1997;41:136. Pooling is the health system function whereby collected health revenues are transferred to purchasing organizations. OECD, Eurostat. (Accessed on 25 February 2018)]. 0000003940 00000 n Higher income persons are usually more likely to have this form of VHI [51]. Australia's health system is a complex mix of service providers and other health professionals from a range of organisations - from Australian and state and territory governments and the non-government sector. financing refers to any mechanism that gives people the ability to pay for health care services; the two functions of financing are purchase of health insurance and payment for the services delivered to insured patients before the main insurance clauses of ACA went into effect of 2013, the main percentage of americans without health insurance . 0000035307 00000 n Kutzin J, Jakab M, Shishkin S. From scheme to system: social health insurance funds and the transformation of health financing in Kyrgyzstan and Moldova. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. PubMed Capacity strengthening of the MSP will also be an important component of this program. 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]. 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/. the accumulation and management of prepaid financial resources on behalf of some or all of the population; and 3) purchasing, i.e. When each level of government in a decentralized setting pools for a distinct level of health services, then it is organized in a territorially distinct way. territorially overlapping pools in terms of service and population coverage; (4.) Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. On the other hand, competition among insurance pools creates an incentive for pool managers to cream skim, i.e. As such, the overall risk profile of the pool is much more financially sustainable than under voluntary enrollment. Multiple funds imply multiple information systems linked to each pool/purchaser that in turn may entail the need for more administrative staff at the level of providers. Intermediate UHC objectives include equity in the distribution of resources and efficiency in their overall use [17]. Today, millions of people do not access services due to the cost. 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]. This entity pools public funding, i.e. 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. Book Ministry of Health Swaziland. the allocation of pooled funds to health service 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. Knaul FM, Gonzlez-Pier E, Gmez-Dants O, Garca-Junco D, Arreola-Ornelas H, Barraza-Llorns M, Sandoval R, Caballero F, Hernndez-Avila M, Juan M, Kershenobich D, Nigenda G, Ruelas E, Seplveda J, Tapia R, Sobern G, Chertorivski S, Frenk J. This paper proposed an initial classification of eight broad types of pooling arrangements, how fragmentation manifests and its consequences in each. Google Scholar. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. to (5.) Health Policy. Geneva: World Health Organization; 2008. The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. However, we recognize that any classification is a simplification of reality and does not substitute for a country-specific analysis of pooling arrangements. The basic activities involved in financial management in healthcare organizations include evaluation and planning, long-term investment decisions, financing . Conversely, schemes that have voluntary membership, i.e. California Privacy Statement, Three key health financing system functions Resource Mobilization: Countries need to consider three issues: What are the sources of funding for health? Szigeti S, Evetovits T, Kutzin J, Gal P. Tax-funded social health insurance: an analysis of revenue sources. Health Spending as % of GDP. This paper attempts to address this problem by providing a conceptual framework that is driven by the normative objective of enhancing the 'insurance function' (access to needed care without financial impoverishment) of health care systems. agencies that manage pools (typically insurance schemes) compete for members. Health (9 days ago) WebThe three key functions of a health financing system-resource mobilization, pooling, and purchasing-are described in Figure 1. 5. https://doi.org/10.1186/s12939-019-1088-x, DOI: https://doi.org/10.1186/s12939-019-1088-x. Health financing is a core function of health systems that can enable progress towards universal health coverage by improving effective service coverage and financial protection. Gottret P, Schieber G. A practitioners guide health financing revisited. Rather it is a first attempt at a classification, which could encourage further useful work from others. ?2$R@a,/|l*K`I(ij6 'I#b *`&IX0*f*@f0 I,dH4BH>o\v^dqY[GraltAL3,;S/R-{zk37IY[?d-. Voluntary health insurance expenditure in low- and middle-income countries: exploring trends during 1995-2012 and policy implications for progress towards universal health coverage. Some countries, such as Rwanda and Ghana, have transformed their earlier CBHI model, which no longer falls under VHI. Bingley: Emerald Group Publishing; 2009. p. 291312. Health Policy. Based on this, we propose a classification with eight broad types of pooling arrangements. 