32
54 51 5349 49 34 54 51
28 3644 25
2729
27 2729
52
4
Sources: PAHO/WHO 2017, Health in the Americas.
29 21 42 38 55 52 46 67 52 59 54 52 61 46 54 69 68 46 49 6751 51 66 46 49 72 64 56 75
73 7173 73
7148
96
Health Financing and Financial Protection in the Americas
6
Figure 3. Fiscal capacity in the Region of the Americas, 2014 and UE average
When analyzing the fiscal priority of health in the Re-
gion (Figure 4), the variability of the indicator is even
greater. While public expenditure in health in the EU
member countries averages 14% of total public expen-
diture, almost half the countries in the Region of the
Americas give higher priority to the health sector. In the
case of Costa Rica and Nicaragua, for example, public
expenditure in health accounts for almost one quarter
of total public expenditure (23% and 24%, respectively).
At the opposite extreme, however, nine countries
allocate less than 10% of their total budget to the
health sector: Haiti (5%), Venezuela (5.8%), Bra-
zil (6.8%), Saint Kitts and Nevis (6.9%), Argentina
(6.9%), Trinidad and Tobago (7.6%), Jamaica (8.1%),
Grenada (9.2%), and Guyana (9.4%).
Gu
atem
ala
Do
min
can
Rep
.
Co
sta
Ric
a
El S
alva
do
r
Per
u
Bah
amas
An
tig
ua
and
Bar
bu
da
Par
agu
ay
Pan
ama
Ch
ile
Nic
arag
ua
Hai
ti
Jam
aica
Mex
ico
Ho
nd
ura
s
Gre
nad
a
St.
Lu
cia
Co
lom
bia
Gu
yan
a
St.
Vin
cen
t an
d t
he
Gre
nad
ines
Su
rin
ame
Uru
gu
ay
St.
Kit
ts a
nd
Nev
is
Do
min
ica
Bel
ize
Un
ited
Sta
tes
of
Am
eric
a
Tri
nid
ad a
nd
Tab
ago
Arg
enti
na
Can
ada
Bra
zil
Ven
ezu
ela
Bo
livia
Ecu
ado
r
Bar
bad
os
Eu
rop
ean
Un
ion
Source: PAHO/WHO 2017, Health in the Americas.
50
45
40
35
30
25
20
15
10
5
0
Total public expenditure as a percentage of GDP
Figure 4. Fiscal priority of health in the Region of the Americas, 2014 and UE average
Ven
ezu
ela
Hai
ti
Bra
zil
St.
Kit
ts a
nd
Nev
is
Arg
enti
na
Jam
aica
Tri
nid
ad a
nd
Tab
ago
Gre
nad
a
Gu
yan
a
Ecu
ado
r
Do
min
ica
Bar
bad
os
St.
Lu
cia
Mex
ico
Bo
livia
Su
rin
ame
Par
agu
ay
Bel
ize
Pan
ama
Bah
amas
St.
Vin
cen
t an
d t
he
Gre
nad
ines
Per
u
Ho
nd
ura
s
OE
CD
Ch
ile
El S
alva
do
r
Do
min
ican
Rep
.
Gu
atem
ala
Cu
ba
An
tig
ua
and
Bar
bu
da
Co
lom
bia
Can
ada
Uru
gu
ay
Un
ited
Sta
tes
of
Am
eric
a
Co
sta
Ric
a
Nic
arag
ua
Source: PAHO/WHO 2017, Health in the Americas.
30
25
20
15
10
5
0
Public health expenditure as a percentage to total public expenditure
7
COnFeRenCe PAPeR2. FInAnCIng HeAlTH In THe AMeRICAS
Painting a more complete picture of the countries’ health financing efforts requires at least this dual
perspective in order to see how countries that prioritize health in their budget may be spending little
due to their excessively low level of total public expenditure, while countries with a high level of total
public expenditure may not be prioritizing the health sector, even though health expenditure figures
are relatively high in absolute terms.
Combining the data on fiscal capacity and fiscal priority reveals very unequal country performance.
For example, despite its relatively low fiscal capacity (25% of GDP), public health expenditure in
Nicaragua is relatively high for the Region (5.1% of GDP), thanks to the high priority of health in the
national budget (24% of total public expenditure). However, in Guatemala, where the fiscal priority of
health is relatively high for the Region (17.8% of total public expenditure), public health expenditure is
low (2.3% of GDP), due to the country’s excessively low fiscal capacity (13.4% of GDP, the lowest in the
Region).
