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Health Systems Financing

Course Title: Health Systems Financing
Course Code

HSRM 553
Teaching/learning methods

Lectures and group work
Assessment methods

Exam questions + group work presentation
Credit points

Semester (1 / 2)

Semester 1

Course objectives/ Learning outcomes: The aim of the course is to introduce the main concepts and options for health systems financing with a focus on achieving universal coverage and financial risk-protection. The course will enable students to discuss different options of health system financing reforms and to analyse their benefits and disadvantages.

Content: The course provides a structured overview to the main health systems financing functions, including (1) resource mobilization, (2) pooling & allocation to third-party payers, (3) purchasing and payer provider relationships. The advantages and disadvantages of typical health financing mechanisms, such as social health insurance, tax-financed systems, community-based health insurances, and private health insurance will be discussed. Different pathways to achieving (effective) universal coverage of persons, benefits, and costs, in various countries are presented. Furthermore, the course provides an overview of the essential role of payment systems and their incentives for achieving efficiency and transparency in service delivery.




Length of course
Block course for 2 weeks

Nov 6th

Nov 15th

SPH combined class
(in the School of Medical Sciences building)

Reinhard Busse
Course coordinator

Reinhard Busse (TUB), Peter Agyei-Baffour (KNUST)
Week 1


Wednesday  (06.11)
Thursday (07.11)
Friday (08.11)
08:00 - 10:00
Group work: finding information from databases 
Social health insurance systems
10:30 - 12:30
Raising resources, pooling and allocation 
Tax financed systems 
13:00 - 15:00
Introduction, expectations, course outline
Out-of-pocket--> voluntary/private health insurance --> community-based health insurance
Group work: advantages/ disadvantages of SHI systems vs. tax financed systems
15:30 - 17:30
Week 2

Monday (11.11)
Tuesday (12.11)
Wednesday (13.11)
Thursday (14.11)
Friday (15.11)
08:00 - 10:00
Payment systems 1: Overview & Primary care
Summary:  Financing for universal coverage
10:30 - 12:30
Group work: different  pathways to UHC - option
Payment systems 2: Hospitals
Equity in financing
Mid-term exam (30  min) + questions and wrap-up
13:00 - 15:00
Moving from fragmented systems to universal coverage
Group work: presenting  the pathway to UHC
Group work: Advantages and disadvantages of DRG vs. capitation
Financial protection, financial accessibility  
15:30 - 17:30
PUBLIC LECTURE: Evidence-informed  health policy: Which evidence? How to inform? Does it work?
Guest lecture by  Francis Adjei (NHIA):Overview of the three health financing functions in Ghana



Examination will be based on group presentation (15%) + written mid-term exam (25%) and written final exam (60%).
Grading CWA/ECTS
Fail =
below 50%
Grade C =
Grade B =
Grade A =
70% and above



Literature (required/additional readings)


Essential reading

Kutzin, J. (2013). “Health financing for universal coverage and health system performance: concepts and implications for policy.” Bulletin of the World Health Organization 91(8). pp. 602-611, available at:  www.ncbi.nlm.nih.gov/pmc/articles/PMC3738310/pdf/BLT.12.113985.pdf

Chapter 1 in: Mossialos, Elias (Hg.) (2003): Funding health care. Options for Europe. Buckingham: Open Univ. Press (European Observatory on Health Care Systems series), available at: www.euro.who.int/__data/assets/pdf_file/0003/98310/E74485.pdf

Lagomarsino, Gina; Garabrant, Alice; Adyas, Atikah; Muga, Richard; Otoo, Nathaniel (2012): Moving towards universal health coverage. Health insurance reforms in nine developing countries in Africa and Asia. In: The Lancet 380 (9845), S. 933–943. DOI: 10.1016/S0140-6736(12)61147-7, available at: www.sciencedirect.com/science/article/pii/S0140673612611477


Raising resources, pooling and allocation

Kutzin, J.; Yip, W.; Cashin, C. (2016):

Alternative Financing Strategies for Universal Health Coverage.

In: World Scientific Handbook of Global Health Economics and Public Policy, S. 267–309. Available at: www.worldscientific.com/doi/abs/10.1142/9789813140493_0005.

Chapters 3 and 4 in: McIntyre, D., Kutzin, J. (2016). Health financing country diagnostic: a foundation for national strategy development.. Health Financing Guidance No. 1, World Health Organization, Geneva, available at:  apps.who.int/iris/bitstream/handle/10665/204283/9789241510110_eng.pdf;jsessionid=E693DB173EA74FB4A76483FA87C0D3E3


Social health insurance systems

Chapter 3 in: Saltman RB, Busse R, Figueras J: Social health insurance systems in western Europe. Berkshire: European observatory on health systems and policies, Open University Press; 2004, available at:  www.who.int/health_financing/documents/shi_w_europe.pdf

Carrin, Guy. "Social health insurance in developing countries: a continuing challenge." International social security review 55.2 (2002): 57-69, available at:  onlinelibrary.wiley.com/doi/abs/10.1111/1468-246X.00124

Olugbenga, Ebenezer Olatunji. "Workable Social Health Insurance Systems in Sub-Saharan Africa: Insights from Four Countries." Africa Development 42.1 (2017): 147-175, available at:  www.ajol.info/index.php/ad/article/viewFile/163629/153106

Barnighausen, T., & Sauerborn, R. (2002). One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries? Soc Sci Med, 54(10), 1559-1587.