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. Geneva: World Health Organization; 2017. The classification, such as the one we are proposing is simply meant to facilitate the reflecting around a response. Berkshire: Open University Press; 2005. van de Ven WP, Beck K, Van de Voorde C, Wasem J, Zmora I. mobilization, accumulation and allocation of money to cover the health needs of the people, individually and collectively, in the health system. Smith P. The role of markets and competition. In the early 1990s, Thailand had a scheme for civil servants and another scheme for private sector employees. Privacy Health financing for universal coverage and health system performance: concepts and implications for policy. population density). Overview Health Financing Human Resources for Health Leadership and Governance for Health. 2012;380(9849):125979. 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). These are 1) the nature of pooling and 2) the structure of pooling. territorially distinct pools; (3.) Bull World Health Organ. endstream endobj 155 0 obj<> endobj 156 0 obj<> endobj 157 0 obj<> endobj 158 0 obj<> endobj 159 0 obj<> endobj 160 0 obj<> endobj 161 0 obj<> endobj 162 0 obj<> endobj 163 0 obj<> endobj 164 0 obj<> endobj 165 0 obj<> endobj 166 0 obj<> endobj 167 0 obj<>stream Mathauer I, Kutzin J. Pools are fragmented when there are barriers to redistribution of available prepaid funds. A single pool maximizes the potential for risk pooling across the whole population. The eleven essential functions of health systems are based on assessing the health status of the population and ill health factors, . Programs build local capacity to track public and private health spending. The purpose of pooling is to spread financial risk across the population so that no individual carries the full burden of paying for health care. Kutzin J, Shishkin S, Bryndov L, Schneider P, Hrobo. Health financing involves the basic functions of revenue collection, pooling of resources, and purchase of interventions. State budget transfers to health insurance funds: extending universal health coverage in low- and middle-income countries of the WHO European region. Health Policy. 0000079931 00000 n different pools for different socio-economic groups with population segmentation; (5.) &E ^3d``}'|W>(G6062q0K x48XiFf uH30~z*F% L{ Complementary insurance for health services covers benefits that are excluded from the public systems package, thereby giving access to a wider range of benefits. 2001;56(3):171204. Risk pooling is the spreading of the financial risk associated with the need to use and pay for health services, rather than to be fully borne by the individual who falls ill [11].The objectives of this paper are to raise the profile of pooling as a health financing policy instrument and to provide a simple classification of country pooling arrangements through which we discuss the challenges typically associated with how fragmentation manifests in each setting. 0000009066 00000 n However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. These tend to reflect particular challenges due to the nature and consequences of fragmentation in each. Thailand Health Systems in Transition. 0000080023 00000 n RAND research explores the effects of corporate and government health care financing policies on such groups as patients, businesses, hospitals, and physician-providers. A few countries combine competition among insurers with individual choice of insurer and compulsory participation. Background paper no. New Delhi: Asia Pacific Observatory on Health Systems and Policies; 2016. In: Kutzin J, Cashin C, Jakab M, editors. there are different funds for different population groups, with the affiliation being based on socio-economic or (socio-) demographic criteria. It also had schemes for the low-income population and the elderly and a subsidized voluntary insurance program for the rest of the population. A desciptive framework for country-level analysis for health care financing arrangements. 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 It is possible to have competition across pools, i.e. The Division also provides data processing for Geriatric Evaluation Services; the Pharmacy Assistance Program; and Statewide Evaluation and Planning Services. However, in most countries with complementary or supplementary VHI, VHI expenditure is below 10% of current health expenditure [29], and when a large part of the population has this form of VHI coverage, spillover effects are less severe [22, 53]. Purchasing to improve health system performance. Hatfield (South Africa): CMS; 2016. 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. Indeed, these arrangements put in place for health financing further exacerbated existing inequalities in these countries rather than compensating for them. PubMed 0000001076 00000 n is the health system function whereby collected health revenues are transferred to purchasing organizations. 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. The resources allocated to these different pools may come from a mix of centrally and sub-nationally raised revenues, with allocations often based on a consistent formula applied across the country. This is the so-called death spiral of voluntary health insurance [24]. Londoo JL, Frenk J. 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. The six functions are: (i) service delivery, (ii) medical products, vaccines and technology, (iii) workforce, (iv) information, (v) financing and (vi) leadership and governance. In: Kutzin J, Cashin C, Jakab M, editors. Latin American development forum. the mobilization of resources for the health sector; 2) pooling, i.e. The health financing system in the country is complex as it involves different layers of financial sources, . WHO Regional Office for Europe: Copenhagen; 2016. PubMed 0 endstream endobj startxref 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]. 3. Structured pluralism: towards an innovative model for health system reform in Latin America. 