In Brazil, public health expenditure stands at 3.8% of GDP, despite a high fiscal capacity (almost 40%
of GDP), since health has a low fiscal priority (6.8%). In general, the data show that in the eight coun-
tries where public health expenditure exceeds 5% of GDP (Canada, Colombia, Costa Rica, Cuba, the
United States, Nicaragua, Panama, and Uruguay) the fiscal priority of health is more than 14% of public
expenditure.
2.2 Out-of-pocket health expenditureWhen examining the impact of health expenditure on household well-being and access and use of
health services, out-of-pocket health expenditure merits special attention. This type of payment is re-
quired at the moment of use of services and generally at the point of service and includes any kind of
cost-sharing (in the presence of insurance), full payment (if no insurance), formal or informal. It should
be measured net of ex-post reimbursements and excludes any form of prepayment such as insurance
premiums.
The fact that this type of payment may be required to receive care or access the necessary health
services makes them a health care access barrier. Even among people who can cover these expenses,
incurring them may adversely affect their household’s well being and the consumption of other goods
and services or may even be harmful to health if the alternative is avoiding medical care.
It also has implications for the efficiency of the health system, since by discouraging the use of the
health services, it deters care seeking to more advanced stages of an illness, requiring more complex
and expensive services at later more expensive stages of illness.
Thus, out of pocket expenditure can result in access barriers to households and higher costs to the
health system in the medium and long term, together with worse health outcomes, poorer health sys-
tem response capacity, and lower efficiency and effectiveness.
Health Financing and Financial Protection in the Americas
8
Figure 4 shows the value of the indicator OOP as a percentage of total health ex-
penditure for the countries of the Region and, as a reference, the average for the
countries of the European Union (EU). 4 First, it shows that while out-of-pocket
health expenditure in the EU countries averages 21% of total health expenditure,
29 countries in the Region (83%) exceed that value.
Furthermore, countries with a lower proportion of out of pocket health expen-
diture are also those with higher public health expenditure (as a percentage of
GDP) (Figure 1): Canada, Colombia, Cuba, the United States, and Uruguay. Some
exceptions are conspicuous: Suriname has low public health expenditure (2.9% of
GDP) and also a low proportion of out-of-pocket expenditure (11% of total health
expenditure); and Costa Rica, with very high public health expenditure for the
Region (6.8% of GDP), has a moderate proportion of out of pocket expenditure
(25% of total health expenditure).
Low out-of-pocket expenditure is not always an indication of equitable access,
since it may also be due to lack of access to the services. Also, it can sometimes
increase with the desired increase in access, although the ratio with coinsurance
rates or unit values of copayment remains constant. For example, Colombia and
the United States show relatively high levels of population coverage for the peri-
od 2010-2015 (around 95 and 90% respectively) but with still relatively high levels
of people reporting monetary barriers to access care (29 and 37% respectively)
and even increasing in the period for Colombia (3)
Figure 5. Proportion of out-of-pocket health expenditure as a % of total health expenditures in the Region of the Americas, 2014
4 European Union parameters are used as representative of the more advanced countries, even though development levels in some EU countries are considered similar to those of several countries in the Americas.
Cu
ba
Un
ited
Sta
tes
of
Am
eric
a
Su
rin
ame
Can
ada
Co
lom
bia
Uru
gu
ay
OE
CD
Do
min
ican
Rep
.
Pan
ama
Bel
ize
Bo
livia
An
tig
ua
and
Bar
bu
da
Co
sta
Ric
a
Bra
zil
Jam
aica
Do
min
ica
Per
u
El S
alva
do
r
Bah
amas
Bar
bad
os
Arg
enti
na
Ch
ile
Hai
ti
Gu
yan
a
Nic
arag
ua
Tri
nid
ad a
nd
Tab
ago
Ho
nd
ura
s
Mex
ico
St.
Lu
cia
Ecu
ado
r
St.
Vin
cen
t an
d t
he
Gre
nad
ines
Par
agu
ay
St.
Kit
ts a
nd
Nev
is
Gre
nad
a
Gu
atem
ala
Ven
ezu
ela
Source: PAHO/WHO 2017, Health in the Americas.
70
60
50
40
30
20
10
0
Out-of-pocket health expenditure as a percentage of total health expenditure
$76
CONFERENCE PAPER2. FInAnCIng HeAlTH In THe AMeRICAS
9
The weight of direct payment (out of-pocket expenditure) by households in total
health expenditure is trending downward in certain countries in the Region, among
them Chile, Colombia, El Salvador, and Mexico (Figure 6).
