The Chapter describes the status of health financing in low- and middle-income countries (L&MICs) and their health financing transition over the past two decades. Advancing Universal Health Coverage (UHC) requires an expansion of coverage over three dimensions: (i) health care benefits, (ii) population coverage, and (iii) cost coverage using prepaid/pooled funds. As national incomes rise, countries undergo a health financing transition, increasing total levels of health expenditure while increasing the publicly financed share of health spending and reducing the external- and OOP-financed share of spending. Two pro-poor paths are common for the expansion of health coverage. Many countries implement health insurance schemes for the poor. Others expand platforms of public providers that are mostly used by the poor, often focusing on community and primary care services. Countries choosing the pro-poor health insurance path develop targeting and enrolment instruments. Targeting tends to be stricter with social security purchasers, compared with ministerial purchasers. Fragmented systems, while suboptimal, can sometimes be more pro-poor than integrated systems.

In the spring of 1974, the 31-year-old junior Senator from Delaware, Joseph R. Biden, Jr., published a law review article in which he decried the traditional system of privately financed election campaigns. Private financing, Senator Biden contended, “affords certain wealthy individuals or special interest groups the potential for exerting a disproportionate influence over both the electoral mechanism and the policy-making processes of the government.” Moreover, Biden urged, private funding poses an obstacle to the candidacies of “individuals of moderate means” and so was at odds with the “concept of American democracy [that] presumes that all citizens, regardless of access to wealth, have equal access to the political process.” In addition, he argued that private funding favored incumbents. To address the “Political Darwinism” of private financing, Biden called on Congress to adopt a system of public funding for all federal candidates.