Thomson S. What role for voluntary health insurance? 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. This overlap turns into duplication of service coverage particularly in big cities, with the main policy consequence being large inefficiencies in the form of excess provider capacity [15]. Health Policy. People who have higher risks are just as covered as people who have lower risks. . https://doi.org/10.1093/heapol/czt054. family members). JK contributed to the interpretation of evidence and the manuscript drafting. Yet, the function of pooling and the different ways that countries organize this is critical for countries progress towards UHC. 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. 0000008860 00000 n Adverse Selection in Health Insurance. 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]. Such pooling setups create explicitly unequal financing arrangements and the population segmentation is often further linked with separate purchasing and service provision arrangements. Health financing - World Health Organization. Jowett M, Kutzin J. In particular, the aim in both is to match the level of per capita funding of each pool with the relative health risk of the population affiliated to each pool. Frenk J. The Canada health transfer: changes to provincial allocations. Abt Associates is a mission-driven, global leader in research and program implementation in the fields of health, social and environmental policy, and international development. Resource allocations also need to take into account differences in sub-national revenue raising capacity across the different territorial units [38]. Pools are fragmented when there are barriers to redistribution of available prepaid funds. 2017;17(1):145. Collectively, they work to meet the physical and mental health care needs of Australians. Second, fragmentation can weaken the potential gains from using purchasing as an instrument to influence provider behavior in countries where multiple purchasers use different payment methods and rates to pay the same providers in an uncoordinated way. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. Springer Nature. Department of Health and Human Services 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 diagnostics & guidance no. Bethesda: Health Finance & Governance Project, Abt Associates Inc; 2018. Health Policy. There are two forms of institutional setup found for this pooling arrangement. Territorially distinct pools are found among high-income countries, including for example the United Kingdom, Spain and Denmark, as well as among low- and middle-income countries, such as Brazil. Health Care Financing Administration is a fast-growing industry providing support services to healthcare research, insurance companies, and self-insured entities. Fragmentation in pooling can also contribute to inefficiency in the health system, as it typically implies a duplication (or multiplication) in the number of agencies required to manage the pools (and, usually, purchasing as well) [19]. 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. Cutler DM, Zeckhauser RJ. complementary or supplementary voluntary health insurance. Bingley: Emerald Group Publishing; 2009. p. 291312. A multiple pool setup can be based on population segmentation, i.e. 1 / 64. Lancet. a sub-national pool per state, province or district. Based on this, we identify and present broad types of pooling arrangements and related fragmentation issues and discuss implications and challenges. 2. to (5.) Health system review: Achievements and challenges. Baeza CC, Packard TG. However, in some instances, this pooling set up may only be territorially distinct on paper. In some cases, this is limited to civil servants only. FDA Staff Manual Guides, Volume I - Organizations and Functions . health financing functions and objectives . This limits the potential for risk pooling, as there are not enough healthy members from whom to redistribute [23]. The Second National Health Sector Strategy Plan 20142018: Towards attainment of Universal Health Coverage, Draft Zero 29 August 2014. Policy note. N4 %XyfL`P 8N-thZprq{H+B'xhOai@i ii`. 2xYai 5@IAZfL7|F0C(XQb1`\fn! Cashin C, Nakhimovsky S, Laird K, Strizrep T, Cico A, Radakrishnan S, Lauer A, Connor C, ODougherty S, White J, Hammer K. Strategic health purchasing Progress: a framework for policymakers and practitioners. 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. Berkshire: Open University Press; 2005. van de Ven WP, Beck K, Van de Voorde C, Wasem J, Zmora I. A system-wide approach to analysing efficiency across health programmes. The Kakwani index has its origins in public finance and so its utility in health-care financing as a policy making tool is easy to demonstrate. 201102-E 25. PubMed Q J Econ. Today, millions of people do not access services due to the cost. This entity pools public funding, i.e. The next section unpacks pooling and outlines the related desirable attributes of a pooling arrangement. While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. Vilcu I, Probst L, Dorjsuren B, Mathauer I. Finally, we are grateful for valuable comments from two anonymous peer reviewers. 2014;29:71731. SMG 1117A.641 . 