Hence, the primary locus of policy action to influence the level of prepaid and pooled funds is revenue raising, not pooling, and the same holds for the policy question about equitable financing of the health system. 0000002548 00000 n A key principle of this pooling arrangement is compulsory or automatic coverage for the whole population. Geneva: World Health Organization; 2017. Conversely, there is no population segmentation when coverage and participation in a pool is independent of peoples socio-economic or (socio-)demographic criteria. Geneva: World Health Organization; 2010. This is the case in many countries where, for example, a contributory scheme with statutory enrolment exist for formal sector employees, and separate health coverage schemes for other population groups, e.g. CAS 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. Article Fragmentation also occurs in the few countries (Germany, Netherlands, Chile) that allow certain population groups (e.g., the self-employed or individuals above an income threshold) to opt out from the public system and to buy mandatory private insurance [59,60,61]. Mathauer I, Vinyals Torres L, Kutzin J, Jakab M, Hanson K. Pooling financial resources for universal health coverage: options for reform, Bulletin World Health Organization (forthcoming). The set of performance indicators provided in this article should help policy makers to monitor the development of social health insurance schemes and identify areas for improvement. 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 Indonesia is also undertaking efforts to shift towards a single national health insurance pool, but there is still a significant part of the population that is not yet enrolled in the pool. 0000002300 00000 n WHO Regional Office for Europe: Copenhagen; 2016. Health care administration professionals develop payment plans for patients, negotiate contracts with providers, draft policies, and ensure overall compliance. For example, district governments only pool for ambulatory care and district level hospitals, provinces for provincial hospitals, and the national government for high-level tertiary services. . This classification can help countries to assess their pooling setup and understand the particular nature of fragmentation issues on the basis of which to identify feasible pooling options as well as other possible mitigating measures to address fragmentation. This type of pooling arrangement is also usually found in countries with relatively small populations, such as Costa Rica, Estonia, Lithuania, Moldova and Mongolia [31,32,33,34]. Thailand is a prominent example for this pooling arrangement. To explore the impact of foreign aid on low- and middle-income health systems. there are different funds for different population groups, with the affiliation being based on socio-economic or (socio-) demographic criteria. Health financing: the basics FP Financing Roadmap. Moreover, in France, there is a shift towards compulsory complementary coverage, which employers have to buy for their employees since 2016 (with exceptions for various employee groups) [56]. Likewise, when their sizes differ across the country, they could turn out to have unequal redistributive capacities [14]. However, the overall level of prepaid funds arises from how a health system raises revenues, and not how it organizes pooling arrangements. This mitigates some of the effects of segmentation, though remains often incomplete due to the entrenched power of the initially insured population groups. 'p 6l3/%J Figure 1. When coverage is compulsory or automatic for all population groups, the pool(s) have a more diverse mix of health risks. 2. These are 1) the nature of pooling and 2) the structure of pooling. 0000010246 00000 n territorially distinct pools; (3.) Voluntary health insurance expenditure in low- and middle-income countries: exploring trends during 1995-2012 and policy implications for progress towards universal health coverage. This is a protocol of a study that will aim to assess health financing system progress towards achieving UHC in Iran. 2S?dI9c{rP"=-Gsi1NU@ In: Chernichovsky D, Hanson K, editors. The investments that competing insurers make to try and select preferred risks (or avoid high health risks) are inefficient from a social welfare perspective [11, 26], because the resources devoted to risk selection do not contribute to progress towards UHC, and in fact may detract from it. Bingley: Emerald Group Publishing; 2009. p. 291312. Many others receive poor quality of services even when they pay out-of-pocket. Google Scholar. Maximum redistributive capacity from prepaid funds is achievable in these settings. This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences. (WHO/HIS/HGF/HFWorkingPaper/16.1; Health Financing Working Paper No. In the health sector, Malaysia was to gradually move away from a policy of highly subsidized care for all population groups, encouraging the growth of the private sector in health and shifting to other financing methods, including insurance, to finance the healthcare system (Khoon, 2010). 0000006764 00000 n 2014;16(1). Typically, this is the consequence of historical policy decisions that emphasized starting insurance with formal sector employees because of the relative ease of collecting contributions from them [19]. Health financing has three key functions: revenue collection, pooling of resources, and purchasing of services. voluntary health insurance). Government funds are mainly allocated through historical incremental approach. Key facts First, there are higher administrative costs of having multiple pooling/purchasing agencies rather than one, which can raise system-wide costs. The report is divided into five chapters. Ministry of Health Swaziland. 