the allocation of pooled funds to health service providers [ 1 ]. 1: World Health Organization, 2015. The authors declare they have no competing interests. To ensure key development programmes are adequately funded [5,6]. Risk pooling in health care financing: the implications for health system performance. Agency's Mandate and Functions Mandate. 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 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. Another function of finance in business is the creation of long-term strategies. 3. Health financing has three key functions: revenue collection, pooling of resources, and purchasing of services. All remaining errors are with the authors. However, evidence for efficiency improvement with increased market competition among purchasers is weak [25]. Mathauer I, Behrendt T. State budget transfers to health insurance to expand coverage to people outside formal sector work in Latin America. These latter three were replaced by a new health coverage scheme that was introduced in 2002, called the Universal Coverage Scheme (UCS), as a response to growing concerns about the huge differences in level of funding per capita across the schemes and the remaining coverage gap due to the failure of the voluntary insurance to reach much of the informal sector. the mobilization of resources for the health sector; 2) pooling, i.e. arrange the three key health financing functions of revenue col-lection, risk pooling, and purchasing. Three key health financing system functions Resource Mobilization: Financial Management Functions. 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. Alhassan RK, Nketiah-Amponsah E, Arhinful DK. Figure 1. Health financing: the basics FP Financing Roadmap. 0000080000 00000 n However, little is known about how best to monitor health financing system progress towards UHC, especially in low- and middle-income countries. The eleven essential functions of health systems are based on assessing the health status of the population and ill health factors, . Subsidized health insurance coverage of people in the informal sector and vulnerable population groups: trends in institutional design in Asia. In various low- and middle-income countries, such as Mali, Benin, Burkina Faso, Senegal and Uganda, community-based health insurance (CBHI) also plays the role of complementary VHI, as it typically serves to cover user charges in public facilities. It also had schemes for the low-income population and the elderly and a subsidized voluntary insurance program for the rest of the population. Figure 1. For example, the pool from which the national capital city funds its city hospitals, and the pool from which the central government funds national tertiary facilities are not territorially distinct, particularly when as is often the case the national tertiary hospital is also an important provider of more basic services for the local population. Systems relying on territorially distinct pools are usually a product of a wider political context of federalism or devolution. As you know, there is a lot that you can find. Its main purpose is to share the financial risk associated with health . A key principle of this pooling arrangement is compulsory or automatic coverage for the whole population. to (5.) Mathauer, I., Saksena, P. & Kutzin, J. Pooling arrangements in health financing systems: a proposed classification. Function. 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]. The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. Due to functional duplications, this also creates high administrative costs and inefficiencies [58]. I'.1~)4CQ~u sd1$V0c: B' {09 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. Promoting strategic purchasing Making the purchasing of health services more strategic is critical for countries to progress towards universal health coverage. 192 0 obj<>stream Fragmentation also occurs in the few countries (Germany, Netherlands, Chile) that allow certain population groups (e.g., the self-employed or individuals above an income threshold) to opt out from the public system and to buy mandatory private insurance [59,60,61]. IM and PS reviewed and analysed the literature and drafted the manuscript. 0000046058 00000 n Finally, we are grateful for valuable comments from two anonymous peer reviewers. Brussels: European Observatory on Health Systems and Policy; 2010. p. 299326. PubMed Central But in contrast to having just one pool, residents of a particular region of the country are served by a regional pool, i.e. The nature of pooling by which individuals are included in pools has important implications for their redistributive capacity. 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. This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences. 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 financing policy is key to the health system, as it determines: i) the sources of fund, and therefore how much is available to the sector; ii) how health risks are pooled; iii) who controls the funds and how they are allocated; iv) The equity of the sector funding, and hence indirectly, how many people will fall into poverty (or not) as a Berkshire: Open University Press; 2005. van de Ven WP, Beck K, Van de Voorde C, Wasem J, Zmora I. Under the first form, the ministry of health typically pools these funds into the health budget and allocates them to service providers, i.e. 154 39 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. Mexicos Seguro Popular also shifted to this principle of automatic coverage of all people who are not part of an insurance scheme for formal sector employees [47, 48]. the mobilization of resources for the health sector; 2) pooling, i.e. Some countries, such as Rwanda and Ghana, have transformed their earlier CBHI model, which no longer falls under VHI. 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. Based on this, we identify and present broad types of pooling arrangements and related fragmentation issues and discuss implications and challenges. 787 0 obj <> endobj Smith P. The role of markets and competition. !{~4nf0QMh92]Ta, *eIF PubMed Washington DC: World Bank; 2006. 2013;91(8):60211. OECD reviews of health systems: Switzerland 2011. Implementing health financing reform: lessons from countries in transition. 2014;29:71731. When coverage is compulsory or automatic for all population groups, the pool(s) have a more diverse mix of health risks. It serves multiple purposes, e.g. Such pooling setups create explicitly unequal financing arrangements and the population segmentation is often further linked with separate purchasing and service provision arrangements. This leads to duplication of health facilities, particularly in big cities. 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 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. Google Scholar. While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. 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. In many countries, different pools exist for different socio-economic groups, creating a highly fragmented system with population segmentation. 1970;84(3):488500. https://doi.org/10.1093/heapol/czt054. 0000006764 00000 n Sparkes S, Durn A, Kutzin J. 3. 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). Thomson S. What role for voluntary health insurance? 0000005327 00000 n Purchasing to improve health system performance. population density). 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. 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). 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]. 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. California Privacy Statement, 0000002548 00000 n An appraisal of the health transformation Programme. there is no explicit purchaser-provider split. voluntary health insurance). Geneva: World Health Organization; 2017. Structured pluralism: towards an innovative model for health system reform in Latin America. complementary or supplementary voluntary health insurance. 0000079977 00000 n `733.aa``:S)C{CXhyB"&B)cc wlVJ36sJ120F0-`jjp`aXir23P'd 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. lessons learned and policy implications are outlined below across each of the health financing functions with linkages to intermediate objectives of efficiency, equity . 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. Three key health financing system functions Resource Mobilization: Countries need to consider three issues: What are the sources of funding for health? Formula funding of health services: learning from experience in some developed countries. 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. To discuss Malawi as a case study in health systems. 814 0 obj <>stream Such systems are primarily found in both large and smaller higher-income countries like Germany, Netherlands, Switzerland, Czech Republic and Slovakia [15, 26]. 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