To cite variations across countries of different income levels. The Division also provides data processing for Geriatric Evaluation Services; the Pharmacy Assistance Program; and Statewide Evaluation and Planning Services. endstream endobj startxref We distinguish two key institutional design aspects of pooling arrangements, drawing upon Kutzins health financing framework (2001) [11] and the World Health Report 2010 [1]. As you can see, out-of-pocket or fee-for-service, government budget, or insurance agencies are all means of purchasing health care from providers. 2019, 5/393(10166):75102. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification. Voluntary health insurance (VHI) with a primary coverage role is usually offered by multiple insurers competing for clients. Promote sustainability of health financing project activities with effective networking, linkages to other programs, and capacity building of NIPs on health financing activities. The finance department functions like bookkeeping, budgeting, forecasting, and management of taxes, and the finance manager functions like financial report preparations contribute to the overall financial wellbeing of an entity. Although this pooling arrangement does not fully overcome fragmentation and population segmentation, it substantially reduces it. are deemed to be particularly problematic forms of fragmentation, because they strongly constrain redistributive capacity. The company has multiple offices in the U.S. and program offices in more than 40 countries. Higher income persons are usually more likely to have this form of VHI [51]. The report is divided into five chapters. Instead, they usually follow a countrys territorial structure, i.e. Smith PC, Witter SN. 0000012547 00000 n Moreover, in Indonesia, there is substantial reliance on supply-side budgets [37] as is the case for Mongolia for example [34]. Such a pool provides compulsory or automatic coverage for the entire population, usually for a defined package of services. Kutzin J. Function. Kutzin J, Jakab M, Shishkin S. From scheme to system: social health insurance funds and the transformation of health financing in Kyrgyzstan and Moldova. Int J Equity Health. Today, millions of 0000003940 00000 n Privacy Results The Kenyan health sector relies heavily on out-of-pocket payments. 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. 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. 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]. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. 0000002097 00000 n 0000002300 00000 n 1 below. Int J Equity Health. ?2$R@a,/|l*K`I(ij6 'I#b *`&IX0*f*@f0 I,dH4BH>o\v^dqY[GraltAL3,;S/R-{zk37IY[?d-. 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. All authors have read and approved the final manuscript. The three roles of health managers are interpersonal, informational and decisional. This chapter provides background on demographic and epidemiological trends, the configuration of Ghana's health system, and health financing functions and health systems goals. This mitigates some of the effects of segmentation, though remains often incomplete due to the entrenched power of the initially insured population groups. Library of Parliamentarians: Ottawa; 2011. U;c!=(i\s Pools are thus not divided along population groups. Inke Mathauer. Such an unequal distribution of resources is frequently found, in that available system resources are strongly skewed to those using VHI as their primary coverage. But services are typically grossly underfunded and often unavailable, thus resulting in implicit benefits [1]. Objective Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. Revenue collection is how health systems raise money from households, businesses, and external sources. The next section unpacks pooling and outlines the related desirable attributes of a pooling arrangement. Pools can be based on compulsory, automaticor voluntary participation. Health financing systems have a key role in achieving universal health coverage (UHC) across the globe. PubMed Intermediate UHC objectives include equity in the distribution of resources and efficiency in their overall use [17]. The three key functions of a health financing system-resource mobilization, pooling, and purchasing-are described in Figure 1. 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. Health financing is central to the functioning of health systems and the attainment of health-related sustainable development goals, including universal health coverage (UHC). Sagan A, Thomson S. Voluntary health insurance in Europe: role and regulation. What are the four major services and healthcare? However, the overall level of prepaid funds arises from how a health system raises revenues, and not how it organizes pooling arrangements. Geneva: World Health Organization; 2019. Cutler DM, Zeckhauser RJ. 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 ]. Health care administration professionals develop payment plans for patients, negotiate contracts with providers, draft policies, and ensure overall compliance. Health Policy. 2019;97:33548. 0000005327 00000 n It is important to mention that supply side financing, where the health budget flows in a vertically integrated way to service providers, constitutes a pool, and in many cases is often the largest pool in low- and middle-income countries. OECD, World Health Organization. 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. Lancet. Pooling arrangements influence not only risk pooling (and via this pathway, financial protection and equity in service use), but also the intermediate UHC objectives of efficiency and equity in the distribution of a health systems resources. Pooling is the health system function whereby collected health revenues are transferred to purchasing organizations. 2. 0000008860 00000 n The level of per capita funding of the UCS has converged with that for the private sector employees scheme, but the civil servants still benefit from much higher levels of spending [45, 46]. 0000007449 00000 n #mHGilaa^{'D. 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 Geneva: World Health Organization; 2008. This is the so-called death spiral of voluntary health insurance [24]. general tax revenues or a combination of those revenues and social insurance contributions from employers and employees [30]. Download and easily browse by indicator:Health Financing Indicators Reference Sheets It is the provision of money to the population for health services (preventive as well as curative), family planning activities, nutrition activities, and emergency aid designated for health. Geneva: World Health Organization; 2010. K]NiGe(T&k,JTNeu@#KWB&@XxDXw-2^ctyc9d"E@yk3'1V-o PKW em2VK: complementary or supplementary voluntary health insurance. Systems relying on territorially distinct pools are usually a product of a wider political context of federalism or devolution. Book Policy note. 154 39 As such, automatic entitlement is typically solely funded from general budget revenues. 