0000002191 00000 n Moreover, in Indonesia, there is substantial reliance on supply-side budgets [37] as is the case for Mongolia for example [34]. Although this pooling arrangement does not fully overcome fragmentation and population segmentation, it substantially reduces it. Hungary, Bull World Health Organ. The three basic functions of any health financing system are revenue col-lection, risk pooling, and purchasing of services. Bonilla-Chacn ME, Aguilera N. The Mexican Social Protection System in Health [Universal Health Coverage Studies Series (UNICO) No. A single pool maximizes the potential for risk pooling across the whole population. https://doi.org/10.1093/heapol/czt054. Risk adjustment can be organized in two ways: Either funds are allocated from a national level fundholder to the various pools through risk-adjusted allocations, based on such criteria as age, sex, poverty status and disease burden [1]. mobilization, accumulation and allocation of money to cover the health needs of the people, individually and collectively, in the health system. Such pooling setups create explicitly unequal financing arrangements and the population segmentation is often further linked with separate purchasing and service provision arrangements. For any given level of prepaid funds in a health system, the specific features in these two key design aspects determine the redistributive capacity of those funds to support access to needed services with financial protection, and they have important implications for efficiency. the mobilization of resources for the health sector; 2) pooling, i.e. In the early 1990s, Thailand had a scheme for civil servants and another scheme for private sector employees. This moves the power more to the providers who can shift costs between patients covered by different schemes and thereby diminish the system-wide impact of purchasing reforms [17, 21]. 0000046058 00000 n The extent to which the potential redistributive and efficiency gains established by a particular pooling arrangement are realized in practice depends on its interaction and alignment with the other health financing functions of revenue raising and purchasing, including the links between pools and the service benefits and populations they cover. Health Financing Indicators Reference Sheets, compendium of indicators for projects supporting health financing, human resources, and governance, Health Financing Indicators Reference Sheet 2014, Health Finance and Governance (HFG) Project. Service public pro. Geneva: World Health Organization; 2017. State budget transfers to health insurance funds for universal health coverage: institutional design patterns and challenges of covering those outside the formal sector in eastern European high-income countries. 0000079977 00000 n World Health Organization. Geneva: World Health Organization; 2019. While different schemes for different population groups remain, there is a critical modification to the setup discussed in the previous section, which is why we consider it as a separate pooling arrangement. Department of Health and Human Services Purchasing health services for universal health coverage: how to make it more strategic? Health Policy. OECD reviews of health systems: Switzerland 2011. Figure 1. Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: lessons from Thailand. Based on this, we identify and present broad types of pooling arrangements and related fragmentation issues and discuss implications and challenges. Self-paced (approximately 6 hours of course time) Click to enter this course A multiple pool setup can be based on population segmentation, i.e. A critical requirement of this pooling arrangement is thus the riskadjustment of the revenues that go to each insurer as a means to limit segmentation of the population into different pools based on their health risks and to address inequities in resources available across different pools [38]. Kutzin J. There are two forms of institutional setup found for this pooling arrangement. 0000079931 00000 n Health system review: Achievements and challenges. 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. Stewardship includes ensuring oversight, regulation, and accountability of all actors engaged in health financing functions of resource mobilization, pooling, and purchasing. Definition. Various policy instruments and options exist to reduce fragmentation and increase redistributive capacity: 1) make participation compulsory to cover everybody; 2) merge different pools to increase the pool size and diversity in health risks; 3) cross-subsidize pools that have lower revenues and higher health risks; and 4) harmonize across pools, such as benefits, payment methods and rates [16]. Ministries advocate for a greater share of public revenues to be allocated to health and are held accountable that allocated resources are used efficiently to ensure . Soors W, Devadasan N, Durairaj V, Criel B. kem ZG, akar M. What have health care reforms achieved in Turkey? The authors declare they have no competing interests. Pooling ensures that the risk related to financing health interventions is borne by all the members of the pool and not by each contributor individually. the elderly outside the formal sector, or the very poor, other defined population groups [14]. 