A/67/302 stakeholder participation in funding processes and programmatic activities in accordance with the right to health approach to health financing. 32 33. In order to shift the global paradigm of international assistance for health from a donor-based charity regime towards an obligatory system based on the principle of solidarity, global pooling mechanisms should be founded upon international or regional treaties under which States incur legal obligations to contribute to the pool according to their ability to pay and through which funds are allocated based upon need. Such a shift is necessary in order to ensure the availability of sustainable international funding as required by the right to health. In order to promote ownership and accountability within the regime, each State would contribute to the fund regardless of its income level and all funding and programmatic processes must be transparent and include the active and informed participation of civil society and affected communities. In order to realize the right to health globally, States should therefore take all necessary steps towards the development of treatybased global pooling mechanisms, comprising compulsory progressive contributions allocated based upon need and driven by transparent, participatory processes. B. Pooling of domestic funds for health 34. The right to health requires States to ensure that good quality health facilities, goods and services are accessible to all without discrimination. To respect and fulfil the right to health, States should remove financial barriers that restrict access to health care. Accordingly, the right to health requires States to ensure that the ability to pay does not affect an individual’s decision whether to access necessary health goods and services. Health systems funded by prepayments, such as tax- and compulsory insurance-based systems, reduce financial barriers through the pooling of funds collected prior to the point of service delivery. Pooling is a method by which funds for health are accumulated and managed in order to spread the financial risk of illness across all members of a pool, over a period of time. 33 Pooling promotes equitable financing for health by facilitating cross-subsidies from healthy to unhealthy and from wealthy to poor members of the pool and across the life cycles of individual members. Pooling also increases efficiency by promoting more equitable improvements in health across populations 34 and hedging against risks associated with uncertainties related to future health and financial capacity. 35 35. The primary financial barrier to accessing health care in most States is out-ofpocket payments. Out-of-pocket payments are payments for health goods and services made by the user at the point of service delivery. In 2007, in 33 mostly lowincome countries, out-of-pocket payments represented more than 50 per cent of total __________________ 32 33 34 35 12-46101 Gian Luca Burci, “Public/Private Partnerships in the Public Health Sector”, International Organizations Law Review, vol. 6 (2009), pp. 359-382. WHO, World Health Report 2000, “Health Systems: Improving Performance” (Geneva, 2000), p. 99. Peter Smith and Sophie Witter, “Risk Pooling in Health Care Financing: The Implications for Health System Performance”, Health, Nutrition and Population Discussion Paper (Washington, D.C., World Bank, 2004), p. 4. Chris James and William Savedoff, “Risk pooling and redistribution in health care: an empirical analysis of attitudes toward solidarity”, World Health Report (2010), Background Paper No. 5, available from: www.who.int/healthsystems/topics/financing/healthreport. 13