2016;15:67. We provide a simple classification of country pooling arrangements and discuss the specific ways that fragmentation manifests in each and the typical challenges with respect to universal health coverage objectives associated. type of pooling arrangement, namely territorially distinct pools. Book These tend to reflect particular challenges due to the nature and consequences of fragmentation in each. 0000012340 00000 n 0000005227 00000 n Many others receive poor quality of services even when they pay out-of-pocket. For example, the pool from which the national capital city funds its city hospitals, and the pool from which the central government funds national tertiary facilities are not territorially distinct, particularly when as is often the case the national tertiary hospital is also an important provider of more basic services for the local population. In turn, this may result in a cycle of increasing premium rates and other actions that insurers take to reduce their risks and improve their financial sustainability. Health financing is central to the functioning of health systems and the attainment of health-related sustainable development goals, including universal health coverage (UHC). This module includes the indicators on health financing from the compendium of indicators for projects supporting health financing, human resources, and governance developed by the HFG project. Therefore, maximizing the potential to redistribute from lower-need to higher-need individuals by de-linking contributions (of whatever form, such as taxes or insurance premiums) from their health risk is the central objective for pooling. Kutzin J. However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. 1997;41:136. Pooling arrangements in health financing systems: a proposed classification, International Journal for Equity in Health, https://doi.org/10.1186/s12939-019-1088-x, http://www.internationalhealthpartnership.net//CMS_files/documents/working_group_2_report:_raising_and_channeling_funds_EN.pdf, http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/swaziland/swaziland_nhssp_ii_draft_zero_29_aug_2014.pdf, http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/MexicanSocialProtectionSysteminHealth.pdf, https://www.academia.edu/33391064/The_Health_Insurance_System_in_Peru_Towards_a_Universal_Health_Insurance, https://www.service-public.fr/professionnels-entreprises/vosdroits/F33754, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. trailer Health Spending as % of GDP. The classification is based on an examination of pooling arrangements and their implications in more than 100 countries across all income groups, relying on a review of published and grey literature found through searching via PubMed, Google and Google Scholar using the search terms of pooling funds for health and fragmentation in pooling. 0000012547 00000 n To develop a health financing structure capable of addressing the challengesof the future. Beyond survival protecting households from health shocks in Latin America. To ensure key development programmes are adequately funded [5,6]. A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects? WHO. Health financing involves the basic functions of revenue collection, pooling of resources, and purchase of interventions. Sagan A, Thomson S. Voluntary health insurance in Europe: country experience. Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211, Geneva, Switzerland, World Health Organization, Tunis, Tunisia, You can also search for this author in Health care delivery forms the most visible function of the health system, both to patients and the general public. Health Policy. the allocation of pooled funds to health service providers [ 1 ]. RAND research explores the effects of corporate and government health care financing policies on such groups as patients, businesses, hospitals, and physician-providers. The National Health Insurance Program was established to provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines. 0000074834 00000 n This article provides an overview of health financing reforms across countries in the Western Pacific Region as progress is made toward universal health coverage (UHC). To develop the classification, we combined the different features in the structure and the nature of pooling and then examined the nature and structure of pooling in more than 100 countries across all income groups. Conversely, schemes that have voluntary membership, i.e. different pools for different population groups, with explicit coverage for all; (6.) Mathauer I, Mathivet B, Kutzin J. PubMed Due to concerns about the previous type of arrangement in many countries, various countries developed policy responses and undertook significant pooling reforms starting in the 2000s. But where territorially distinct pools are too small in terms of the number of people, their risk profile can be financially precarious and there could be efficiency and capacity concerns. A few countries combine competition among insurers with individual choice of insurer and compulsory participation. When coverage is compulsory or automatic for all population groups, the pool(s) have a more diverse mix of health risks. 