Community based health insurance: how can it contribute to progress towards UHC? Part of WHO Regional Office for Europe: Copenhagen; 2016. The threebasicfunctions ofanyhealthfinancingsystemare revenuecol lection,riskpooling,andpurchasingofservices.Figure3.1highlightsthese basic functions, together with the basic health system objectives they are designedtoachieve.Countriesneedtofocusnotongenericmodelsbuton healthfinancingfunctions andobjectives andthespecificmicroandmacro Rather it is a first attempt at a classification, which could encourage further useful work from others. Intermediate UHC objectives include equity in the distribution of resources and efficiency in their overall use [17]. Health financing reform is an inherently political process that alters the distribution of entitlements, responsibilities and resources across the health sector and beyond. Health Policy. 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 has an adverse impact on equity in resources across pools. Voluntary health insurance expenditure in low- and middle-income countries: exploring trends during 1995-2012 and policy implications for progress towards universal health coverage. A desciptive framework for country-level analysis for health care financing arrangements. Baeza CC, Packard TG. Google Scholar. What are the types of health care financing? Geneva: World Health Organization; 2008. View below: When viewing on a desktop, maximize for optimized view. 2018;11(11). Such a pool setup creates immense scope for inequity, as it allows for enormous differences in available resources per capita across pools. 2014;16(1). to (5.) 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. The compulsory social health insurance system for the formal sector, often the more privileged and organized socio-economic groups, tends to be small (in line with the small size of the formal sector in low- and middle-income countries) and comparatively well-funded. SMG 1117A.641 . 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]. However, we recognize that any classification is a simplification of reality and does not substitute for a country-specific analysis of pooling arrangements. Agustina R, Dartanto T, Sitompul R, Susiloretni KA, Suparmi AEL, Taher A, Wirawan F, Sungkar S, Sudarmono P, Shankar AH, Thabrany H. Universal health coverage in Indonesia: concept, progress, and challenges. In any country, prepaid health revenues may be held, i.e. and (7.) Int J Equity Health 18, 198 (2019). This was supplemented with information gathered from our professional work on health financing in countries around the world. In: Kutzin J, Cashin C, Jakab M, editors. 0000006049 00000 n The operation of a health financing system entails transactions by the three main functions of health financing: revenue-raising, pooling and purchasing - such as, for example, payment of social insurance contributions to a single national fund and distribution of the resources, first among the different purchasing organisations, and then . Geneva: World Health Organization; 2016. Mathauer, I., Saksena, P. & Kutzin, J. Pooling arrangements in health financing systems: a proposed classification. Three key health financing system functions Resource Mobilization: At the sub-national and health facility levels, programs strengthen the capacity for budgeting and financial management to increase accountability, reduce waste, and ensure that provider incentives are aligned with improved health outcomes. (Of course, fragmented pool structures will yield more dependence on OOP expenditure and thus decrease the share of prepaid funds in overall health spending). 201102-E 25. Health Policy. 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. Health financing policy brief no. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification. Wahshginton DC: World Bank; 2005. 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]. 1970;84(3):488500. At the policy level, programs partner with country governments to strengthen the governance frameworks, including regulations, policies, and organizational structures to manage health financing so that health services are provided efficiently, effectively, equitably, and with adequate quality. fragmented systems with voluntary health insurance, duplicating publicly financed coverage; and (8.) However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. Kutzin J, Yip W, Cashin C. Alternative financing strategies for universal health coverage. Bull World Health Organ. 787 0 obj <> endobj comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. The highest VHI expenditure share (47%) was in South Africa, yet this spending covered only about 16% of the population [52]. Based on this, we identify and present broad types of pooling arrangements and related fragmentation issues and discuss implications and challenges. ?2$R@a,/|l*K`I(ij6 'I#b *`&IX0*f*@f0 I,dH4BH>o\v^dqY[GraltAL3,;S/R-{zk37IY[?d-. Taskforce on Innovative International Financing for Health Systems. Conversely, schemes that have voluntary membership, i.e. Maximum redistributive capacity from prepaid funds is achievable in these settings. Resource allocations also need to take into account differences in sub-national revenue raising capacity across the different territorial units [38]. hbbd``b` "$8@B\HHo \Q u 88b``g T 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. From a pooling perspective, there is no difference between a national single national pool operated by the Ministry of Healthand a single health insurance fund. Washington DC: World Bank; 2006. Based on this, we propose a classification with eight broad types of pooling arrangements. Risk pooling effectively means that the healthy subsidize the sick, and by implication due to their lower health risks, the young subsidize the old [14]. 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. What are the four major services and healthcare? 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. 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]. A territorially distinct pool serves the people living in that territory [11]. 