Tax financed systems

WHO (2004):  Tax-Based Financing for Health Systems:  Options and Experiences, World Health Organization (WHO), Geneva. Available at:  www.who.int/health_financing/taxed_based_financing_dp_04_4.pdf

Reeves, Aaron, et al. "Financing universal health coverage—effects of alternative tax structures on public health systems: cross-national modelling in 89 low-income and middle-income countries." The Lancet 386.9990 (2015): 274-280, available at:  www.sciencedirect.com/science/article/pii/S0140673615605748

Cashin, C., Sparkes, S., Bloom, D. (2017). Earmarking for health: from theory to practice. Health Financing Working Paper No. 5, World Health Organization, Geneva , available at:  apps.who.int/iris/bitstream/handle/10665/255004/9789241512206-eng.pdf;jsessionid=0019A781F30997988B38E90856825BB7


Private health insurance systems and community-based health insurance:

Carrin, G., Waelkens, M. P., & Criel, B. (2005). Community-based health insurance in developing countries: a study of its contribution to the performance of health financing systems. Trop Med Int Health, 10(8), 799-811, available at:  onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-3156.2005.01455.x

Fadlallah, Racha; El-Jardali, Fadi; Hemadi, Nour; Morsi, Rami Z.; Abou Samra, Clara Abou; Ahmad, Ali et al. (2018): Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review. In: International journal for equity in health 17 (1), S. 13. DOI: 10.1186/s12939-018-0721-4, available at: equityhealthj.biomedcentral.com/articles/10.1186/s12939-018-0721-4

Chapter 2 in:  Sagan, Anna; Thomson, Sarah (2016): Voluntary health in insurance in Europe. Role and regulation. Copenhagen, Copenhagen: World Health Organization Regional Office for Europe; European Observatory on Health Systems and Policies (Observatory studies series, 43), www.euro.who.int/__data/assets/pdf_file/0005/310838/Voluntary-health-insurance-Europe-role-regulation.pdf


Moving from fragmented systems to universal coverage:

Chapter 2 in: Cotlear, Daniel; Nagpal, Somil; Smith, Owen; Tandon, Ajay; Cortez, Rafael (2015): Going universal. How 24 developing countries are implementing universal health coverage reforms from the bottom up. Washington, DC: World Bank Group. Online available at: openknowledge.worldbank.org/handle/10986/22011.



Robinson, R., E. Jakubowski, et al. (2005). Organization of purchasing in Europe. Purchasing to improve health systems performance. J. Figueras, R. Robinson and E. Jakubowski, available at:  www.euro.who.int/__data/assets/pdf_file/0004/98428/E86300.pdf   

Figueras, J., R. Robinson, et al. (2005). Purchasing to improve health systems performance: drawing the lessons. Purchasing to improve health systems performance. J. Figueras, R. Robinson and E. Jakubowski, available at:  www.euro.who.int/__data/assets/pdf_file/0004/98428/E86300.pdf   

Introduction Chapter in: Preker, Alexander S., Xingzhu Liu, and Edit V. Velenyi, eds. Public ends, private means: strategic purchasing of health services. The World Bank, 2007, available at: openknowledge.worldbank.org/bitstream/handle/10986/6683/399790PAPER0Pu101OFFICIAL0USE0ONLY1.pdf


Payment systems 1: Overview

Ellis, R. P. & Miller, M. M. 2009. Provider Payment Methods and Incentives. In: CARRIN, G. (ed.) Health systems policy, finance, and organization. Amsterdam: Elsevier Academic Press

Quinn, Kevin. "The 8 basic payment methods in health care." Annals of internal medicine 163.4 (2015): 300-306, available at:

Group work: Advantages and disadvantages of DRG vs. capitation


Payment systems 2: Paying hospitals

Quentin, W., D. Scheller-Kreinsen, M. Blumel, A. Geissler and R. Busse (2013). "Hospital payment based based on diagnosis-related groups differs in Europe and holds lessons for the United States." Health Aff (Millwood) 32(4): 713-723, available at:  www.healthaffairs.org/doi/10.1377/hlthaff.2012.0876

Mathauer I, Wittenbecher F (2013): Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries. Bulletin of the World Health Organization 2013;91:746-756A. doi: dx.doi.org/10.2471/BLT.12.115931


Financial protection, financial accessibility:

Chapter 2: Tracking universal health coverage: 2017 global monitoring report. World Health Organization and International Bank for Reconstruction and Development / The World Bank; 2017, available at:  apps.who.int/iris/bitstream/handle/10665/259817/9789241513555-eng.pdf;jsessionid=37CBF860DBB98AFA7FF01F33BF77D623

Wagstaff, Adam; Flores, Gabriela; Hsu, Justine; Smitz, Marc-François; Chepynoga, Kateryna; Buisman, Leander R. et al. (2018): Progress on catastrophic health spending in 133 countries. A retrospective observational study. In: The Lancet Global Health 6 (2), S. e169-e179. DOI: 10.1016/S2214-109X(17)30429-1, available at:  www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30429-1/fulltext


Equity in financing:

Mills, Anne, et al. "Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage." The Lancet 380.9837 (2012): 126-133, available at: researchonline.lshtm.ac.uk/21118/1/Equity%20in%20financing%20and%20use_GREEN%20AAM.pdf

Asante A, Price J, Hayen A, Jan S, Wiseman V (2016) Equity in Health Care Financing in Low- and Middle-Income Countries: A Systematic Review of Evidence from Studies Using Benefit and Financing Incidence Analyses. PLoS ONE 11(4): e0152866., available at: doi.org/10.1371/journal.pone.0152866

Zusatzinformationen / Extras


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Wilm Quentin
+49 30 314 29420
Sekretariat H80
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