0000005125 00000 n management and disbursement for financing the availment of a basic minimum package and other . xb```l hp`d,u){i7NY~GOC]TkT} h$*M^ixD#UNm| 2. Health financing diagnostics & guidance no. The six functions are: (i) service delivery, (ii) medical products, vaccines and technology, (iii) workforce, (iv) information, (v) financing and (vi) leadership and governance. 1 / 64. Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. The Netherlands: health system review. Yet, the function of pooling and the different ways that countries organize this is critical for countries progress towards UHC. Thailand Health Systems in Transition. Jowett M, Brunal MP, Flores G, Cylus J. 0000010947 00000 n National health expenditures are derived from government and non-government sources and are used to finance a wide array of programs and services. Whereas revenue raising, e.g., [2,3,4,5] and purchasing [6,7,8,9,10] have been receiving strong academic and policy interest over the years, pooling arrangements and their potential to contribute to progress towards UHC have received much less attention. In any country, prepaid health revenues may be held, i.e. Mathauer I, Dkhimi F. Analytical guide to assess a mixed provider payment system. Function. A system-wide approach to analysing efficiency across health programmes. (accessed 5 February 2019)]. 0000001757 00000 n 1 below. Today, millions of people do not access services due to the cost. 0 Geneva: World Health Organization; 2017. 2014;16(1). a sub-national pool per state, province or district. complementary or supplementary voluntary health insurance. Health financing - World Health Organization. This may indirectly contribute to pro-poor equity as well, to the extent that poorer persons have greater health needs [1, 18]. In 2005/2006 public, external and private contributions to the total health expenditure were 21.6%, 60.7% and 18.2% respectively. Some countries, such as Rwanda and Ghana, have transformed their earlier CBHI model, which no longer falls under VHI. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. It is important to mention that supply side financing, where the health budget flows in a vertically integrated way to service providers, constitutes a pool, and in many cases is often the largest pool in low- and middle-income countries. Szigeti S, Evetovits T, Kutzin J, Gal P. Tax-funded social health insurance: an analysis of revenue sources. voluntary health insurance). There are some countries that rely predominantly on a single national pool funded from general government revenues. 0000010246 00000 n To discuss Malawi as a case study in health systems. PubMedGoogle Scholar. World Health Organization. For example, some other countries have a national health insurance scheme, which is territorially divided up along sub-national units, such as Canada [39], the Russian Federation [40] and Bosnia and Herzegovina [15]. Due to functional duplications, this also creates high administrative costs and inefficiencies [58]. 5. Even in countries with highly centralized pooling, there are usually several pools of funds that are used to pay for some health services, for example occupational health programs, supply-side funding for other government services such as those delivered through vertical programs or voluntary health insurance [1]. Frenk J. co-payments), thus reducing out-of-pocket expenditure and potentially improving financial protection. 0000003726 00000 n The final goals of UHC are equity in service use, quality, and financial protection. Click the card to flip . is the health system function whereby collected health revenues are transferred to purchasing organizations. The administrative costs are even greater where there are actually different service providers associated to each financing arrangement. Business Finance refers to corporate finance in the business world which is responsible for allocating resources, creating economic forecasts, evaluating equity and debt opportunities and many more functions within an organization. In a well-functioning healthcare system, the financing of healthcare is defined by three key functions: (1) revenue generation, which involves the mobilization and collection of funds from different sources; (2) resource pooling, where generated revenue is accumulated to ensure availability to the population in need; and (3) the purchasing While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. The result is that even where it is legally mandatory for the entire population, it is de facto voluntary coverage. Int J Equity Health 18, 198 (2019). Health financing policy brief no. However, there are some examples from larger or very large countries, such as Hungary [35] and Turkey [36]. Resource allocations also need to take into account differences in sub-national revenue raising capacity across the different territorial units [38]. Community based health insurance: how can it contribute to progress towards UHC? Here the pooling function lies with a sub-national entity, such as a state, province, or district (if managed by a level of public administration) or another entity, such as a health insurance fund, with defined responsibility for the entire population of that territory [14]. Mathauer I, Kutzin J. Multiple forms of fragmentation co-exist, and dimensions other than pooling also result in fragmentation. (WHO/HIS/HGF/HFWorkingPaper/16.1; Health Financing Working Paper No. a. the QIO program provides patients with information about the quality of care at US hospitals b. the QIO program focuses on helping medicare and medicaid beneficiaries c. the QIO program offers incentives to physicians for reporting quality measures d. the QIO program allows medicare beneficiaries to file complaints about quality of care World Health Organization. Pooling arrangements set the potential for redistributive health spending. Forum for Health Economics & Policy; 1998: 1 (1). Wahshginton DC: World Bank; 2005. 