Added value and possible areas of cooperation
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Added value and possible areas of cooperation. Serge Heijnen Executive Secretary. Carrin et al. 2008 Key health financing options at different stages of the evolution towards universal coverage. Tax-based financing Social health insurance Mix of tax-based and social health insurance.

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Added value and possible areas of cooperation

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Added value and possible areas of cooperation

Serge Heijnen

Executive Secretary

Carrin et al. 2008

Key health financing options at different

stages of the evolution towards universal coverage

Tax-based financing

Social health insurance

Mix of tax-based and

social health insurance

Mixes of community -, cooperative -

and enterprise-based health insurance and other private insurance. Social health insurance- type coverage for specific groups and limited tax-based financing

Health expenditure

dominated by

out-of-pocket spending

PHC reforms

Financing reforms

“The responses of many health systems so far have been generally considered inadequate and naive. Inadequate, insofar as they not only fail to anticipate, but also to respond appropriately – too often with too little, too late, or too much in the wrong place. Naive, insofar as a system’s failure requires a system’s solution – not a temporary remedy.”WHO World Health Report, 2008

“A system to a large extent causes its own behaviour. Once we see the relationships between structure and behaviour, we can begin to understand how systems work, what make them produce poor results, and how to shift them into better behaviour patterns. System structure is the source of system behaviour. System behaviour reveals itself as a series of events over time”.

Meadows, 2008

Relationships between the key functions of health financing reform, policy processes and UC

Health financing function

Revenue collection



Actors and process: policy formulation and implementation

Sufficient, equitable, efficient revenue collection

Financial accessibility

Efficiency, equity in purchasing / provision

Health financing norms

Universal Coverage (UC): adequate health services coverage of the whole population (the breadth, depth and height of coverage)

Adapted from Carrin, et al. 2008

Systems thinking in health places high value on understanding context and looking for connections between the parts, actors and processes of the system.

Systems thinking requires a deliberate and continuous approach to anticipate rather than to react, and to identify upstream points of leverage.

High leverage points are usually governance and information systems, but they receive least attention!

PHC reforms

Financing reforms

Learning workshops / networks on universal coverage can definately be a good point of entry not only for exchanging information about health systems’ status, structure or technical pathway towards universal coverage. It allows meaningful discussions about context, actors and their behaviour which caused a policy or measure to succeed or fail.

What is the added value of the Dutch experience?

I would argue that the added value of the Dutch experience to countries that are exploring options to extend coverage lies particularly in:

Gradually strengthening the public stewardship role and information systems in health within a context of 1) dominant private care provision and financing – both for profit and not-for-profit and 2) a historically very weak role of the government in the health sector.

What useful NL knowledge & experience for DCs?

  • Most important successes: achieving universal coverage and maintaining solidarity, innovation.

  • Most important failures: inefficient and unsustainable due to fragmentation, commercialization and bureaucratization. How can we support others to prevent making these mistakes?

  • Formal regulation of the private sector (for profit and not-for profit): insurance, care provision and pharmaceutical markets. What has contributed to strengthening coverage (depth, height and breadth)?

  • Insurance, care and competition inspection functions.

  • Lot of experience with insurance / risk management, provider payment mechanisms and cost control elements.

What useful NL knowledge & experience for DCs?

  • Checks and balances through consultation of stake-holders in policy processes and negotiation. Downside: compromises and power imbalances undermine efficient functioning of the health system

  • “System management information”: annual financial overview care, zorgbalans, VTV, now the HIT.

  • Well-trained health systems analysts

    Our health system only works below sea-level. Successes are more difficult to copy than mistakes.

So, in line with the recommendations of the WRR, I would argue for development aid to:

Invest more in “the brains of health systems”: individuals, institutions and infrastructures, next to offering direct care or insurance products / solutions.

HIP and Platform GHPHSR

  • Common interest to explain the added value of Dutch – health sector - development aid within the current political environment and WRR recommendations (“height”)

  • Common interest for health systems strengthening and opportunities for business in developing countries (“breadth”). Therefore,

  • Common interest to identify the added value of Dutch health sector knowledge with a view to supporting, on demand, developing countries and global investors/regulators (“depth”)

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