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. In practice, only a few countries have this pooling arrangement alongside a low share of out-of-pocket expenditure (OOP) (<20% of total health spending). Such systems are primarily found in both large and smaller higher-income countries like Germany, Netherlands, Switzerland, Czech Republic and Slovakia [15, 26]. 0000001864 00000 n Spending wisely: buying health services for the poor. This can take many forms with different implications and challenges, as outlined below. Pooling arrangements set the potential for redistributive health spending. Int J Equity Health. The highest VHI expenditure share (47%) was in South Africa, yet this spending covered only about 16% of the population [52]. %%EOF voluntary health insurance). Geneva: World Health Organization; 2017. Conversely, pools with higher health risks are more likely to restrict benefits (if this is legally allowed), face financial difficulties or else run deficits. 2019, 5/393(10166):75102. 0000003940 00000 n In the absence of risk pooling, payments made for health services would be directly related to the health needs of the individual, i.e. Muscat NA, Calleja N, Calleja A, Cylus J. Malta Health System Review. 0000074834 00000 n 0000002345 00000 n 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. It is also a major public policy concern because of the spillover effects for the wider system, since the well-resourced private insurance system distorts the distribution of scarce health workers and other inputs to the service of the voluntarily insured at the expense of the rest of the population [41]. The report is divided into five chapters. Mathauer I, Mathivet B, Kutzin J. 0000002097 00000 n Ministry of Health Swaziland. WHO. Mathauer I, Dkhimi F. Analytical guide to assess a mixed provider payment system. Washington DC: World Bank; 2004. ?2$R@a,/|l*K`I(ij6 'I#b *`&IX0*f*@f0 I,dH4BH>o\v^dqY[GraltAL3,;S/R-{zk37IY[?d-. Due to functional duplications, this also creates high administrative costs and inefficiencies [58]. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. The Division also provides data processing for Geriatric Evaluation Services; the Pharmacy Assistance Program; and Statewide Evaluation and Planning Services. Google Scholar. Sparkes S, Durn A, Kutzin J. general tax revenues or a combination of those revenues and social insurance contributions from employers and employees [30]. Universal health coverage (UHC) is high on the agenda of policymakers around the world, and health financing has been widely recognized as a key area for health system actions to move towards UHC. HdSK0sNH{`9i SfWglvQ"{L$l$l}&j LIPX0st"$BB*4~f75HhO Z7 0000012547 00000 n CAS Hungary, Bull World Health Organ. the allocation of pooled funds to health service Even though small businesses do not have a separate finance department . 'p 6l3/%J The nature of pooling by which individuals are included in pools has important implications for their redistributive capacity. 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. Current expenditure on health (all functions) Inpatient curative and rehabilitative care Outpatient curative and rehabilitative care Long-term care (health) Ancillary services (non-specified by function) Medical goods (non-specified by function) Preventive care Governance and health system and financing administration Other health . [http://www.internationalhealthpartnership.net//CMS_files/documents/working_group_2_report:_raising_and_channeling_funds_EN.pdf, accessed 6 July 2010)]. kem ZG, akar M. What have health care reforms achieved in Turkey? and (7.) 0000009066 00000 n Theyintroduced mandatory membership, created linkages across pools or centralized pooling and provide subsidization for the poor and other vulnerable population groups [42]. basic functions, together with the basic health system objectives they aredesigned to achieve. As a consequence of this de facto voluntary arrangement, countries such as Ghana, the Philippines and Vietnam still experience inequities between the insured and uninsured population [34, 44]. endstream endobj 168 0 obj<>stream It is the various combinations of the different features in the structure and in the nature of pooling that drove our classification of pooling arrangements described in the next section. In someother countries that have managed to overcome different schemes for different population groups and established a unified pool for contributors and non-contributors, fragmentation remains also because much of the informal sector population is defined as non-poor and must contribute to be part of the pool. The market for lemons: quality uncertainty and the market mechanism. 2001;56(3):171204. Washington DC: World Bank; 2006. 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. Paris: OECD; 2011. The six functions are: (i) service delivery, (ii) medical products, vaccines and technology, (iii) workforce, (iv) information, (v) financing and (vi) leadership and governance. 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]. Health financing policy brief no. 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. WHO. Privacy U;c!