**1. Introduction**

United Nations formulated transformational Sustainable Development Goals (SDGs) vision to transform our world to be free of poverty and disease by 2030 [1], and WHO invented the UHC framework to be a glocalization model to achieve health-related SDGs [2]. The existing outcomes of health-related SDGs in World Health Statistics showed that life expectancy at birth improved 5.5 years globally from 66.5 to 72.0 years between 2000 and 2016 [3]. Life expectancy was 62.7 years in low-income countries and 80.8 years in high-income countries, so it was 18.1 years low in low-income countries in 2016 [3]. Life expectancy progress in low-income countries between 2000 and 2016 was 21%, compared with 8% globally and 4% in high- income countries [3]. Premature deaths in low-income countries were caused by lower respiratory infections, diarrhea diseases, acquired immunodeficiency syndrome (AIDS), malaria, and preterm birth complications [3]. The top three causes of premature death in other countries occurred due to ischemic heart disease, lung cancer, and suicides [3].

Globally in 2015 [4], the figure of maternal deaths was 216 per 100,000 live births. This means the complications of pregnancy and childbirth killed almost 830 women every single day [4]. Poor women in remote areas suffer lack of adequate health care [4]. However, these deaths happened in low-resource settings [4] and could be prevented. The two-thirds of global maternal deaths happened generally in the WHO African Region [4]. The possibility of a 15-year-old girl in the region ultimately dying from a maternal reason remained as high as 1 in 37 compared with 1 in 3400 in the WHO European Region [4]. The maternal deaths occur mainly due to hemorrhage, hypertension during pregnancy, infections, and indirect causes and interaction between preexisting medical conditions and pregnancy [4].

The reduction of the global under-five mortality rate has been reduced from 93 per 1000 live births in 1990 to 41 per 1000 live births in 2016 [5]. Nevertheless in 2016, 15,000 children died before reaching their fifth birthday [5]. In 2016, the majority of 2.6 million newborn deaths occurred in the first week of life [5]. Three-quarters of all neonatal deaths occurred due to prematurity, intrapartum-associated events such as birth asphyxia and birth trauma, and neonatal sepsis [5]. In 2016, the leading causes of death in children aged 1–59 months were acute respiratory infections, diarrhea, and malaria. Older children (aged 5–14 years) died from preventable causes [5].

The causes of death in children under-5 years of age in 2016 were "prematurity, acute respiratory infections, birth asphyxia and birth trauma, tetanus, HIV/AIDS, measles, meningitis/encephalitis, other noncommunicable diseases, malaria, injuries, neonatal sepsis, diarrhea, congenital anomalies, other communicable, perinatal and nutritional conditions" [5]. In 2017, three-quarters (22%) of 151 million stunted (too short for their age) children under the age of 5 live in the WHO South-East Asia Region or WHO African Region [5]. High levels of stunting associated with childhood morbidity and mortality risks, learning capacity, and NCDs later in life have a negative impact on the development of countries [5]. In 2017, the overweight (too heavy for their height) children under the age of 5 were 38 million (5.6%), and the wasted (too light for their height) were 51 million (7.5%) [5].

In 2016, noncommunicable diseases caused 41 million deaths, which were 71% of all deaths worldwide [3]. Most of those deaths occurred from cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes mellitus [3]. The risk factors of noncommunicable diseases include unhealthy diets, insufficient physical activity, raised blood pressure, tobacco use, harmful use of alcohol, obesity, overweight among children, and air pollution [3].

The desired outcomes of health-related SDGs were identified for designing the functions of the universal health insurance coverage. United Nations formulated SDGs 1, 2, 3, 6, and 10 to transform our world to be free of poverty and diseases by 2030 [1]. The SDGs 1, 2, 3, 6, and 10 consist of ending poverty in all its forms everywhere, generating healthy lives and promoting well-being for all at all ages, ending hunger, achieving food security, improving nutrition, and promoting sustainable agriculture, ensuring availability and sustainable management of water and sanitation for all, and reducing inequality within and among countries [1, 6].

#### *The Innovation of Six-Dimensional Pooling Risk Framework in Universal Health Insurance… DOI: http://dx.doi.org/10.5772/intechopen.106963*

SDG's targets are to reduce global maternal mortality, end preventable deaths of newborns and children under-5 years of age, to end the epidemics of communicable diseases through the three levels of prevention, to reduce premature mortality from communicable and noncommunicable diseases through health promotion and three levels of prevention promote mental health and well-being, strengthen health promotion and treatment of substance abuse (including narcotic drug abuse and harmful use of alcohol), reduce global deaths and injuries from road traffic accidents, ensure universal access to sexual and reproductive healthcare services (including family planning, information and education, and the integration of reproductive health into national strategies and programs), achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, affordable and quality essential medicines and vaccines for all, reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination, strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries (as appropriate), ensure equal opportunity and reduce inequalities of outcome, achieve substantial coverage of the poor and vulnerable by implementing national appropriate social protection systems [1, 6].

The strategic health goals are to reduce inequality within and among countries through equal opportunity by reducing outcome inequalities [1, 6], to achieve healthy lives and promote well-being for all at all ages through health promotion and the higher levels of disease prevention, and to end poverty in all its forms everywhere through universal health insurance coverage [1, 6].

The UHC framework was introduced to ensure everyone has equity in accessibility to promotion, prevention, treatment, and rehabilitation healthcare services, without suffering financial hardship by paying for them [2, 7, 8]. The UHC framework is built around three-dimension components [8]. The components contain universal healthcare services coverage, universal financial risk protection and population coverage with a proportion of the costs covered (**Figure 1**) [2, 7, 8]. The elements are considered in UHC such as the population covered, the services package, cost sharing for pooling, cost payment for services, and the cost pay by pooling [2, 7, 8].

The six functions of the universal health insurance coverage–Bismarck Model were formulated based on SDG 1,2,3,6 and 10 targets. The overarching goal of these functions transforms the determinants of health-related SDGs to produce healthier populations by 2030. Firstly, they protect an insured population from financial risk to reduce out of pocket eradication of poverty in all its forms everywhere. Secondly, they promote health to ensure healthy lives and promote well-being for all at all ages. Thirdly, they prevent diseases to end the epidemics of communicable diseases through the three levels of disease prevention. Fourthly, they finance leaving no district behind universal healthcare services coverage. Fifthly, they finance health promotion, disease prevention, treatment, and palliative services, to transform ecological social determinants of health, to decrease morbidity and mortality rate of communicable diseases and noncommunicable diseases. Finally, they function to ensure equity in access to four types of healthcare services, for leaving no one behind. The Bismarckian model is a sickness fund approach and a state social insurance based on prepayment by employees and their employers [9].

The functional problems of the universal health insurance coverage-Bismarck Model program originated from the lack of health promotion, disease prevention, and reduction of health inequity funds. Those problems make the program ineffective in reducing the morbidity and mortality rate of communicable and noncommunicable

#### **Figure 1.**

*Three dimensions to consider when moving toward universal coverage. Source: the world health report: health systems financing: the path to universal coverage. 2010.*

diseases and inequity in healthcare service accessibility. This study aims to transform the three-dimension pooling risk framework of the universal health insurance coverage-Bismarck Model to finance healthy lives and equity in healthcare services accessibility.