0000002097 00000 n Voluntary health insurance: its potentials and limits in moving towards UHC, health financing policy brief no. It concentrates on patient flows as well as the organization and delivery of all services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health. Yet, the function of pooling and the different ways that countries organize this is critical for countries progress towards UHC. . Raising revenues for health in support of UHC: strategic issues for policy makers, health financing policy brief no. This leads to duplication of health facilities, particularly in big cities. Government funds are mainly allocated through historical incremental approach. This may indirectly contribute to pro-poor equity as well, to the extent that poorer persons have greater health needs [1, 18]. 2017;17(1):145. Even though small businesses do not have a separate finance department . 1995;32:25777. Bonilla-Chacn ME, Aguilera N. The Mexican Social Protection System in Health [Universal Health Coverage Studies Series (UNICO) No. In 2005/2006 public, external and private contributions to the total health expenditure were 21.6%, 60.7% and 18.2% respectively. Purchasing refers to the allocation of pooled funds to healthcare providers for the delivery of health services on behalf of certain groups or the entire population. HSn0|lDP@bQlXdhe)o8NP*!}73H$8xKSY=5MfrjOj#]GIKz*=nE{/fw3A&/4`CJj+@K,*0'P2 mkgXEi{i5wD But it has important implications and impacts on the other pooling arrangements, which is why it is discussed here as a separate type of pooling arrangement. Paris: OECD; 2011. 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. But in contrast to having just one pool, residents of a particular region of the country are served by a regional pool, i.e. Forum for Health Economics & Policy; 1998: 1 (1). Akerlof GA. In: Figueras J, editor. BMC Health Serv Res. Geneva: World Health Organization; 2017. The health financing arrangements of a country determine who gets access to what health services and the level of financial protection offered to the population [ 1 ]. ), (7.) This chapter provides background on demographic and epidemiological trends, the configuration of Ghana's health system, and health financing functions and health systems goals. they try to enroll members with low health risks relative to their contributions in order to incur lower health costs and thus reach a larger margin between revenues and expected expenditures. Health care delivery forms the most visible function of the health system, both to patients and the general public. Adverse Selection in Health Insurance. Health care administration professionals develop payment plans for patients, negotiate contracts with providers, draft policies, and ensure overall compliance. This health budget pool is included in the pooling arrangements outlined below and is also often characterized by fragmentation. 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). Strategic purchasing for universal health coverage: key policy issues and questions. Vilcu I, Mathauer I. When people have access to publicly financed coverage schemes, this VHI is duplicating. . Today, millions of people do not access services due to the cost. The authors declare they have no competing interests. Smith PC. Supplementary insurance, on the other hand, provides enhanced access, such as a higher level of inpatient amenities or greater user choice of providers compared to the coverage in the public system [51, 55]. SMG 1117A.641 . 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]. 0000064650 00000 n When pooling also follows the countrys administrative structure, the mandates for service coverage (and hence population coverage) of different government level pools may overlap, thus creating an additional layer of fragmentation. Mexicos Seguro Popular also shifted to this principle of automatic coverage of all people who are not part of an insurance scheme for formal sector employees [47, 48]. the mobilization of resources for the health sector; 2) pooling, i.e. 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. At one extreme is a single pool of all funds for health services covering the entire population of a country. xref The better-off groups - those in formal employment benefit from much higher per capita funding and a much higher level of benefits compared to the rest of the population with much lower levels of financial protection. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification. This has an adverse impact on equity in resources across pools. hmo6 hbbd``b` "$8@B\HHo \Q u 88b``g T 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. Many others receive poor quality of services even when they pay out-of-pocket. Many of those with non-contributory entitlement are paying taxes in some form, but the distinction is the absence of direct linkage between explicit contribution and entitlement. Hungary, Bull World Health Organ. 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. 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. 8. Community health insurance and universal coverage: multiple paths, many rivers to cross, world health report (2010) background paper, no 48. Formula funding of health services: learning from experience in some developed countries. 2023 BioMed Central Ltd unless otherwise stated. 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. 