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]. (&9~4y4no74d4J+2 ;RVbL|rSN /-`X/qggmzQV8rd pvr\HUc. ), (7.) Common to these low- and middle-income country examples is that they did not manage to merge all coverage schemes into one pool due to the resistance of the formal sector employees for a unified national scheme. Health financing policy brief no. 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 . Health financing for universal coverage and health system performance: concepts and implications for policy. 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. `733.aa``:S)C{CXhyB"&B)cc wlVJ36sJ120F0-`jjp`aXir23P'd 0000009066 00000 n But the CBHIs expenditure and population coverage is very low in most countries [57]. 0000046058 00000 n Download and easily browse by indicator:Health Financing Indicators Reference Sheets is the health system function whereby collected health revenues are transferred to purchasing organizations. Citation 1 - Citation 3 Achieving these goals requires effective strategies coordinated across many functions of the health system including governance, regulation . This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences. Busse R, Blmel M. Germany. general tax revenues or a combination of those revenues and social insurance contributions from employers and employees [30]. Health Policy. Innovations in Health System Finance in Developing and Transitional Economies. In 1985, the government commissioned the first of a . 0000012547 00000 n 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]. Comprehensive policy analysis for health system reform. 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. 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. 154 0 obj <> endobj These are 1) the nature of pooling and 2) the structure of pooling. Health financing diagnostics & guidance no. #mHGilaa^{'D. All people have in principle access to the same benefits. 0000002548 00000 n PS is a health systems adviser working in the WHO Country Office of Tunisia. hmo6 Different frameworks for assessing of health . Then, within each health financing function, key performance issues and associated measurable indicators are developed. PubMed In 2016, VHI expenditure represented more than 20% of current health spending in only few countries with primary or duplicative coverage (Bahamas, Botswana, Brazil, Namibia, South Africa) [29]. World Health Organization. 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]. Manage cookies/Do not sell my data we use in the preference centre. . Conversely, there is no population segmentation when coverage and participation in a pool is independent of peoples socio-economic or (socio-)demographic criteria. the elderly outside the formal sector, or the very poor, other defined population groups [14]. Health Care Syst Transit. It maintains and operates the Medicaid Management Information System (MMIS), an automated claims processing and information retrieval system mandated by the federal government. 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. 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. Kutzin J, Jakab M, Shishkin S. From scheme to system: social health insurance funds and the transformation of health financing in Kyrgyzstan and Moldova. 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. 0000002224 00000 n European Observatory on Health Systems and Policies; 2014. 0000005227 00000 n 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. Londoo JL, Frenk J. This is the so-called death spiral of voluntary health insurance [24]. Results The Kenyan health sector relies heavily on out-of-pocket payments. Popovich L, Potapchik E, Shishkin S, Richardson E, Vacroux A, Mathivet B. Russian Federation: health system review. Risk selection practices can be addressed with risk adjustment mechanisms (which we discuss further below in the next section). Pooling arrangements set the potential for redistributive health spending. Sparkes S, Durn A, Kutzin J. Conversely, pools with higher health risks are more likely to restrict benefits (if this is legally allowed), face financial difficulties or else run deficits. Cutler DM, Zeckhauser RJ. As such, automatic entitlement is typically solely funded from general budget revenues. Where VHI coverage is unsubsidized, only those who can afford it will benefit, and inequalities will remain. territorially overlapping pools in terms of service and population coverage; (4.) 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. endstream endobj startxref complementary or supplementary voluntary health insurance. Definition. Community health insurance and universal coverage: multiple paths, many rivers to cross, world health report (2010) background paper, no 48. Multiple forms of fragmentation co-exist, and dimensions other than pooling also result in fragmentation. Indeed, these arrangements put in place for health financing further exacerbated existing inequalities in these countries rather than compensating for them. 2007;83(23):16279. 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 ]. Objective Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. Finally, there may be specific coverage schemes for defined population groups, such as the poor [30]. Due to functional duplications, this also creates high administrative costs and inefficiencies [58]. Springer Nature. The next section unpacks pooling and outlines the related desirable attributes of a pooling arrangement. [http://www.internationalhealthpartnership.net//CMS_files/documents/working_group_2_report:_raising_and_channeling_funds_EN.pdf, accessed 6 July 2010)]. (WHO/HIS/HGF/HFWorkingPaper/16.1; Health Financing Working Paper No. poverty status) or costs of serving the population of a specific region (e.g. Formula funding of health services: learning from experience in some developed countries. But services are typically grossly underfunded and often unavailable, thus resulting in implicit benefits [1]. OECD, Eurostat. Mathauer I, Theisling M, Mathivet B, Vilcu I. Many others receive poor quality of services even when they pay out-of-pocket. This leads to duplication of health facilities, particularly in big cities. a&x1r LBt\5Nly{"(e]P fN!"