The World Health Report to be rationed like other services. Identifying the opportunity cost of additional technology in terms of other needed services may help to present the case to the public. PROTECTING THE POOR In the world s poorest countries, most people, particularly the poor, have to pay fo health care from their own pockets at the very time they are sick and most in need of it They are less likely to be members of job-based prepayment schemes, and have less access than better-off groups to subsidized services This report presents convincing evidence that prepayment is the best form of revenue collection, while out-of-pocket payment tends to be quite regressive and often impede access to care. In poor countries, the poor often suffer twice -all of them have to pay an unfair share through taxes or insurance schemes, whether or not they use health services, and some of them have also to pay an even more unfair contribution from their pockets Evidence from many health systems shows that prepayment through insurance schemes leads to greater financing fairness. The main challenge in revenue collection is to expand prepayment, in which public financing or mandatory insurance will play a central role. In the case of revenue pooling, creating as wide a pool as possible is critical to spreading financial risk for health care, and thus reducing individual risk and the spectre of impover Insurance systems entail integration of resources from individual contributors or sources both to pool and to share risks across the population. Achieving greater fairness in finan- cing is only achievable through risk pooling -that is, those who are healthy subsidize those who are sick, and those who are rich subsidize those who are poor. Strategies need to be designed for expansion of risk pooling so that progress can be made in such subsidies Raising the level of public finance for health is the most obvious route to increased prepayment. But the poorest countries raise less, in public revenue, as a percentage of na- onal income than middle and upper income countries Where there is no feasible organi- zational arrangement to boost prepayment levels, both donors and govenments should explore ways of building enabling mechanisms for the development or consolidation of very large pools. Insurance schemes designed to expand membership among the poor would, moreover, be an attractive way to channel external assistance in health, alongside government revenue Many countries have employment-based schemes which increase benefits for their priv ged membership-mainly employees in the formal sector of the economy -rather than widen them for a larger pool. Low income countries could encourage different forms of prepayment-job-based, community-based, or provider-based -as part of a preparatory process of consolidating small pools into larger ones. Governments need to promote com- munity rating (i.e. each member of the community pays the same premium), a common benefit package and portability of benefits among insurance schemes, and public funds In middle income countries the policy route to fair prepaid systems is through strength ing the often substantial mandatory, income-based and risk-based insurance schemes, countries already have very high levels of prepayment, some of these strategies are alsoxviii The World Health Report 2000 to be rationed like other services. Identifying the opportunity cost of additional technology in terms of other needed services may help to present the case to the public. PROTECTING THE POOR In the world’s poorest countries, most people, particularly the poor, have to pay for health care from their own pockets at the very time they are sick and most in need of it. They are less likely to be members of job-based prepayment schemes, and have less access than better-off groups to subsidized services. This report presents convincing evidence that prepayment is the best form of revenue collection, while out-of-pocket payment tends to be quite regressive and often impedes access to care. In poor countries, the poor often suffer twice – all of them have to pay an unfair share through taxes or insurance schemes, whether or not they use health services, and some of them have also to pay an even more unfair contribution from their pockets. Evidence from many health systems shows that prepayment through insurance schemes leads to greater financing fairness. The main challenge in revenue collection is to expand prepayment, in which public financing or mandatory insurance will play a central role. In the case of revenue pooling, creating as wide a pool as possible is critical to spreading financial risk for health care, and thus reducing individual risk and the spectre of impover￾ishment from health expenditures. Insurance systems entail integration of resources from individual contributors or sources both to pool and to share risks across the population. Achieving greater fairness in finan￾cing is only achievable through risk pooling – that is, those who are healthy subsidize those who are sick, and those who are rich subsidize those who are poor. Strategies need to be designed for expansion of risk pooling so that progress can be made in such subsidies. Raising the level of public finance for health is the most obvious route to increased prepayment. But the poorest countries raise less, in public revenue, as a percentage of na￾tional income than middle and upper income countries. Where there is no feasible organi￾zational arrangement to boost prepayment levels, both donors and governments should explore ways of building enabling mechanisms for the development or consolidation of very large pools. Insurance schemes designed to expand membership among the poor would, moreover, be an attractive way to channel external assistance in health, alongside government revenue. Many countries have employment-based schemes which increase benefits for their privi￾leged membership – mainly employees in the formal sector of the economy – rather than widen them for a larger pool. Low income countries could encourage different forms of prepayment – job-based, community-based, or provider-based – as part of a preparatory process of consolidating small pools into larger ones. Governments need to promote com￾munity rating (i.e. each member of the community pays the same premium), a common benefit package and portability of benefits among insurance schemes, and public funds should pay for the inclusion of poor people in such schemes. In middle income countries the policy route to fair prepaid systems is through strength￾ening the often substantial mandatory, income-based and risk-based insurance schemes, again ensuring increased public funding to include the poor. Although most industrialized countries already have very high levels of prepayment, some of these strategies are also relevant to them