Here, the case of El Salvador is worth examining (Figure 6). In 1995, more than 60%
of its health expenditure was financed through direct payments; today, the figure is
less than 30% and though still high, represents a significant decline. In Colombia, the
indicator fell from 38% to 15% in that same period, and the country currently has one
of the lowest percentages of out-of-pocket expenditure in the Region. Other countries
show certain stability in the indicator and remain at very high levels, as in Guatemala
(above 52% throughout the period), or low levels, as in Costa Rica, although with a
certain upward trend (from 21% to 25% during the period) (Figure 6).
In Ecuador, a marked increase in the indicator was observed between 1995 and 2000
(moving from 32% to 62%), subsequently shifting downward, but nevertheless remain-
ing at very high levels (48% in 2014).
Figure 6. Trends in out-of-pocket health expenditure in the Americas, 1995–2014 (selected countries)
Argentina
Bahamas
Bolivia
Brasil
Chile
Colombia
Costa Rica
Ecuador
El Salvador
Guatemala
Jamaica
México
Nicaragua
Panama
Perú
América Latinay el Caribe
199
5
199
6
199
7
199
8
199
9
200
0
200
1
200
2
200
3
200
4
200
5
200
6
200
7
200
8
200
9
2010
2011
2012
2013
2014
Sources: PAHO/WHO 2017, Health in the Americas.
70
60
50
40
30
20
10
0
Health Financing and Financial Protection in the Americas
10
2.3 Financial protectionOut-of-pocket expenditure is generally more of a direct barrier to care for house-
holds with lower purchasing power, but it can also be one for the middle class
(15). Thus, having access to health services does not prevent out-of-pocket pay-
ments from undermining health equity, since “overcoming” the barrier can signifi-
cantly jeopardize a household’s well-being, driving it into poverty (impoverishing
expenditure) or exceeding a given proportion of its total expenditure or ability to
pay (catastrophic expenditure).
Expenditure is considered impoverishing for a household when it represents the
difference between being above or below the poverty line (16). Different poverty
lines can be used. Expenditure is considered catastrophic when out-of-pocket
health expenditure represents a substantial percentage of household expendi-
ture––usually 30% or 40% 5 of its ability to pay (12, 13), or 10% or 25% of total
expenditure or income (17, 2), with “ability to pay” understood as total household
income (measured as total household expenditure) minus the expenditure neces-
sary for meeting basic subsistence needs (20, 21). The incidence of catastrophic
and impoverishing expenditure indicators vary with the methodology used, as dif-
ferent poverty lines can be used to assess the extent of impoverishment in each
country and regionally.
However, a recent PAHO study with data within the period 2004-2015 (22) for 11
countries in the region shows that in 7 of them, 2.5% of households have cata-
strophic expenditures, regardless of the methodology used. These methodol-
ogies use different catastrophe thresholds, based on the measure of ability to
pay. Hence, some use a threshold of 30% or 40% of a household’s ability to pay
because they discount basic needs. More recently, within the SDG monitoring
framework two thresholds are used to define catastrophic expenditures (10% and
25% of total household expenditure.
Regardless of the methodological differences of the primary sources of data
and considering the 25% threshold, 6 of the 11 countries face catastrophic ex-
penditures in over 2% of households, while only Costa Rica and Uruguay have an
incidence below 1% (Table 1). Over 1% of households in Guatemala and Nicaragua
incur in impoverishing health expenditures when considering the USD1.90 per day
poverty threshold, while in Bolivia and Peru it is above 0.5%.
Countries can be classified into three groups (Table 1). In one group, Uruguay,
Panama, Mexico, Costa Rica and Bolivia have an incidence of catastrophic health
expenditure in less than 2% of households (less than 8% for the 10% threshold),
but Mexico and Bolivia have an impoverishing expenditure above 0.5%. In another
group, Chile, Argentina, Peru, and Nicaragua show an incidence of catastrophic
expenditures between 2% and 4%, (10-15% for the 10% threshold) but with high
variance in the incidence of impoverishing expenditures: Chile and Argentina
face a negligible incidence of impoverishing expenditures, while Peru and Nicara-
gua show an incidence above 0.5% (Nicaragua reaches 1.2%). Finally, in the third
group, Guatemala and Ecuador have a high incidence of catastrophic and impov-
erishing expenditure.