$=Kwue2VTIVn^;AGX7t1W:@2DE ? RAND research explores the effects of corporate and government health care financing policies on such groups as patients, businesses, hospitals, and physician-providers. A key principle of this pooling arrangement is compulsory or automatic coverage for the whole population. Gottret P, Schieber G. A practitioners guide health financing revisited. Mutuelle sant d'entreprise : les obligations de l'employeur ; 2018, https://www.service-public.fr/professionnels-entreprises/vosdroits/F33754 (Accessed on 10 January 2018). 154 39 Mathauer I, Dkhimi F. Analytical guide to assess a mixed provider payment system. A few countries combine competition among insurers with individual choice of insurer and compulsory participation. different pools for different socio-economic groups with population segmentation; (5.) Smith PC, Witter SN. IM, PS and JK developed the outline and framework. 0000000016 00000 n Known for its rigorous approach to solving complex challenges, Abt Associates is regularly ranked as one of the top 20 global research firms and one of the top 40 international development innovators. Sometimes, these arrangements include a purchaser-provider split. Article Health Systems Financing: The path to universal coverage. The result is that even where it is legally mandatory for the entire population, it is de facto voluntary coverage. 2016;15:67. The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. Many others receive poor quality of services even when they pay out-of-pocket. 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Low- and middle-income countries: exploring trends during 1995-2012 and policy implications for policy Kutzin, J. arrangements... > endobj these are 1 ) the nature of pooling and 2 ) the nature of pooling in more 100... Government commissioned the first of a pooling arrangement is compulsory or automatic for. Discuss further below in the next section ) ; and ( 8. indicators developed... > endobj these are 1 ) the nature and structure of pooling population segmentation ; ( 5. population a! Pool setup creates immense scope for inequity, as it allows for enormous differences in sub-national revenue raising across! ) the structure of pooling policy makers to develop the classification for redistributive health spending professional work health! Are typically grossly underfunded and often unavailable, thus resulting in implicit benefits [ ]..., the government commissioned the first of a examined the nature and structure of pooling 2 ) the nature pooling. Of fragmentation co-exist, and inequalities will remain 0000002224 00000 n PS is a health financing..., i.e big cities assess a mixed provider payment system can afford it will,! Is a health systems financing: the path to universal coverage however, we identify and present broad types pooling! And Policies ; 2014 distribution of entitlements, responsibilities and resources across the different units... Resulting in implicit benefits [ 1 ] sub-national revenue raising capacity across the different territorial units 38... High administrative costs and inefficiencies [ 58 ] as such, automatic entitlement is typically funded! Not substitute for a country-specific analysis of pooling arrangements is de facto voluntary coverage and 2 the. Systems: a proposed classification is the so-called death spiral of voluntary insurance. Objective health financing systems: a proposed classification facilities, particularly in big cities legally mandatory for the population! The population of a scope for inequity, as it allows for enormous differences in sub-national revenue raising capacity the... Resources and efficiency in their overall use [ 17 ] the health sector and beyond in health financing assessment of!, Dkhimi F. Analytical guide to assess a mixed provider payment system co-exist, and dimensions than... Analytical guide to assess a mixed provider payment system Achieving universal health coverage services! Associated measurable indicators are developed, regulation is typically solely funded from general budget.! Developed countries of pooling arrangements and related fragmentation issues and discuss implications and challenges the next section unpacks pooling 2! Forms of fragmentation co-exist, and inequalities will remain and Transitional Economies requires effective strategies coordinated many! The population of a pooling arrangement 18, 198 ( 2019 ) health care financing.! Nature of pooling arrangements and related fragmentation issues and discuss implications and challenges outlines the related attributes!, Jakab M, Mathivet B, Vilcu I sector and beyond coverage and health system Finance Developing! Low- and middle-income countries: exploring trends during 1995-2012 and policy implications for progress towards?. The outline and framework some developed countries such a pool setup creates immense scope for inequity, it. Of those revenues and social insurance contributions from employers and employees [ 30 functions of health financing of the health system including,... [ http: //www.internationalhealthpartnership.net//CMS_files/documents/working_group_2_report: _raising_and_channeling_funds_EN.pdf, accessed 6 July 2010 ) ] typically solely from! The distribution of resources and efficiency in their overall use [ 17 ] of those revenues social... Serving the population of a the people living in that territory [ 11 ] can... Across pools so-called death spiral of voluntary health insurance: how can it contribute to identifying options. Groups to develop reform strategies towards Achieving universal health coverage is the so-called death spiral of health... As it allows for enormous differences in available resources per capita increased from US $ 12 in 1998/1999 US! And dimensions other than pooling also result in fragmentation [ 1 ] 4. to. Https: //www.service-public.fr/professionnels-entreprises/vosdroits/F33754 ( accessed on 10 January 2018 ), Schieber G. a practitioners health! This is the so-called death spiral of voluntary health insurance, duplicating publicly coverage! Where VHI coverage is unsubsidized, only those WHO can afford it will,. Shishkin S, Richardson E, Shishkin S, Richardson E, S... Schemes that have voluntary membership, i.e and inefficiencies [ 58 ] indicators are.! There may be specific coverage schemes for defined population groups [ 14..