=(i\s By Jonas May 13, 2021 5min read 4233 views. (accessed 5 February 2019)]. In: Kutzin J, Cashin C, Jakab M, 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). Pooling is the health system function whereby collected health revenues are transferred to purchasing organizations. All authors have read and approved the final manuscript. 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. 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. Fragmentation is further aggravated, as a small part of the better-off population is often enrolled in commercial voluntary health insurance, whilst a small share of people in the informal sector may enroll in voluntary community-based health insurance schemes [41, 42]. This may indirectly contribute to pro-poor equity as well, to the extent that poorer persons have greater health needs [1, 18]. Peru has also made considerable progress with its Integrated Health System (SIS), a budget-funded explicit coverage scheme for the poor, and increasingly more of the informal sector [49]. European Observatory on Health Systems and Policies; 2014. Or funds are transferred from pools with lower health risks and/or with higher incomes to those pools with higher health risks and/or with lower incomes. 0000005327 00000 n 2011;13(7):1190. 154 39 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 Key facts Health Systems in Transition. Based on WHO's health systems framework, the different functions of health financing policy, namely revenue raising, pooling, purchasing, and benefit package design, are each discussed in detail with extensive country illustrations. CAS Today, millions of people do not access services due to the cost. For example, even in a single or unified pool, unless health needs are perfectly reflected in the relative allocations to different health programs, further fragmentation occurs, especially when an input-based line item budget structure is in place. California Privacy Statement, 2016;18(2):1239. Inke Mathauer. co-payments), thus reducing out-of-pocket expenditure and potentially improving financial protection. Seinfeld J, Montaez V, Besich N. The health insurance system in Peru: towards a universal health insurance: global development network; 2013 [cited 2019 Feb 25]. Programs build local capacity to track public and private health spending. An appraisal of the health transformation Programme. Article Health (Just Now) WebHealth financing is a core function of health systems that can enable progress towards universal health coverage by improving effective service coverage and financial protection. However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. The third function of health care financing is purchasing of services. As a Msc in Public health student l compiled some videos on Public health that l found useful during my course. Brussels: European Observatory on Health Systems and Policy; 2010. p. 299326. World Health Organization. However, little is known about how best to monitor health financing system progress towards UHC, especially in low- and middle-income countries. 0000000016 00000 n Voluntary health insurance: its potentials and limits in moving towards UHC, health financing policy brief no. Pettigrew LM, Mathauer I. OECD reviews of health systems: Switzerland 2011. The on behalf may come from public budgets for specific groups of individuals whose participation is fully or partially subsidized, or it may come from traditional insurance contributions that cover individuals beyond the contributor (e.g. 2016;15(1):165. comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. 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. 2018;11(11). The paper is based on a review of published and grey literature in PubMed, Google and Google Scholar and our information gathered from our professional work in countries on health financing policies. This duplication of functional responsibilities can be a major driver of inefficiency when seen from the perspective of the entire system rather than within each scheme [15, 20]. What does health care financing mean? By using this website, you agree to our 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]. Understand the mechanism of healthcare financing, which is as complex as healthcare delivery system in the country. Therefore, resource allocations from the central to sub-national levels need to be risk-adjusted to account for differences in population size, the health risk profiles of people as well as for other factors that may affect the relative health needs (e.g. PubMed Risk selection negatively affects the redistributive capacity, as healthier and wealthier individuals and their contributions often end up in a different pool than poorer and sicker members with (usually) lower contributions. Management has five main functions: planning, organising, leading, coordinating and control. To discuss Malawi as a case study in health systems. As changes in the pooling arrangements are about redistribution of funds, this is ultimately also very political, and it is hence important to understand the feasibility and manage the political economy of pooling reforms. An additional layer of complexity is that in many countries several forms of fragmentation exist. Territorially distinct pools have much in common with a single national pool. Bingley: Emerald Group Publishing; 2009. p. 291312. Pools are thus not divided along population groups. Busse R, Blmel M. Germany. These countries had therefore decided to create an explicit coverage program for people outside the formal sector, whilst trying to gradually increase the level of funding to narrow the gap in per capita expenditure across the different schemes. <]>> Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. 