A/67/302 41. However, community-based health insurance programmes may be unable to achieve effective cross-subsidization owing to the size and constitution of community pools. In most cases, community-based pools are very small in size and comprise poor individuals at high risk for illness; financial and health risks therefore may not be effectively subsidized across pool members. Contributions to community-based health insurance have also been shown to be regressive in some instances, as contributions are made as flat amounts and income-rated contributions and exemptions for the poor have been difficult to implement owing to challenges in determining household incomes. 45 Moreover, the costs associated with collecting contributions from populations in rural areas and informal urban areas are high relative to the revenue generated from contributions. Thus, while in some cases community-based insurance programmes may be used to increase access to health facilities, goods and services for vulnerable or marginalized groups and facilitate the participation of communities in health-related decision-making processes, they are not a substitute for larger, more centralized pooling mechanisms. Social health insurance 42. Social health insurance is a pooling mechanism funded by compulsory prepayments collected through individual and organizational contributions supplemented by taxation. Social health insurance programmes are generally administered by the State, which uses funds raised through compulsory contributions and tax revenues to purchase health goods and services for the insured. In contrast to pooling mechanisms that comprise smaller, fragmented pools, social health insurance programmes establish sufficiently large pools, through compulsory contributions, to facilitate effective cross-subsidization of financial and health risks across large populations. 46 Social health insurance thus increases utilization of and promotes equity in access to health facilities, goods and services and affords higher levels of financial protection for the poor. 47 Social health insurance programmes may take the form of single payer systems, which tend to encourage efficient health spending and lower administrative costs, or multiple payer systems, which encourage competition and allow other entities to purchase health services. Social health insurance programmes are therefore one example of a pooling mechanism that promotes the realization of the right to health. 43. Social health insurance programmes must be funded through compulsory contributions in the form of prepayments in order to achieve universal access to good quality health facilities, goods and services and robust cross-subsidization of financial and health risks. Voluntary contribution schemes may help raise funds in the absence of widespread payment and pooling, familiarize individuals with the benefits of insurance, and serve as an intermediate funding mechanism that eases the transition towards a more inclusive compulsory contribution scheme, but they do not necessarily increase rates of insurance coverage because enrolment is not compulsory. In contrast to a system of voluntary contributions, compulsory __________________ 45 46 47 16 See Anne Mills et al., “Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage”, The Lancet, vol. 380, Issue 9837 (2012), pp. 126-133. Pablo Gottret and George Schieber, “Health financing revisited: a practitioner’s guide” (World Bank, Washington, D.C., 2006), pp. 58-59. Regional Committee for the Eastern Mediterranean, “Technical Paper: The impact of health expenditure on households and options for alternative financing” (WHO, 2004), p. 9. 12-46101