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. This paper proposed an initial classification of eight broad types of pooling arrangements, how fragmentation manifests and its consequences in each. Health Policy. 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. a sub-national pool per state, province or district. 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. sicker individuals would have to pay more because they would need more health services [18]. An additional layer of complexity is that in many countries several forms of fragmentation exist. Figure 1. taxes, user fees, private health insurance), business (e . Three key health financing system functions Resource Mobilization: Health financing reform is an inherently political process that alters the distribution of entitlements, responsibilities and resources across the health sector and beyond. Innovations in health system finance in developing and transitional economies. Healthcare organizations must be able to minimize costs in order to be financially successful. ?2$R@a,/|l*K`I(ij6 'I#b *`&IX0*f*@f0 I,dH4BH>o\v^dqY[GraltAL3,;S/R-{zk37IY[?d-. Washington DC: World Bank; 2006. Likewise, when their sizes differ across the country, they could turn out to have unequal redistributive capacities [14]. 0000001757 00000 n Which approach is used will have a big impact on equity, on efficiency, on incentives, and on the supply of health care. As you can see, out-of-pocket or fee-for-service, government budget, or insurance agencies are all means of purchasing health care from providers. But where territorially distinct pools are too small in terms of the number of people, their risk profile can be financially precarious and there could be efficiency and capacity concerns. The UCS pooled together all of those revenues plus increased budget allocations. 0000008166 00000 n The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. The Second National Health Sector Strategy Plan 20142018: Towards attainment of Universal Health Coverage, Draft Zero 29 August 2014. Background paper no. Bingley: Emerald Group Publishing; 2009. p. 291312. 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]. Bull World Health Organ. Latin American development forum. This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences. The result is that even where it is legally mandatory for the entire population, it is de facto voluntary coverage. Correspondence to complementary or supplementary voluntary health insurance. Provided by the Springer Nature SharedIt content-sharing initiative. 1.2.1. Instead, they usually follow a countrys territorial structure, i.e. fragmented systems with voluntary health insurance, duplicating publicly financed coverage; and (8.) 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]. View below: When viewing on a desktop, maximize for optimized view. FDA Staff Manual Guides, Volume I - Organizations and Functions . Mathauer I, Theisling M, Mathivet B, Vilcu I. Raising and channeling funds: Working Group 2 report, 2009. Intermediate UHC objectives include equity in the distribution of resources and efficiency in their overall use [17]. Results The Kenyan health sector relies heavily on out-of-pocket payments. Frenz P, Delgado I, Kaufman JS, Harper S. Achieving effective universal health coverage with equity: evidence from Chile. Google Scholar. 2016;15:57. Brussels: European Observatory on Health Systems and Policy; 2010. p. 299326. Preker A, Langenbrunner J. 6. Mathauer I, Vinyals Torres L, Kutzin J, Jakab M, Hanson K. Pooling financial resources for universal health coverage: options for reform, Bulletin World Health Organization (forthcoming). California Privacy Statement, Int J Equity Health. 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]. Raising revenues for health in support of UHC: strategic issues for policy makers, health financing policy brief no. Function. CAS In many countries, different pools exist for different socio-economic groups, creating a highly fragmented system with population segmentation. Countries need to focus not on generic models but on. Sometimes, these arrangements include a purchaser-provider split. 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 financing for UHC consists of three core functions: 1) revenue raising, i.e. 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]. Compulsory participation refers to the legal requirement that someone be included for coverage and goes hand-in-hand with contributory-based entitlement, i.e. the allocation of pooled funds to health service Policy note. As a result of inadequate diversity of healthier and sicker people, the costs of care for a pool based on voluntary coverage are in principle higher than for the average in the population. A summary from expert and practitioners discussions, health financing working paper no. 0000012547 00000 n The third function of health care financing is purchasing of services. 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. This health budget pool is included in the pooling arrangements outlined below and is also often characterized by fragmentation. The National Health Insurance Program was established to provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines. 154 0 obj <> endobj World Health Report 2010 Technical Brief Series - Technical Brief No. 0000013724 00000 n The investments that competing insurers make to try and select preferred risks (or avoid high health risks) are inefficient from a social welfare perspective [11, 26], because the resources devoted to risk selection do not contribute to progress towards UHC, and in fact may detract from it. 2. 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. It maintains and operates the Medicaid Management Information System (MMIS), an automated claims processing and information retrieval system mandated by the federal government. %PDF-1.5 % In: Chernichovsky D, Hanson K, editors. . Health care delivery forms the most visible function of the health system, both to patients and the general public. 0000008860 00000 n Territorially distinct pools have much in common with a single national pool. Health Financing. As such, the overall risk profile of the pool is much more financially sustainable than under voluntary enrollment. Lancet. Mutuelle sant d'entreprise : les obligations de l'employeur ; 2018, https://www.service-public.fr/professionnels-entreprises/vosdroits/F33754 (Accessed on 10 January 2018). Google Scholar. 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. BMC Health Serv Res. Systems relying on territorially distinct pools are usually a product of a wider political context of federalism or devolution. Risk adjustment and risk selection in Europe: 6 years later. comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. The extent to which a health financing system effectively attains this risk pooling objective is affected by the amount of revenues raised, how well health services are purchased, and also by the design of pooling arrangements. Popovich L, Potapchik E, Shishkin S, Richardson E, Vacroux A, Mathivet B. Russian Federation: health system review. Soors W, Devadasan N, Durairaj V, Criel B. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. 5. https://doi.org/10.1093/heapol/czt054. In some cases, this is limited to civil servants only. Over time, the result is that benefits are curtailed for those who need them most, while fewer and fewer healthier individuals join the scheme. 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. A system-wide approach to analysing efficiency across health programmes. statement and Manage cookies/Do not sell my data we use in the preference centre. 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. These are 1) the nature of pooling and 2) the structure of pooling. All authors have read and approved the final manuscript. Article Geneva: World Health Organization; 2019. Sparkes S, Durn A, Kutzin J. It has important similarities with the (2.) hmo6 Many others receive poor quality of services even when they pay out-of-pocket. 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. 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