5 There is no absolute consensus regarding a threshold. For example, Wagstaff and van Doorslaer (18) examine threshold differenc-es in the case of Vietnam. Knaul et al. (19) define a threshold of 30% of the non subsistence expenditure or the total expenditure of a household once the international poverty line of US$ 1 per day is discounted.
COnFeRenCe PAPeR2. FInAnCIng HeAlTH In THe AMeRICAS
11
Country Catastrophic Health
expenditure (SDg
indicator 3.8.2,
25% threshold) In %
Catastrophic Health
expenditure (SDg
indicator 3.8.2, 10%
threshold) In %
Impoverishing
Health expenditure
(uSD1,90 per day in
2011 PPPs) In %
Survey year
Argentina 2.518 10.890 0.007 2012-2013
Bolivia 1.403 6.612 0.616 2014
Chile 2.31 12.230 0.000 2012
Costa Rica 0.833 5.182 0.021 2013
ecuador 4.453 20.430 0.453 2011-2012
guatemala 4.149 11.781 1.076 2014
Mexico 1.324 4.658 0.230 2014
nicaragua 3.239 14.982 1.218 2014
Panama 1.301 6.280 0.018 2007-2008
Peru 2.564 12.974 0.536 2015
uruguay 0.638 7.177 0.009 2005-2006
Source: Preliminary estimates prepared for PAHO (PAHO 2017). Country level estimates may not yet be included in the global database on financial protection assem-bled by WHO and the World Bank.
*: considering monetary expenditures including imputed rent
Table 1: Catastrophic Health Expenditure and Impoverishing Health Expendi-ture* (% of households). Preliminary data
12
Health Financing and Financial Protection in the Americas
According to Figures 7 and 8, the poorest households have a greater risk
of impoverishment, while wealthier households have a greater possibility
of facing financial catastrophe due to health events.
Figure 7: Distribution of catastrophic health expenditure in % (SDG indicator 3.8.2, 25% threshold) by household consumption/income quintiles, in 11 countries. Preliminary data
Q1 Q2 Q3 Q4 Q5 Average
Costa Rica2012-2013
Argentina2012-2013
Bolivia2014
Chile2012
Ecuador2011-1012
Guatemala2014
México2014
Nicaragua2014
Panamá2007-2008
Perú2015
Uruguay2005-2006
Source: Preliminary estimates prepared for PAHO (PAHO 2017). Country level estimates may not yet beincluded in the global database on financial protection assembled by WHO and the World Bank.
8
7
6
5
4
3
2
1
0
CONFERENCE PAPER2. FInAnCIng HeAlTH In THe AMeRICAS
13
Figure 8: Distribution of impoverishment due to out-of-pocket health spending in % (USD1.90 poverty line) by household consumption/expenditure quintiles, in 11 countries. Preliminary data
Figure 9 also shows that rural households have a higher incidence of impoverishment
and the distribution of catastrophic health expenditures similar between rural and urban
households.
Figure 9: Impoverishing out-of-pocket heatlh expenditures (left) and catastrophic expenditure (SDG indicator 3.8.2, 25% threshold) (right) by area of residence in 7 countries* in % of households. Preliminary data
Q1 Q2 Q3 Q4 Q5 Average
Costa Rica2012-2013
Argentina2012-2013
Bolivia2014
Chile2012
Ecuador2011-1012
Guatemala2014
México2014
Nicaragua2014
Panamá2007-2008
Perú2015
Uruguay2005-2006
Source: Preliminary estimates prepared for PAHO ( PAHO 2017). Country level estimates may not yet beincluded in the global database on financial protection assembled by WHO and the World Bank.
6
5
4
3
2
1
0
Urban Rural Urban Rural
Source: Preliminary estimates prepared for PAHO ( PAHO 2017). Country level estimates may not yet beincluded in the global database on financial protection assembled by WHO and the World Bank.
3.5
3
2.5
2
1.5
1
0.5
0
12
10
8
6
4
2
0
Bo
livia
20
14
Co
sta
Ric
a 20
12-2
013
Ecu
ado
r 20
11-2
012
Gu
atem
ala
2014
Méx
ico
20
14
Nic
arag
ua
2014
Per
ú 2
015
Bo
livia
20
14
Co
sta
Ric
a 20
12-2
013
Ecu
ado
r 20
11-2
012
Gu
atem
ala
2014
Méx
ico
20
14
Nic
arag
ua
2014
Per
ú 2
015
14
Health Financing and Financial Protection in the Americas
In the case of Chile, there is a lower incidence in Santiago than in the Regions for both indicators. In
Ecuador, households in rural areas present a higher catastrophic expenditure incidence than those in
urban areas. In Guatemala, this is reversed and urban households have a higher incidence of catastroph-
ic spending.
