Correspondence to Bonilla-Chacn ME, Aguilera N. The Mexican Social Protection System in Health [Universal Health Coverage Studies Series (UNICO) No. ?2$R@a,/|l*K`I(ij6 'I#b *`&IX0*f*@f0 I,dH4BH>o\v^dqY[GraltAL3,;S/R-{zk37IY[?d-. Mathauer I, Behrendt T. State budget transfers to health insurance to expand coverage to people outside formal sector work in Latin America. Popovich L, Potapchik E, Shishkin S, Richardson E, Vacroux A, Mathivet B. Russian Federation: health system review. In doing so, policy makers can come closer . 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. are deemed to be particularly problematic forms of fragmentation, because they strongly constrain redistributive capacity. 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. World Health Report 2010 Technical Brief Series - Technical Brief No. co-payments), thus reducing out-of-pocket expenditure and potentially improving financial protection. Council for Medical Schemes (CMS). Preker A, Langenbrunner J. the allocation of pooled funds to health service providers [1]. Improved equity in service use and financial protection involve expanding risk pooling, and as such pooling is a policy objective in itself. From a system perspective, this pooling arrangement has major disadvantages with regards to redistributive capacity. and (7.) A system-wide approach to analysing efficiency across health programmes. 1 / 64. Heal Policy Plan. 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]. 0000005327 00000 n 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. 1970;84(3):488500. the accumulation and management of prepaid financial resources on behalf of some or all of the population; and 3) purchasing, i.e. Finally, it is important to keep in mind that while pooling reforms are needed to enhance redistributive capacity, realizing the gains set by the potential of a pooling arrangement requires more than pooling. International Journal for Equity in Health 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. hmo6 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. 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. the mobilization of resources for the health sector; 2) pooling, i.e. 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. From these two institutional design aspects, we need to distinguish the level of prepaid funding, which is not considered in this classification. 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. a single pool; (2.) 0000014440 00000 n 2019, 5/393(10166):75102. While the issue of segmentation first emerged in Latin America [43], it is not limited to that region. Where VHI coverage is unsubsidized, only those who can afford it will benefit, and inequalities will remain. taxes, user fees, private health insurance), business (e . Conversely, schemes that have voluntary membership, i.e. &E ^3d``}'|W>(G6062q0K x48XiFf uH30~z*F% L{ Alternatively, in a non-competitive arrangement, people could be assigned to specific pools, with enrollment being based on explicit criteria, so that the different pools cannot compete for beneficiaries [11]. The attributes of a countrys pooling arrangements that have positive implications for UHC goals are in many ways the opposite of what is implied by fragmentation. 2016;18(2):1239. 0000064650 00000 n First, there are higher administrative costs of having multiple pooling/purchasing agencies rather than one, which can raise system-wide costs. Thus, the proposed classification is not a substitute for detailed country-specific analysis of pooling arrangements. To cite variations across countries of different income levels. different pools for different socio-economic groups with population segmentation; (5.) Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: lessons from Thailand. VHI with a complementary or supplementary role exists in most countries [53, 54]. Figure 3.1 highlights these. A few countries combine competition among insurers with individual choice of insurer and compulsory participation. 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. 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. The final goals of UHC are equity in service use, quality, and financial protection. To understand the components of a health system. %%EOF Adverse Selection in Health Insurance. However, there are some examples from larger or very large countries, such as Hungary [35] and Turkey [36]. 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. 0000010246 00000 n 0000079931 00000 n It also describes Ghana's health financing system. Article Geneva: World Health Organization; 2017. Spending targets for health: no magic number. 154 0 obj <> endobj 2S?dI9c{rP"=-Gsi1NU@ 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. 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 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. Raising and channeling funds: Working Group 2 report, 2009. Health Policy. Article World Health Organization. Health Policy. Table1 outlines the respective features under each. However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. Results The Kenyan health sector relies heavily on out-of-pocket payments. However, in some instances, this pooling set up may only be territorially distinct on paper. 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]. Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. The Netherlands: health system review. 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. Berkshire: Open University Press; 2005. van de Ven WP, Beck K, Van de Voorde C, Wasem J, Zmora I. 'p 6l3/%J In: Kutzin J, Cashin C, Jakab M, editors. Based on this, we identify and present broad types of pooling arrangements and related fragmentation issues and discuss implications and challenges. In the absence of risk pooling, payments made for health services would be directly related to the health needs of the individual, i.e. 0000080023 00000 n 3. Geneva: World Health Organization; 2016. A key principle of this pooling arrangement is compulsory or automatic coverage for the whole population. a sub-national pool per state, province or district. A single pool maximizes the potential for risk pooling across the whole population. Mathauer I, Dale E, Meessen B. When coverage is compulsory or automatic for all population groups, the pool(s) have a more diverse mix of health risks. Promoting strategic purchasing Making the purchasing of health services more strategic is critical for countries to progress towards universal health coverage. 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. They also need to monitor cash on hand, businesses may be profitable but have a shortage of cash and. Geneva: World Health Organization; 2017. Health Spending as % of GDP. In contrast, voluntary participation means that an individual or firm makes a voluntary pre-payment and enrolls on a voluntary basis in a health coverage scheme (i.e. Only a few publications [1, 11,12,13,14,15,16] provide conceptual insights into the structure of and mechanisms for pooling arrangements. Health financing policies are marked by confusion between policy tools and policy objectives, especially in low and middle income countries. 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). 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. It also had schemes for the low-income population and the elderly and a subsidized voluntary insurance program for the rest of the population. 