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]. We also like to thank Lisa Seidelmann, Carlo Schmid Fellow and volunteer with the Department of Health Systems Governance and Financing at the time of producing this draft for her research assistance. Article 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. 0000006049 00000 n Wahshginton DC: World Bank; 2005. The complex structure of Australia's . Overview 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 . In Switzerland, this insurance system is further territorially divided up, in that the multiple pools operate within each sub-national unit [50]. The Second National Health Sector Strategy Plan 20142018: Towards attainment of Universal Health Coverage, Draft Zero 29 August 2014. The Health Financing Specialist will be based in the Abt office in Antananarivo. 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. From these two institutional design aspects, we need to distinguish the level of prepaid funding, which is not considered in this classification. Yet, the function of pooling and the different ways that countries organize this is critical for countries progress towards UHC. hb```c, 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]. The relative reliance of the health system on the aggregate level of prepaid funds versus out-of-pocket payments (OOP) is an important driver to achieve the UHC goals. We propose eight broad types of pooling arrangements: (1.) Overview Health Financing Human Resources for Health Leadership and Governance for Health. However, evidence for efficiency improvement with increased market competition among purchasers is weak [25]. In turn, this can help countries assess their pooling arrangements and contribute to identifying policy options to address fragmentation or mitigate its consequences. Innovations in Health System Finance in Developing and Transitional Economies. Health nutrition and population discussion paper. The explicit nature of the coverage schemes puts greater focus on the equally explicit inequities in the levels of public funding per capita for the formal and informal sector populations. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Terms and Conditions, 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. Improved equity in service use and financial protection involve expanding risk pooling, and as such pooling is a policy objective in itself. territorially distinct pools; (3.) 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. We help governments and development partners achieve their public health goals by ensuring adequate, efficient, and appropriately targeted health sector financing How a health system is financed has a big impact on how people access health services, how much they pay for their care, which services are provided, and how well they are provided. An appraisal of the health transformation Programme. It is found in several low- and middle-income countries that have started to introduce social health insurance for formal sector employees only, such as El Salvador, Guatemala, Togo and Cape Verde. 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. There are two forms of institutional setup found for this pooling arrangement. RAND research explores the effects of corporate and government health care financing policies on such groups as patients, businesses, hospitals, and physician-providers. In the absence of risk pooling, payments made for health services would be directly related to the health needs of the individual, i.e. 787 0 obj <> endobj 1 / 64. Only a few publications [1, 11,12,13,14,15,16] provide conceptual insights into the structure of and mechanisms for pooling arrangements. 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. Click the card to flip . 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. is the health system function whereby collected health revenues are transferred to purchasing organizations. there must be a specific contribution made by or on behalf of the covered person. 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. Multiple forms of fragmentation co-exist, and dimensions other than pooling also result in fragmentation. Article The third function of health care financing is purchasing of services. For example, in France and Slovenia, 90 and 84% respectively of the population have complementary VHI coverage, and premiums for complementary VHI are subsidized for low-income households. comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. different pools for different population groups, with explicit coverage for all; (6.) 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. Each of the insurance schemes thus constitutes a separate pooling agency. 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. As the name suggests, it exists in addition to and along the other main pooling arrangements, as outlined above. It serves multiple purposes, e.g. Heal Policy Plan. In: Kutzin J, Cashin C, Jakab M, editors. In many countries, different pools exist for different socio-economic groups, creating a highly fragmented system with population segmentation. WHO Regional Office for Europe: Copenhagen; 2016. Geneva: World Health Organization; 2017. 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. -U+:V\GCs2C /L7w0X-O`>2h?! voluntary contributions from beneficiaries, are prone to adverse selection: people with higher risks are more likely to enroll than people with lower health risks. IM is a senior health financing specialist; JK is the coordinator of the Health Financing Team, they both work in the Department of Health Systems Governance and Financing at the World Health Organization in Geneva. Such a pool setup creates immense scope for inequity, as it allows for enormous differences in available resources per capita across pools. 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. Programs to improve health financing work at multiple levels to strengthen all three functions in both the public and private health sectors. It also describes Ghana's health financing system. Its main purpose is to share the financial risk associated with health . Int J Equity Health. 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. 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). Taskforce on Innovative International Financing for Health Systems. fragmented systems with voluntary health insurance, duplicating publicly financed coverage; and (8.) (Accessed on 25 February 2018)]. But in contrast to having just one pool, residents of a particular region of the country are served by a regional pool, i.e. Implementing health financing reform: lessons from countries in transition. Here the pooling function lies with a sub-national entity, such as a state, province, or district (if managed by a level of public administration) or another entity, such as a health insurance fund, with defined responsibility for the entire population of that territory [14]. Klasa K, Greer S, van Ginneken E. Strategic purchasing in practice: comparing ten European countries. 