Bolivia shows several exceptions. First, it is the only country where the poorest face a greater propor-
tion of catastrophic health expenditure and spending is impoverishing also for the non-poor, although
not at the level of Guatemala and Nicaragua. Households in rural areas are twice as likely to face cata-
strophic expenditures than those in urban areas.
In Costa Rica, households in urban areas show higher catastrophic spending, while in Uruguay and Mex-
ico, households in rural areas have a higher incidence of catastrophic health expenditures. For Mexico,
rural areas are the ones that incur catastrophic expenses the most, as in Nicaragua and Peru.
CONFERENCE PAPER3. DISCuSSIOn AnD CHAllengeS
15
3.1 Increasing public investment: a priority needHealth financing in the Region is far from meeting the objectives set by the countries
in 2014 when they adopted the strategy for universal health. In fact, as mentioned, only
a small group of countries have achieved a public expenditure in health of 6% of GDP
(Figure 10), and direct expenditure in the Region accounts for 33% of total health expen-
diture.
3. Discussion and Challenges
Figure 10: Public health expenditure as % GDP and out-of-pocket health expenditure as %THE in the Americas, 2014
Increase in per capita public expenditure has historically been moderate, with rela-
tively low elasticities in health expenditure with respect to economic growth (below 1
in many countries).
Even the peak public health expenditure of 2009 was due to the impact of the eco-
nomic crisis on the GDP of the countries of the Region and not to an absolute in-
crease in public expenditure. However, although the average GDP growth rate would
recover by 2010 and continue until 2014 (23), the particular situations in the Region
in response to the global crisis caused the decline in public health expenditure as a
percentage of GDP to continue in several countries, as seen in Figure 11.
Sources: PAHO/WHO 2017, Health in the Americas.
70
60
50
40
30
20
10
0
ATG
ARGBAH BAR
BIZBOL
BRA
CAN
CHI
COL
COR
CUB
0 2 4 6 8 10 12
DOM
RDO
ECU
GRDGUT
GUY
HAI HON
JAM
MEX
NIC
PAN
PAR
PER
SKN
SLASVG
SUR
TRT
USA
URU
VEN
OOP expenditure as a % of total health expenditure
Public expenditure in health as a % of GDP
OECD
16
Health Financing and Financial Protection in the Americas
Figure 11. Trends in public health expenditure in the Americas, 1995–2014 (selected countries)
Several studies show that countercyclical government spending has been essential for
meeting long term economic and human development targets (17–21) and will surely be
today to meet the United Nations Sustainable Development Goals adopted in 2015 with
a 2030 horizon.
Sources: PAHO/WHO 2017, Health in the Americas.
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
200
0
200
1
200
2
200
3
200
4
200
5
200
6
200
7
200
8
200
9
2010
2011
2012
2013
2014
Argentina
Bahamas
Bolivia
Brazil
Chile
Colombia
Costa Rica
Ecuador
El Salvador
Guatemala
Jamaica
Mexico
Nicaragua
Panama
Peru
Latin America andthe Caribbean
Public expenditure in health as a percentage of GDP
CONFERENCE PAPER3. DISCuSSIOn AnD CHAllengeS
17
3.2 More efficiency: necessary, but not enoughEfficiency in the organization of services implies the adoption of people- and communi-
ty-centered models of care and the delivery of quality services by strengthening the first
level of care and building integrated networks.
Resource allocation in a health system is efficient when it achieves an optimal combi-
nation of morbidity and mortality reduction and greater financial protection for house-
holds that permits equitable access to health services with given resources. In this case,
the efforts are designed to yield what society needs and expects in terms of health and
well-being—a task that involves both the State and society.
The degree of productive and technical efficiency achieved will depend on how the
health services are managed—or to put it another way, on obtaining the best response
capacity through better coordination and linkage between levels of care and care net-
works.
To enhance efficiency in the health system, resources need to be allocated towards gen-
erating those health goods and services that society values the most (allocative efficien-
cy) and in the least costly way, or using the least possible amount of resources (technical
efficiency). Dynamic efficiency, in turn, implies guaranteeing conditions and efficiency
levels over time through innovation in the health systems in the broadest sense of the
word (29).