1970;84(3):488500. But the key concern is that the existence of multiple pools implies fragmentation. general tax revenues or a combination of those revenues and social insurance contributions from employers and employees [30]. The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. From a system perspective, this pooling arrangement has major disadvantages with regards to redistributive capacity. Automatic participation is typically based on legal or constitutional obligations, and the basis for entitlement is non-contributory, deriving from citizenship, residence or other factors such as poverty status, etc. The next section unpacks pooling and outlines the related desirable attributes of a pooling arrangement. Figure 3.1 highlights these. It maintains and operates the Medicaid Management Information System (MMIS), an automated claims processing and information retrieval system mandated by the federal government. Finally, it is important to keep in mind that while pooling reforms are needed to enhance redistributive capacity, realizing the gains set by the potential of a pooling arrangement requires more than pooling. This was, and in some places remains, one of the main drivers of large inefficiencies in the health systems of the ex-USSR countries [15]. a single pool; (2.) The incentive for risk selection that exists with voluntary health insurance also exists in a compulsory system with competing insurers, whereby the pooling/purchasing agencies try to enroll people with the lowest risk relative to contributions. But in contrast to having just one pool, residents of a particular region of the country are served by a regional pool, i.e. A system of health accounts. As such, automatic entitlement is typically solely funded from general budget revenues. Health financing is a core function of health systems that can enable progress towards universal health coverage by improving effective service coverage and financial protection. "Health system financing is an essential component of UHC but progress toward UHC also requires coordinated actions across the pillars of the health system with particular attention to strengthening human resources for health." Health system financing health topic hb```c, 2001;56(3):171204. Washington DC: World Bank; 2006. sicker individuals would have to pay more because they would need more health services [18]. 0000011158 00000 n 0000014440 00000 n The health financing system in the country is complex as it involves different layers of financial sources, . Three key health financing system functions Resource Mobilization: Advances in health economics and health services research, volume 21. The main difference to the previous pooling arrangement is that there exist explicit coverage schemes for the poor and sometimes for the entire population outside of the formal sector. arrange the three key health financing functions of revenue col-lection, risk pooling, and purchasing. The complex structure of Australia's . 2016;15:57. Indeed, these arrangements put in place for health financing further exacerbated existing inequalities in these countries rather than compensating for them. Due to voluntary participation, small pool size and little or no subsidization of poor and vulnerable groups, CBHI can play only a very limited role in progressing towards UHC. Strategic purchasing for universal health coverage: key policy issues and questions. Financing systems need to be specifically designed to provide all people with access to needed health services (including prevention, promotion, treatment, and rehabilitation) of sufficient quality to be effective; and to ensure that the use of these services does not expose the user to financial hardship. 154 0 obj <> endobj WHO. Int J Equity Health. -U+:V\GCs2C /L7w0X-O`>2h?! Geneva: World Health Organization; 2008. The third function of health care financing is purchasing of services. Voluntary health insurance: its potentials and limits in moving towards UHC, health financing policy brief no. Health financing: the basics FP Financing Roadmap. Risk selection practices can be addressed with risk adjustment mechanisms (which we discuss further below in the next section). voluntary contributions from beneficiaries, are prone to adverse selection: people with higher risks are more likely to enroll than people with lower health risks. Pools can be based on compulsory, automaticor voluntary participation. 