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]. https://doi.org/10.1093/heapol/czt054. a single pool; (2.) Three key health financing system functions Resource Mobilization: Countries need to consider three issues: What are the sources of funding for health? It maintains and operates the Medicaid Management Information System (MMIS), an automated claims processing and information retrieval system mandated by the federal government. WHO. 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. Berkshire: Open University Press; 2005. van de Ven WP, Beck K, Van de Voorde C, Wasem J, Zmora I. 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. 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. Rather it is a first attempt at a classification, which could encourage further useful work from others. Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: lessons from Thailand. 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 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. Table1 outlines the respective features under each. the mobilization of resources for the health sector; 2) pooling, i.e. Discussion paper. Healthcare organizations must be able to minimize costs in order to be financially successful. Compulsory participation refers to the legal requirement that someone be included for coverage and goes hand-in-hand with contributory-based entitlement, i.e. 1997;41:136. population density). 0000005125 00000 n Risk adjustment and risk selection in Europe: 6 years later. While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. 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]. Health financing involves the basic functions of revenue collection, pooling of resources, and purchase of interventions. SMG 1117A.641 . However, there are some examples from larger or very large countries, such as Hungary [35] and Turkey [36]. different pools for different socio-economic groups with population segmentation; (5.) Comprehensive policy analysis for health system reform. The function of pooling and the ways that countries organize this is critical for countries progress towards universal health coverage, but its potential as a policy instrument has not received much attention. OECD reviews of health systems: Switzerland 2011. Thus, the proposed classification is not a substitute for detailed country-specific analysis of pooling arrangements. 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. PLoS ONE. 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 Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. 1.2.1. territorially overlapping pools in terms of service and population coverage; (4.) A single pool maximizes the potential for risk pooling across the whole population. Where service provision is integrated with pooling and purchasing within each government level, the different (horizontally organized) pools overlap and effectively serve the same population. Department of Health and Human Services But a system with territorially distinct pools can suffer from fragmentation, if and when their population size or the territory are too small to ensure redistributive capacity, or when sub-national territories have very different levels of average per capita expenditure on health. This can take many forms with different implications and challenges, as outlined below. By Jonas May 13, 2021 5min read 4233 views. mobilization, accumulation and allocation of money to cover the health needs of the people, individually and collectively, in the health system. Structured pluralism: towards an innovative model for health system reform in Latin America. However, in some instances, this pooling set up may only be territorially distinct on paper. Health financing sub-functions Revenue generation: As shown in Figure 1, funds for health financing are generated majorly by government (57%), about Springer Nature. Geneva: World Health Organization; 2016. Popovich L, Potapchik E, Shishkin S, Richardson E, Vacroux A, Mathivet B. Russian Federation: health system review. lessons learned and policy implications are outlined below across each of the health financing functions with linkages to intermediate objectives of efficiency, equity . Agency's Mandate and Functions Mandate. [3] Health financing is a key function of the health care system, and is a complex issue. 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. 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. the allocation of pooled funds to health service providers [1]. Health financing policies are marked by confusion between policy tools and policy objectives, especially in low and middle income countries. Among the eight types of pooling arrangements, types (3.) Health (9 days ago) WebThe three key functions of a health financing system-resource mobilization, pooling, and purchasing-are described in Figure 1. Examples usually come from countries with small populations, including high-income countries such as Malta [27] and lower middle-income countries such as Swaziland [28]. Today, millions of people do not access services due to the cost. Collectively, they work to meet the physical and mental health care needs of Australians. 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). As such, the overall risk profile of the pool is much more financially sustainable than under voluntary enrollment. Programs build local capacity to track public and private health spending. Health financing policy brief no. 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. 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. Kutzin J, Yip W, Cashin C. Alternative financing strategies for universal health coverage. Smith PC. A territorially distinct pool serves the people living in that territory [11]. 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. 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. 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. Health Spending as % of GDP. ), (7.) 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. , in the distribution of resources and efficiency in their overall use 17... Ways that countries organize this is the so-called death spiral of voluntary functions of health financing,. Comparing ten European countries income levels [ 11 ] identifying policy options to address fragmentation or mitigate its.. In implicit benefits [ 1, 11,12,13,14,15,16 ] provide conceptual insights into the structure of Australia & # ;... Of institutional setup found for this pooling arrangement their pooling arrangements, Zero. 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