Payment mechanisms must be aligned with system objectives. Thus, it is important to
note that territorial and population-based payment systems––keeping in mind morbidity
levels and combined with mixed-level payment mechanisms––are potentially effective
regulatory mechanisms for meeting these objectives (30, 31).
Aligning incentives with health system objectives to promote integrated care and com-
prehensive services, and putting emphasis on the first level of care are initiatives that
can boost the efficiency of the system as a whole. Studies coincide in recommending the
adoption of payment mechanisms with circumstantial margins of flexibility and empirical-
ly contrasted macro- and micro-allocation instruments. Territorial capitation and epi-
sode-based payment (also called bundled payment or case rates, as in diagnosis-related
groups) are two examples of tools that can boost the efficiency of expenditure (32).
There are known mechanisms for boosting efficiency in resource utilization, among them
protocols for reducing clinical variability, centralized drug procurement systems, eco-
nomic evaluation, and the evaluation of other aspects, such as safety and quality in the
introduction of new technologies, programs to boost workforce efficiency and productiv-
ity, and the strengthening of disease prevention and health promotion. In this context, the
measures with the greatest short-term impact are related to resource allocation mecha-
nisms, including those involving drug procurement.
From 2010 to 2015, several countries in the Region, among them Brazil, El Salvador, and
Ecuador, made progress in this regard, channeling most of the growth in expenditure to
the first level of care to broaden access to these services and improve their quality. For
cases like those of Chile, Mexico, Peru, and Uruguay, results based payment systems were
18
Health Financing and Financial Protection in the Americas
also established (33). The 2008 reform in Uruguay involved the expansion of coverage and
pooling of social security and State funds to finance services to the beneficiaries of FONASA,
the national health insurance program that currently covers more than 70% of the population.
The risk-adjusted capitation payment system used in this fund also considers four targeted
areas associated with preventive measures for pregnant women and older persons and the
allocation of human resources.
During this period, Peru launched a results-based payment system through a project imple-
mented at the more general level of results-based budgets. Chile, in turn, introduced targets
in the per capita transfer system in primary health care and is developing a hospital payment
system based on diagnosis-related groups, aspiring to be the first country in LAC to employ
this tool. Suriname currently uses a capitation system for first-level providers and payment per
day and bed in the hospital setting.
3.3 Improving financial protection through pooled fundingIncreasing financial protection requires greater public expenditure, adopting efficient interven-
tions primarily at the first level of care to boost response capacity and increase linkage among
service networks. Increasing financial protection will reduce inequity in access. However, the re-
placement of direct payments should be done gradually through collective prepayment mech-
anisms involving different sources of financing, such as contributions to social security, taxes,
and fiscal revenues. Thus, the main components of a financing system designed to guarantee
financial protection to the population are the elimination or minimization of direct payments by
households and the pooling of funds.
Pooled funds, in which the risk of disease and the need for health services are shared by a
group of people through collectively financed prepayment mechanisms, is therefore key to
financial protection. Sharing risk under any institutional arrangement implies the transfer of
resources or a subsidy from healthy people to patients, as well as from young people to older
people – basically, from people who are not using the health services at a particular moment to
those who are. Moreover, these arrangements need to be mandatory, as opposed to voluntary,
to advance in the direction of universal health.
Moreover, for this financing to be solidarity-based, there should also be a subsidy, grounded
in redistributive policies, from households with greater contributory capacity (the wealthiest)
to those with fewer resources (the poorest), whose contributions are limited but whose health
care needs tend to be greater.
CONFERENCE PAPER3. DISCuSSIOn AnD CHAllengeS
19
The existence of numerous small and fragmented funds
hinders the cross subsidies mentioned above, since it
provides an incentive for risk selection: each fund will at-
tempt to capture people who are better off economically
and in better health (the less risky) and exclude those
with limited resources and more health problems (the
higher risks). Smaller funds are more vulnerable to spe-
cific risks, such as illnesses that require more expensive
treatment. Therefore, funds that cover a small number
of people tend not to be economically viable in the long
term (7).
Furthermore, when the members of a fund share similar
characteristics in terms of the social and environmental
determinants of health to which they are exposed, the
risk of health problems tends to be inefficiently diluted,
implying a higher cost per person to treat episodes of
illness than in funds that cover people with different
characteristics. This is a powerful reason for advising
against segmented funds for communities with limited
resources.