14]: The World Bank; 2013 [http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/MexicanSocialProtectionSysteminHealth.pdf. complementary or supplementary voluntary health insurance. Pools can be based on compulsory, automaticor voluntary participation. Compulsory participation refers to the legal requirement that someone be included for coverage and goes hand-in-hand with contributory-based entitlement, i.e. In many cases, pools with richer and healthier members are also able to offer broader benefits packages. World Health Organization. . As a result of inadequate diversity of healthier and sicker people, the costs of care for a pool based on voluntary coverage are in principle higher than for the average in the population. Int J Equity Health. However, relevant responses to improving pooling depend on the specific nature and the broader context of the country. Objective Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. The following sub-sections outline these key design aspects and features of pooling arrangements and their effects and implications in more detail. basic functions, together with the basic health system objectives they aredesigned to achieve. 1). Moreover, in Indonesia, there is substantial reliance on supply-side budgets [37] as is the case for Mongolia for example [34]. Washington DC: World Bank; 2004. Geneva: World Health Organization; 2010. type of pooling arrangement, namely territorially distinct pools. 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. Global Health Expenditure Database: National Health Accounts [http://apps.who.int/nha/database (accessed on 1 September 2018)]. !{~4nf0QMh92]Ta, *eIF 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]. Each of the insurance schemes thus constitutes a separate pooling agency. fragmented systems with voluntary health insurance, duplicating publicly financed coverage; and (8.) Health financing refers to the "function of a health 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 the purpose of health financing is to make funding available, as well as to set the right. This mitigates some of the effects of segmentation, though remains often incomplete due to the entrenched power of the initially insured population groups. Figure 1. What are the functions of health financing mechanisms? World Health Organization. Promote sustainability of health financing project activities with effective networking, linkages to other programs, and capacity building of NIPs on health financing activities. Health financing sub-functions Revenue generation: As shown in Figure 1, funds for health financing are generated majorly by government (57%), about But the key concern is that the existence of multiple pools implies fragmentation. European Observatory on Health Systems and Policies; 2014. The major health financing mechanisms in Nigeria are namely: (i) government budget using general tax revenue; (ii) direct out-of-pocket payments; (iii) a social insurance scheme known as the Formal Sector Social Health Insurance Programme (FSSHIP) that is implemented by the National health insurance scheme; and (iv) donor funding. The interplay between the core functions of health financing are brought to light by studies that have shown that increased financial resources for health do not necessarily The company has multiple offices in the U.S. and program offices in more than 40 countries. Baeza CC, Packard TG. Sparkes S, Durn A, Kutzin J. 814 0 obj <>stream the elderly outside the formal sector, or the very poor, other defined population groups [14]. and (7.) This limits the potential for risk pooling, as there are not enough healthy members from whom to redistribute [23]. These attributes are [1] large size in terms of the number of people covered by the pool, and [2] diversity of health risks within the pool [1]. View below: When viewing on a desktop, maximize for optimized view. 799 0 obj <>/Filter/FlateDecode/ID[<0390BB992C88AA479032C87A0FBB6257><540FDF402BF7DC42AD0DD7B5A9813B14>]/Index[787 28]/Info 786 0 R/Length 75/Prev 299315/Root 788 0 R/Size 815/Type/XRef/W[1 2 1]>>stream Service public pro. Health Policy. In: Chernichovsky D, Hanson K, editors. (Of course, fragmented pool structures will yield more dependence on OOP expenditure and thus decrease the share of prepaid funds in overall health spending). Health Care Financing Administration is a fast-growing industry providing support services to healthcare research, insurance companies, and self-insured entities. hb```c, The three roles of health managers are interpersonal, informational and decisional. 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. Purchasing health services for universal health coverage: how to make it more strategic? Health Care Syst Transit. (&9~4y4no74d4J+2 ;RVbL|rSN /-`X/qggmzQV8rd pvr\HUc. 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 . Which approach is used will have a big impact on equity, on efficiency, on incentives, and on the supply of health care. This is followed by an outlineof the key institutional design aspects of pooling arrangements and how these can create fragmentation. 0000008166 00000 n 0000002345 00000 n 0000001757 00000 n [http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/swaziland/swaziland_nhssp_ii_draft_zero_29_aug_2014.pdf. Frenz P, Delgado I, Kaufman JS, Harper S. Achieving effective universal health coverage with equity: evidence from Chile. Int J Equity Health. Sagan A, Thomson S. Voluntary health insurance in Europe: country experience. SMG 1117A.641 (02/09/2022) 1 . 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. HdSK0sNH{`9i SfWglvQ"{L$l$l}&j LIPX0st"$BB*4~f75HhO Z7 xb```l hp`d,u){i7NY~GOC]TkT} h$*M^ixD#UNm| Health system review. What are the four major services and healthcare? 0000005327 00000 n Article Innovations in health system finance in developing and transitional economies.