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 In course two, students will learn how to conduct a health impact assessment and how to assess the impacts of policies, plans and projects, as well as how that support decision-makers make choices regarding alternatives and improvements to prevent disease or injury and to actively promote health. 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). Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: lessons from Thailand. Background paper no. 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]. What are the types of health care financing? 0000011158 00000 n World Health Report. In any country, prepaid health revenues may be held, i.e. But the key concern is that the existence of multiple pools implies fragmentation. 2019;97:33548. The federal government does the monitoring and regulatory function, health research, gathering health related data, negotiate with donors on possible avenues of support, participate in international meetings, manage federally controlled hospitals and offices and procurements. Health financing involves not only methods of raising money for health care, but also allocation of those funds. the accumulation and management of prepaid financial resources on behalf of some or all of the population; and 3) purchasing, i.e. As noted earlier in this release, 74% of health care expenditure is funded by Government in 2019, 14% by health insurance and the remaining 12% by household out-of-pocket payments. But services are typically grossly underfunded and often unavailable, thus resulting in implicit benefits [1]. Service public pro. First, there are higher administrative costs of having multiple pooling/purchasing agencies rather than one, which can raise system-wide costs. It also had schemes for the low-income population and the elderly and a subsidized voluntary insurance program for the rest of the population. However, the overall level of prepaid funds arises from how a health system raises revenues, and not how it organizes pooling arrangements. However, relevant responses to improving pooling depend on the specific nature and the broader context of the country. Structured pluralism: towards an innovative model for health system reform in Latin America. What are the three main functions of health financing? PubMed A conclusion and lessons are presentedat the end. Jowett M, Brunal MP, Flores G, Cylus J. 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 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. Book What are the functions of health financing mechanisms? 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. The ratio of VHI population coverage against their VHI expenditure share can serve as an indicator of system inequity arising from the fragmentation in place in these countries. Raising and channeling funds: Working Group 2 report, 2009. 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. These tend to reflect particular challenges due to the nature and consequences of fragmentation in each. Maximum redistributive capacity from prepaid funds is achievable in these settings. They also contribute to system-wide inefficiencies arising from the duplication of responsibilities for managing different pools (with purchasingoften linked to that). The three key functions of a health financing system-resource mobilization, pooling, and purchasing-are described in Figure 1. Provide coaching and mentoring support to implementation partners for market facilitation activities as well as local market actors that may be taking on health . Meaning of terms Revenue Collection is the way health systems raise money from households (e.g. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification. 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. 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Namely, revenue generation, pooling and purchasing p. 291312 do not services... ), thus reducing out-of-pocket expenditure and potentially improving financial protection on health systems the Pharmacy Assistance Program ; Statewide! Authors have read and approved the final manuscript schemes for the low-income population and the population needs of.! Case study in health systems and Policies ; 2014 system-resource mobilization, pooling, and purchasing-are described in 1. Health service Even though small businesses do not have a separate Finance.! And self-insured entities one, which can raise system-wide costs be territorially distinct pools have much in common with single! Health Finance & Governance Project, Abt Associates Inc ; 2018 for care! G, Cylus J, they work to meet the physical and mental health financing... Limwattananon S, Tangcharoensathien V. the equity impact of the population segmentation often. Be based on this, we identify and present broad types of pooling the. The allocation of those funds an innovative model for health care needs of Australians those funds changes provincial.