The existence of numerous funds with their respective
mechanisms for collecting and pooling resources and
contracting services compromises the efficiency of the
entire health system due to the administrative costs
that it entails, as well as the cumulative superimposed
transaction costs. Single large funds tend to be a more
efficient type of organization than competing funds, as
long as organizational and institutional incentives are
adequate (34). Economies of scale in the operation of
these funds can generally be expected––not only in the
collection and pooling of resources, but in the contract-
ing of services for large numbers of people.
In addition to increasing access to quality health ser-
vices, financial protection is an important tool for fight-
ing inequity and poverty, as it converges with policies for
development and the social and economic protection of
societies. In other words, it represents a specific contri-
bution from the health sector to human development
strategies.
$76
20
Health Financing and Financial Protection in the Americas
4. Conclusion
By instituting reforms, changes, or transformations grounded in the values
of health as a right, equity, and solidarity, PAHO’s Member States have com-
mitted to moving toward the elimination of direct payment or out-of-pocket
expenditure, the creation of the largest possible pooled funds, and more
efficient public financing as the way of promoting greater individual and
community access to comprehensive quality services in integrated health
systems, with strengthening of the first level of care.
Advances in general are oriented in the right direction but are slow and
are reflected in the slow increase in public spending and the consequent
slow decrease in out-of-pocket expenses. The efforts to expand the gov-
ernment’s role in financing health using public financing have been insuf-
ficient so far to replace direct payments at the point of service (including
cost-sharing in government funded and private insurance schemes) as
source of funding. In consequence, financial barriers to access are still in
place, and households continue bearing an important share of the financial
burden to access health services and remain at risk of falling into financial
catastrophe or impoverishment.
It is necessary to accelerate the speed of changes towards universal health,
so that financing is no longer a barrier and a factor of catastrophe and
impoverishment and allows access to quality health services, in an equitable
and timely manner.
CONFERENCE PAPERReFeRenCeS
21
References
1. Pan American Health Organization. Strategy
for universal access to health and universal
health coverage. 53rd Directing Council of
PAHO, 66th Session of the Regional Committee
of WHO for the Americas, Washington, D.C.,
2014 Sept. 29–3 Oct. 2014 (CD53.R14). Avail-
able from: http://www.paho.org/uhexchange/
index.php/en/uhexchange-documents/techni-
cal-information/26-strategy-for-universal-ac-
cess-to-health-and-universal-health-coverage/
file.
2. World Health Organization. Tracking universal
health coverage: first global monitoring report.
World Health Organization; 2015 Jul 21.
3. Pan American Health Organization. Health in
the Americas+, 2017 Edition. Summary: Region-
al Outlook and Country Profiles. Washington,
D.C.: PAHO; 2017.
4. Nixon J, Ulmann P. The relationship between
health care expenditure and health out-
comes. Evidence and caveats for a causal link.
The European Journal of Health Economics
2006;7(1):7–18.
5. World Health Organization. Global Health
Observatory (GHO) data [Internet]. Available
from: www.who.int/gho/database/en.
6. Organisation for Economic Co-operation and
Development. OECD data. Available from:
https://data.oecd.org.
7. World Health Organization. World Health
Report. Health Systems Financing: the path to
universal coverage. Geneva: WHO; 2010.
8. Jowett M, Kutzin J, World Health Organization.
Raising revenues for health in support of UHC:
strategic issues for policy makers. InRaising
revenues for health in support of UHC: strategic
issues for policy makers 2015.
9. World Bank. Investing in health: World develop-
ment report 1993.
10. Pan American Health Organization. Regional
meeting report. Payment systems and strategic
purchasing: how can they support progress to-
wards universal health?. Forthcoming working
document, Washington, DC
11. Pan American Health Organization. El Salvador
en el camino hacia la cobertura universal de
salud. Logros y Desafíos. San Salvador; 2014
12. Xu K, Saksena P, Jowett M, Indikadahena C,
Kutzin J, Evans DB. Exploring the thresholds
of health expenditure for protection against
financial risk. World Health Report 2010, Back-
ground paper, 19. Geneva: WHO; 2010.
13. PAHO/WHO. Health in The Americas, 2017.
Washington DC, September 2017.
14. National Research Council, Institute of Medi-
cine. U.S. health in international perspective:
shorter lives, poorer health. Washington, D.C.:
The National Academies Press; 2013.
15. Ferreira FH, Messina J, Rigolini J, López-Calva
LF, Lugo MA, Vakis R. 2012. Economic mobility
and the rise of the Latin American middle class.
Washington, D.C.: World Bank; 2013. Available
from: https://openknowledge.worldbank.org/
bitstream/handle/10986/11858/978082346.pdf.
