A/67/302 health expenditures. 36 Out-of-pocket payments may also lead to catastrophic health expenditures. 37 Every year approximately 100 million people, in mostly low-income countries, are pushed into poverty owing to excessive or catastrophic spending on health care. 38 At a minimum, the right to health requires States to reduce out-ofpocket payments for health and eliminate those payments that disproportionately impact on the poor. The pooling of prepayments for health goods and services reduces out-of-pocket payments for all users and may eliminate these payments for the poor. 39 Pooling thus insulates users against catastrophic health expenditures through the cross-subsidization of financial risks associated with expenditures on health. 36. Single payer systems with a single risk pool or multiple payer systems with multiple risk pools reduce financial barriers to accessing health facilities, goods and services, as required under the right to health approach. In single payer systems, one organization collects and pools funds and purchases services for the entire population. In most cases, all pool members within the system are provided access to the same health goods and services. 40 Owing to its ability to generate and raise funds, through mechanisms such as taxation, and compulsorily enrol large numbers of people, the Government, in most cases, administers the pool and purchases health goods and services in a single payer system. Single risk pools promote equitable access to health facilities, goods and services in accordance with the right to health approach by allowing for greater cross-subsidization than systems with smaller, fragmented pools. Single payer systems are thus effective in promoting universal access to health facilities, goods and services, reducing out-of-pocket payments, and insulating users from catastrophic health expenditures. 37. Private health-care providers may also operate alongside single payer systems. Private hospitals and doctors may be allowed to opt out of the publicly funded system and collect private fees from patients. As a result, the public system may be left underfunded, if users are exempt from contributions upon exit from the system, and understaffed, if large numbers of health workers exit the public system for higher pay in the private sector. This, in turn, may reduce the overall quality of public health facilities, goods and services. The poor and other groups who are unable to exit the public system because they cannot afford private care are the most negatively affected under those circumstances. A parallel private health system may thus result in infringements of the right to health because it may reduce overall access to and quality of health facilities, goods and services in the public sector. 38. In contrast to single payer systems, multiple payer systems typically comprise multiple insurance pools operated by competing private insurers, but do not rule out the possibility of government-run insurance programmes. The existence of multiple pools allows for packages of health goods and services offered by insurers to be more specifically tailored to the needs of different groups. Insurers in multiple payer systems raise funds through contributory mechanisms such as insurance premiums. __________________ 36 37 38 39 40 14 WHO, World Health Report, “Health Systems Financing: The path to universal coverage” (Geneva, 2010), p. 12. Ke Xu et al., “Household catastrophic health expenditure: a multicountry analysis”, The Lancet, vol. 362, Issue 9378 (July 2003), pp. 111-117. WHO, World Health Report, “Health Systems Financing: The path to universal coverage”, p. 8. Margaret Kruk et al., “Borrowing And Selling To Pay For Health Care In Low- And MiddleIncome Countries”, Health Affairs, vol. 28, No. 4 (2009), pp. 1056, 1063. Gerald F. Anderson and Peter Hussey, Special Issues with Single-Payer Health Insurance Systems, Health, Nutrition and Population (HNP) Discussion Paper (World Bank, 2004), p. 28. 12-46101