Allotey et al. BMC Public Health 2012, 12(Suppl 1):S1 http://www.biomedcentral.com/1471-2458/12/S1/S1 and access to health services. In the background concept paper, Allotey et al. flip this idea of vulnerability, how- ever, to also explore vulnerability in health systems. We know that people who are economically disadvantaged are at higher risk of poor health, and then for financial or other social reasons find it harder to access health services. In a world that expects health systems to pro- vide universal coverage, however, one can see the issue not as one of “the poor”, “the vulnerable”, and “the dis- advantaged”; rather, the vulnerability lies in the health system. Some health systems are more vulnerable to fail- ure (ie., incapacity to deliver UHC) than others. What then are the determinants of the vulnerability of a health system? In a historical case study of South Africa, Alex van den Heever identifies a series of political choices, for instance, that made the health system more or less vulnerable to providing UHC including restrictions on risk-pooling. Seddoh and Akor also highlight similar challenges in their case study of Ghana. Requiring a health system to provide care to a whole population carries with it significant marginal costs for the delivery of care to the most inaccessible or most at need sections of the population. The costs of delivering care to geographically remote or sparsely distributed populations can be much higher than the concentrated delivery of care in urban settings. Delivery of care to those with pre-exist- ing, chronic conditions is often more expensive as is the treatment of rare diseases compared with common ones. This can give way to discussions of “equity versus effi- ciency”, or the “equity-efficiency trade off.” Reidpath et al. argue that the discussion of the trade off arises from a fun- damental misunderstanding of the kind efficiency required from a health system. If UHC requires the equitable deliv- ery of services, then the only useful measure of efficiency must include equitable delivery. A trade off may occur between equity and, say the number of people treated, if the delivery of equitable care means treating less people, but the trade off is not a trade off with efficiency. Insurance and financing It is impossible to imagine a meeting about UHC that is not significantly concerned with the mechanisms for financing the delivery of health services. One of the key impediments to implementation of UHC is the lack of funds to finance the health sector coupled with inefficient allocation and use of health resources. This is exacer- bated in countries with a fragmented healthcare system consisting of a public-private mix, where there are gaps in health service delivery and different levels of services (primary, secondary, tertiary) are disjointed between the public and private sector health sector. Major health pol- icy reforms can also result in gaps in health governance which can hinder the progress towards universal coverage. Page 2 of 3 The financing mechanisms, including insurance, were explored based on regional analyses from Mahal and James and with more country specific case studies from Thailand, the Philippines and Singapore. Chua and Cheah discuss the WHO Health Financing Strategy for the Asia Pacific (2010-2015) as a framework for evaluating UHC in Malaysia using national health accounts data. They did not identify serious concerns with the financing directly, but they do observe issues around the workforce – specifi- cally the loss of expertise from the public to the private system. And they also highlight the cost implications for UHC of a shifting burden of disease in Malaysia from dis- ease requiring acute care with costs constrained at least by the short treatment period to chronic care of conditions such as diabetes and kidney disease. The disease transition is not peculiar to Malaysia and will have many govern- ments worried because of the implications for health financing. Elsewhere Allotey and colleagues have argued that the increasing burden of chronic disease will require a fundamental rethink of what it means for health services to deliver care [4]. van den Heever in his historical analysis of changes in insurance and health financing regulation in South Africa observes the way that the private sector responds to government shifts. He noted positive aspects of the role of the private sector extending UHC by mobilising additional funds from those able to afford private cover, and negative aspects when the sector was permitted to entrench inequalities by excluding people with poor health from insurance cover. Because of the historical perspective van den Heever is able to track changes over time often missing in other policy analyses; some- thing important for those interested in insurance, regu- lation, and financing. Even if governments can achieve UHC, the financial challenges continue. China has seen the coverage of its population grow from 30% in 2003 to over 90% by the end of 2010 (See Tang et al.). Simultaneously there has been extraordinary increase in the cost of healthcare in China. Tang and colleagues consider a series of initia- tives to curb cost escalation from changes in drug pro- curement mechanisms to the application of standard clinical pathways in hospitals. Coverage and satisfaction Monitoring and evaluation must be integral to any suc- cessful implementation of UHC. Tang et al. describe the increase in insurance coverage of the population of China, and the simultaneous increase in healthcare costs. These kinds of effects need to be monitored. Does an increase in coverage translate into equitable use of health services across the social strata? Elsewhere Reidpath and colleagues had looked at this question with respect to urban-rural dif- ferences in health service utilisation in China [5].