16. Wagstaff A. Measuring financial protection in
health. World Bank Policy Research Working
Paper 4554. Washington, D.C.: World Bank;
2008.
17. World Health Organization. Tracking uni-
versal health coverage: first global moni-
toring report. Geneva: WHO; 2015. Avail-
able from: http://apps.who.int/iris/bitstre
am/10665/174536/1/9789241564977_eng.pdf.
Health Financing and Financial Protection in the Americas
22
18. Perticara M. Incidencia de los gastos de bolsillo
en salud en siete países latinoamericanos. San-
tiago: Economic Commission for Latin America
and the Caribbean; 2008.
19. Cid Pedraza C, Prieto Toledo L. El gasto de
bolsillo en salud: el caso de Chile, 1997 y
2007. Revista Panamericana de Salud Pública
2012;31(4):310–316.
20. Wagstaff A, van Doorslaer E. Catastophe and
impoverishment in paying for health care: with
applications to Vietnam 1993–1998. Health Eco-
nomics 1003;12(11):921–933.
21. Knaul FM, Wong R, Arreola-Ornelas H, Mén-
dez O, Bitrán R, Campino AC, et al. Household
catastrophic health expenditures: a compar-
ative analysis of twelve Latin American and
Caribbean countries. Salud Pública de México
2011;53:S85–S95.
22. PAHO/WHO. Gasto catastrófico y empobrece-
dor en países de América Latina y el Caribe.
Washington DC, 2017. En prensa.
23. Economic Commission for Latin America and
the Caribbean. Social Panorama of Latin Ameri-
ca, 2015. Santiago de Chile: ECLAC; 2016.
24. Brahmbahatt M, Canuto O. Fiscal policy for
growth and development. Economic Prem-
ise 91. World Bank; October 2012. Available
from: http://siteresources.worldbank.org/EXT-
PREMNET/Resources/EP91.pdf.
25. Braun M, di Gresia L. Towards effective social
insurance in Latin America: the importance of
countercyclical fiscal policy. IDB Publications
(Working Papers) 6508. Washington, D.C.: In-
ter-American Development Bank; 2004.
26. Darby J, Melitz J. Social spending and automat-
ic stabilizers in the OECD. Oxford Review of
Economic Policy 2008;23:715–756.
27. Doytch N, Hu B, Mendoza RU. Social spending,
fiscal space and governance: an analysis of pat-
terns over the business cycle. UNICEF Policy
and Practice, second draft, April 2010.
28. Valenyi E. Health care spending and economic
growth. In: Scheffler RM, ed. The economics
of heath and health systems. World Scientific
Handbook of Global Health Economics and
Public Policy, Vol. 1. Singapore: World Scientific
Publishing; 2016:1–154.
29. Cid C, Báscolo E, Morales C. La eficiencia en
la agenda de la estrategia de acceso univer-
sal a la salud y cobertura universal en salud
en las Américas. Salud Pública de México
2016;58(5):496–503.
30. Cid C, Ellis RP, Vargas V, Wasem J, Prieto
L. Global risk-adjusted payment models. In:
Scheffler RM, ed. The economics of heath and
health systems. World Scientific Handbook of
Global Health Economics and Public Policy,
Vol. 1. Singapore: World Scientific Publishing;
2016:311–362.
31. Ortún V, López G, Puig J, Sabés R. El sistema
de financiación capitativo: posibilidades y lim-
itaciones. Fulls Econòmics del Sistema Sanitari
2001;35:8–16.
32. Cid C, Cuadrado C, Fábrega R. Noncommunica-
ble diseases: challenges and opportunities for
health system response. In: Legetic B, Medici A,
Hernández-Avila M, Alleyne G, Hennis A, eds.
Economic dimensions of noncommunicable
diseases in Latin America and the Caribbean.
Washington, D.C.: Pan American Health Organi-
zation/University of Washington; 2016:109–132.
33. Friedman J, Scheffler R. Pay for performance
in health systems: theory, evidence and case
studies. In: Scheffler RM, ed. Health system
characteristics and performance. World Scien-
tific Handbook of Global Health Economics and
Public Policy, Vol. 3. Singapore. World Scientific
Publishing; 2016:295–332.
34. World Health Organization. The world health
report 2000. Health systems: improving
performance. Geneva: WHO; 2000. Available
from: http://www.who.int/entity/whr/2000/en/
whr00_en.pdf?ua=1.