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. Community based health insurance: how can it contribute to progress towards UHC? Such systems are primarily found in both large and smaller higher-income countries like Germany, Netherlands, Switzerland, Czech Republic and Slovakia [15, 26]. Health financing diagnostics & guidance no. K]NiGe(T&k,JTNeu@#KWB&@XxDXw-2^ctyc9d"E@yk3'1V-o PKW em2VK: 0000035307 00000 n 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]. mobilization, accumulation and allocation of money to cover the health needs of the people, individually and collectively, in the health system. Health Care Syst Transit. For illustration we provide various country examples. 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. 2016;15:67. 0000009066 00000 n PubMed <]>> Another function of finance in business is the creation of long-term strategies. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. (accessed 5 February 2019)]. family members). 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]. Complementary insurance for health services covers benefits that are excluded from the public systems package, thereby giving access to a wider range of benefits. 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]. Google Scholar. 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. a&x1r LBt\5Nly{"(e]P fN!"$=Kwue2VTIVn^;AGX7t1W:@2DE ? European Observatory on Health Systems and Policies; 2014. To develop a health financing structure capable of addressing the challengesof the future. 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. While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. Health financing: the basics FP Financing Roadmap. Hatfield (South Africa): CMS; 2016. Health financing involves not only methods of raising money for health care, but also allocation of those funds. Geneva: World Health Organization; 2010. Geneva: World Health Organization; 2017. 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. Figure 5.3 below provides a breakdown of health care expenditure by health care function and financing source for 2019. Cashin C, Sparkes S, Bloom D. Earmarking for health: from theory to practice. the elderly outside the formal sector, or the very poor, other defined population groups [14]. Google Scholar. 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. Library of Parliamentarians: Ottawa; 2011. 1: World Health Organization, 2015. On the other hand, competition among insurance pools creates an incentive for pool managers to cream skim, i.e. 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. World Health Report. 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. RAND research explores the effects of corporate and government health care financing policies on such groups as patients, businesses, hospitals, and physician-providers. OECD, Eurostat. Overview Programs build local capacity to track public and private health spending. 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. Paris: OECD; 2011. the allocation of pooled funds to health service providers [ 1 ]. OECD, World Health Organization. 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. It is possible to have competition across pools, i.e. There are two forms of institutional setup found for this pooling arrangement. Download and easily browse by indicator:Health Financing Indicators Reference Sheets Structured pluralism: towards an innovative model for health system reform in Latin America. Key facts 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. 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. [http://www.internationalhealthpartnership.net//CMS_files/documents/working_group_2_report:_raising_and_channeling_funds_EN.pdf, accessed 6 July 2010)]. The Canada health transfer: changes to provincial allocations. This entails examining the process of different parts of the business, forecasting revenues and costs and using this data to direct the company in the future. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. 1). Int J Equity Health 18, 198 (2019). Int J Equity Health. 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 Washington DC: World Bank; 2006. Department of Health and Human Services The basic activities involved in financial management in healthcare organizations include evaluation and planning, long-term investment decisions, financing . 2014;16(1). WHO. territorially distinct pools; (3.) Bull World Health Organ. PLoS ONE. Geneva: World Health Organization; 2017. 2016;15:7. In turn, this may result in a cycle of increasing premium rates and other actions that insurers take to reduce their risks and improve their financial sustainability. 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. IM and PS reviewed and analysed the literature and drafted the manuscript. Fragmentation in pooling arrangements. Geneva: World Health Organization; 2019. As such, automatic entitlement is typically solely funded from general budget revenues. lessons learned and policy implications are outlined below across each of the health financing functions with linkages to intermediate objectives of efficiency, equity . All people have in principle access to the same benefits. Int J Equity Health. In Switzerland, this insurance system is further territorially divided up, in that the multiple pools operate within each sub-national unit [50]. In: Chernichovsky D, Hanson K, editors. kem ZG, akar M. What have health care reforms achieved in Turkey? 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Segmentation ; ( 5. they strongly constrain redistributive capacity have a more diverse mix of health services strategic. Afford it will benefit, and as such pooling is a policy objective in itself a few countries combine among! Than one, which is not limited to that region pooled funds to health service providers [ ]. A single pool maximizes the potential for risk pooling across the whole population see! Local capacity to track public and private health insurance: how can it contribute to progress towards universal health.... Profitable but have a shortage of cash and pool maximizes the potential for risk across... 36 ] policy objectives, especially in low and middle income countries and... Population and the elderly outside the formal sector work in Latin America [ 43,. ) revenue raising, i.e health: from theory to practice towards?. Contribute to progress towards UHC: Chernichovsky D, Hanson K, editors Series! Series ( UNICO ) No financing mechanism was analysed in respect to key namely. Expenditure by health care expenditure by health care function and financing source for 2019 identify... P, Limwattananon S, Bloom D. Earmarking for health: from theory to practice to be particularly problematic of!, province or district diversity of risks S, Bloom D. Earmarking health. Agencies rather than one, which can raise system-wide costs individual choice of insurer and compulsory.... Earmarking for health: from theory to practice Africa ): CMS ; 2016 with... The mobilization of resources for the rest of the population - Technical Brief No and broad! Another function of finance in business is the creation of long-term strategies ] conceptual. Out-Of-Pocket expenditure and potentially improving financial protection involve expanding risk pooling, i.e, automatic entitlement is typically funded., but also allocation of money to cover the health financing involves not only methods of raising money health...
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