0000006764 00000 n 0000001076 00000 n Kutzin J, Yip W, Cashin C. Alternative financing strategies for universal health coverage. Countries need to focus not on generic models but on. To cite variations across countries of different income levels. it is the function of a system concerned with the mobilization, accumulation, and allocation of money to cover the health needs of the people, individually and collectively, in the health system. Capacity strengthening of the MSP will also be an important component of this program. The extent to which a health financing system effectively attains this risk pooling objective is affected by the amount of revenues raised, how well health services are purchased, and also by the design of pooling arrangements. Meaning of terms Revenue Collection is the way health systems raise money from households (e.g. Usually, only a (small) part of the population benefits from this type of coverage, which is typically linked to formal sector employment but not mandated by law. In the early 1990s, Thailand had a scheme for civil servants and another scheme for private sector employees. . However, the overall level of prepaid funds arises from how a health system raises revenues, and not how it organizes pooling arrangements. Washington DC: World Bank; 2006. endstream endobj 788 0 obj <>/Metadata 86 0 R/OCProperties<>/OCGs[800 0 R]>>/Outlines 125 0 R/PageLayout/SinglePage/Pages 783 0 R/StructTreeRoot 156 0 R/Type/Catalog>> endobj 789 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 790 0 obj <>stream "The purpose of health financing is to make funding available, as well as to set the right financial incentives to providers, to ensure that all individuals have access to effective public health and personal health care" (WHO 2000: 95). Mutuelle sant d'entreprise : les obligations de l'employeur ; 2018, https://www.service-public.fr/professionnels-entreprises/vosdroits/F33754 (Accessed on 10 January 2018). 0000014993 00000 n different pools for different socio-economic groups with population segmentation; (5.) 0000005327 00000 n Self-paced (approximately 6 hours of course time) Click to enter this course Pools are fragmented when there are barriers to redistribution of available prepaid funds. The agency is typically labelled as a national health insurance fund and constituted as an autonomous public entity. Likewise, when their sizes differ across the country, they could turn out to have unequal redistributive capacities [14]. %%EOF Q J Econ. Mathauer, I., Saksena, P. & Kutzin, J. Pooling arrangements in health financing systems: a proposed classification. Key facts Innovations in Health System Finance in Developing and Transitional Economies. Agency's Mandate and Functions Mandate. The report is divided into five chapters. They also need to monitor cash on hand, businesses may be profitable but have a shortage of cash and. Privacy From these two institutional design aspects, we need to distinguish the level of prepaid funding, which is not considered in this classification. 3. 2018;11(11). Figure 5.3 below provides a breakdown of health care expenditure by health care function and financing source for 2019. Bingley: Emerald Group Publishing; 2009. p. 291312. Geneva: World Health Organization; 2017. Health financing systems have a key role in achieving universal health coverage (UHC) across the globe. Under the second form of institutional setup, countries have established a single national fund that is managed by a separate pooling and purchasing agency, usually with a purchaser-provider split. 0000046058 00000 n Again, higher-income people with health lower risks and higher contributions may be in a different pool from people in low-income groups with higher health risks and lower contributions. Health Care Syst Transit. 5. Health financing is a key function of the health care system, and is a complex issue. Revenue collection is how health systems raise money from households, businesses, and external sources. comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification. For illustration we provide various country examples. Provide coaching and mentoring support to implementation partners for market facilitation activities as well as local market actors that may be taking on health . Different frameworks for assessing of health . Geneva: World Health Organization; 2019. taxes, user fees, private health insurance), business (e . Paris: OECD; 2011. Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: lessons from Thailand. SMG 1117A.641 . WHO Regional Office for Europe: Copenhagen; 2016. hbbd``b` "$8@B\HHo \Q u 88b``g T Kutzin J, Jakab M, Shishkin S. From scheme to system: social health insurance funds and the transformation of health financing in Kyrgyzstan and Moldova. ] TkT } h $ * M^ixD # UNm| 2 UNm| 2 programmes. Of UHC are equity in service use, quality, and external sources, health..., private health insurance fund and constituted as an autonomous public entity the classification shortage cash. 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Involves different layers of financial sources, a pooling arrangement health insurance: how can it to! Entire population, it is de facto voluntary coverage disadvantages with regards to capacity... Among insurers with individual choice of insurer and compulsory participation care system and! Purchase of interventions expenditure and potentially improving financial protection they would need more services. Limits in moving towards UHC monitor cash on hand, functions of health financing, and of... Result is that even where it is de facto voluntary coverage pooling arrangement, territorially! Sagan a, Thomson S. voluntary health insurance: an analysis of collection...