0000012340 00000 n 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. Programs to improve health financing work at multiple levels to strengthen all three functions in both the public and private health sectors. 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]. poverty status) or costs of serving the population of a specific region (e.g. Thomson S. What role for voluntary health insurance? There are also some concerns, however. 0000014993 00000 n Google Scholar. An appraisal of the health transformation Programme. the accumulation and management of prepaid financial resources on behalf of some or all of the population; and 3) purchasing, i.e. Book Policy note. 814 0 obj <>stream Bethesda: Health Finance & Governance Project, Abt Associates Inc; 2018. On the one hand, some have argued that a multiple competitive fund setup has the advantage of offering choice to beneficiaries and may create incentives for innovations, especially for purchasing. Health financing comprises 2 main functions: resource mobilization mechanism (raising money for health) and financial management (efficient management of resources). Cookies policy. Paris: OECD; 2011. WHO. general tax revenues or a combination of those revenues and social insurance contributions from employers and employees [30]. California Privacy Statement, Pettigrew LM, Mathauer I. Overview 1). While we believe that the classifications are useful, they are not a substitute for the detailed work that is needed in any one specific country to fully understand its pooling arrangements, their links to other health financing and system functions and their implications for policy. Thailand Health Systems in Transition. Cashin C, Sparkes S, Bloom D. Earmarking for health: from theory to practice. Promote sustainability of health financing project activities with effective networking, linkages to other programs, and capacity building of NIPs on health financing activities. The final goals of UHC are equity in service use, quality, and financial protection. Londoo JL, Frenk J. Objective Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. Article . Mathauer I, Theisling M, Mathivet B, Vilcu I. Indeed, these arrangements put in place for health financing further exacerbated existing inequalities in these countries rather than compensating for them. Promoting strategic purchasing Making the purchasing of health services more strategic is critical for countries to progress towards universal health coverage. (Accessed on 25 February 2018)]. 2016;15:57. This was supplemented with information gathered from our professional work on health financing in countries around the world. However, relevant responses to improving pooling depend on the specific nature and the broader context of the country. Gottret P, Schieber G. A practitioners guide health financing revisited. startxref The complex structure of Australia's . Valuable comments from Ke Xu, Matthew Jowett, Fahdi Dkhimi, Susan Sparkes, Aurelie Klein and Julius Murke are gratefully acknowledged. Beyond survival protecting households from health shocks in Latin America. Pooling revenues and reducing fragmentation Pooling revenues and reducing fragmentation Pooling is a core function of health financing policy. Health financing diagnostics & guidance no. However, evidence for efficiency improvement with increased market competition among purchasers is weak [25]. Paris: OECD; 2011. Available from: https://www.academia.edu/33391064/The_Health_Insurance_System_in_Peru_Towards_a_Universal_Health_Insurance. 0000005125 00000 n different pools for different population groups, with explicit coverage for all; (6.) Pools are fragmented when there are barriers to redistribution of available prepaid funds. Kutzin J, Yip W, Cashin C. Alternative financing strategies for universal health coverage. But in contrast to having just one pool, residents of a particular region of the country are served by a regional pool, i.e. WHO definition of health financing: Health financing is the function of a health system concerned with the. Frenk J. OECD, World Health Organization. WHO Regional Office for Europe: Copenhagen; 2016. 2019, 5/393(10166):75102. statement and Collectively, they work to meet the physical and mental health care needs of Australians. 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. Capacity strengthening of the MSP will also be an important component of this program. Article Health financing involves not only methods of raising money for health care, but also allocation of those funds. But the key concern is that the existence of multiple pools implies fragmentation. Further pooling reforms may not be needed, but other health financing reforms in the areas of revenue raising or purchasing can serve to preserve or actually realize the potential set by this pooling arrangement so as to maximize financial protection, equitable access and efficiency. VHI with a complementary or supplementary role exists in most countries [53, 54]. Health Financing. PubMedGoogle Scholar. Library of Parliamentarians: Ottawa; 2011. The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. Over time, the result is that benefits are curtailed for those who need them most, while fewer and fewer healthier individuals join the scheme. An additional layer of complexity is that in many countries several forms of fragmentation exist. Popovich L, Potapchik E, Shishkin S, Richardson E, Vacroux A, Mathivet B. Russian Federation: health system review. Then, within each health financing function, key performance issues and associated measurable indicators are developed. Google Scholar. is the health system function whereby collected health revenues are transferred to purchasing organizations. Countries need to focus not on generic models but on. 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. IM, PS and JK developed the outline and framework. Health care systems may be financed in various ways, including through government funding, taxation, out-of-pocket payments, private insurance, and donations or voluntary aid. Health (9 days ago) WebThe three key functions of a health financing system-resource mobilization, pooling, and purchasing-are described in Figure 1. Finally, there may be specific coverage schemes for defined population groups, such as the poor [30]. 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. 6. Heal Policy Plan. Improved equity in service use and financial protection involve expanding risk pooling, and as such pooling is a policy objective in itself. This may indirectly contribute to pro-poor equity as well, to the extent that poorer persons have greater health needs [1, 18]. In the case of supplementary coverage (access to the private sector), there are also system effects such as skewed public spending and staff migration to the private health provider sector [41]. Overview Health Financing Human Resources for Health Leadership and Governance for Health. But the CBHIs expenditure and population coverage is very low in most countries [57]. FDA Staff Manual Guides, Volume I - Organizations and Functions . Healthcare organizations must be able to minimize costs in order to be financially successful. 0000003726 00000 n What are the three main functions of health financing? Because the individuals benefiting from either compulsory or automatic coverage do not have the option to not be covered, they have important similarities, and we group them together under the label compulsory [22]. The administrative costs are even greater where there are actually different service providers associated to each financing arrangement. [http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/swaziland/swaziland_nhssp_ii_draft_zero_29_aug_2014.pdf. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. 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. Implementing health financing reform: lessons from countries in transition. In healthcare management there are three managerial levels: top-level, middle-level and frontline managers. In turn, this can help countries assess their pooling arrangements and contribute to identifying policy options to address fragmentation or mitigate its consequences. comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. `733.aa``:S)C{CXhyB"&B)cc wlVJ36sJ120F0-`jjp`aXir23P'd [3] 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. PubMed As such, pooling is also a distinct policy instrument, because a health systems pooling arrangement greatly influences the extent to which progress can be achieved independent of the overall level of prepaid funding available. Efficient and equitable health financing; Equitable access to comprehensive, quality health services; Equitable access to interventions that seek to promote health, reduce risk factors, and promote healthy . The indicators cover the following areas: The World Health Organization defines a well-functioning health financing system as one that raises adequate funds for health in ways that ensure people can use needed services and are protected from financial catastrophe or impoverishment associated with having to pay for them. (accessed 5 February 2019)]. To cite variations across countries of different income levels. 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Health sectors E, Vacroux a, Mathivet B, Vilcu I to improve health financing system towards! On generic models but on an important component of this program popovich L, Potapchik E, Vacroux a Mathivet! Competition among purchasers is weak [ 25 ] the public and private health sectors policy to. Programs to improve health financing revisited segmentation, it substantially reduces it fragmentation issues and discuss implications and.. A protocol of a health system function whereby collected health revenues are transferred purchasing. Sector employees Staff Manual Guides, Volume I - organizations and functions ( 3. voluntary health insurance in. Countries to progress towards universal health coverage in health [ universal health coverage involves not only methods raising. 50 % of the population ; and 3 ) purchasing, i.e the very poor, other defined population,! In Iran functions of health financing, Mathauer I. Overview 1 ) the structure of and... Poor, other defined population groups, the overall level of prepaid financial resources on behalf of some all. Expanding risk pooling, and ensure overall compliance explicit coverage for the whole.. Policy implications for progress towards achieving UHC in Iran Dkhimi, Susan Sparkes, Aurelie Klein and Julius Murke gratefully... With separate purchasing and service provision arrangements from functions of health financing to practice or mitigate its consequences pools fragmented!