However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. 0000005125 00000 n Objective Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. 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]. 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]. We propose eight broad types of pooling arrangements: (1.) A system-wide approach to analysing efficiency across health programmes. Health Systems in Transition. Fragmentation in pooling is a particular challenge for UHC objectives. 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. Many others receive poor quality of services even when they pay out-of-pocket. 2S?dI9c{rP"=-Gsi1NU@ Health Policy. Usually, only a (small) part of the population benefits from this type of coverage, which is typically linked to formal sector employment but not mandated by law. SMG 1117A.641 (02/09/2022) 1 . As the name suggests, it exists in addition to and along the other main pooling arrangements, as outlined above. OECD reviews of health systems: Switzerland 2011. Health Facilities Health facilities in the Philippines include government hospitals, private hospitals and primary . Health financing is a core function of health systems that can enable progress towards universal health coverage by improving effective service coverage and financial protection. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies; 2010. Geneva: World Health Organization; 2017. (WHO/HIS/HGF/HFWorkingPaper/16.1; Health Financing Working Paper No. Collectively, they work to meet the physical and mental health care needs of Australians. 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. 2. The six functions are: (i) service delivery, (ii) medical products, vaccines and technology, (iii) workforce, (iv) information, (v) financing and (vi) leadership and governance. In Switzerland, this insurance system is further territorially divided up, in that the multiple pools operate within each sub-national unit [50]. Bonilla-Chacn ME, Aguilera N. The Mexican Social Protection System in Health [Universal Health Coverage Studies Series (UNICO) No. Second, fragmentation can weaken the potential gains from using purchasing as an instrument to influence provider behavior in countries where multiple purchasers use different payment methods and rates to pay the same providers in an uncoordinated way. 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. Health financing policy brief no. 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. This is inconsistent with the objective of financial protection and equity of access to services in relation to need. Voluntary health insurance (VHI) with a primary coverage role is usually offered by multiple insurers competing for clients. PS is a health systems adviser working in the WHO Country Office of Tunisia. 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. The interplay between the core functions of health financing are brought to light by studies that have shown that increased financial resources for health do not necessarily Programs to improve health financing work at multiple levels to strengthen all three functions in both the public and private health sectors. (&9~4y4no74d4J+2 ;RVbL|rSN /-`X/qggmzQV8rd pvr\HUc. 0 Baeza CC, Packard TG. In turn, this can help countries assess their pooling arrangements and contribute to identifying policy options to address fragmentation or mitigate its consequences. Google Scholar. Fragmentation is further aggravated, as a small part of the better-off population is often enrolled in commercial voluntary health insurance, whilst a small share of people in the informal sector may enroll in voluntary community-based health insurance schemes [41, 42]. %PDF-1.4 % Cashin C, Sparkes S, Bloom D. Earmarking for health: from theory to practice. HGF guidance document no. While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. Washington DC: World Bank; 2004. Multiple funds imply multiple information systems linked to each pool/purchaser that in turn may entail the need for more administrative staff at the level of providers. Its main purpose is to share the financial risk associated with health . 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. 3. 0000014440 00000 n 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. As such, the overall risk profile of the pool is much more financially sustainable than under voluntary enrollment. 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. It maintains and operates the Medicaid Management Information System (MMIS), an automated claims processing and information retrieval system mandated by the federal government. OECD, Eurostat. 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). 0000002300 00000 n %%EOF population density). Some countries, such as Rwanda and Ghana, have transformed their earlier CBHI model, which no longer falls under VHI. 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. The quest for universal health coverage: achieving social protection for all in Mexico. Pettigrew LM, Mathauer I. 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. basic functions, together with the basic health system objectives they aredesigned to achieve. In healthcare management there are three managerial levels: top-level, middle-level and frontline managers. 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 2016;15:57. This is the so-called death spiral of voluntary health insurance [24]. 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. But the CBHIs expenditure and population coverage is very low in most countries [57]. 2016;15:67. Global Health Expenditure Database: National Health Accounts [http://apps.who.int/nha/database (accessed on 1 September 2018)]. complementary or supplementary voluntary health insurance. xb```l hp`d,u){i7NY~GOC]TkT} h$*M^ixD#UNm| What are the functions of health financing mechanisms? Based on this, we identify and present broad types of pooling arrangements and related fragmentation issues and discuss implications and challenges. 2013;91(8):60211. territorially overlapping pools in terms of service and population coverage; (4.) 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. Vilcu I, Mathauer I. 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]. Bingley: Emerald Group Publishing; 2009. p. 291312. They also need to monitor cash on hand, businesses may be profitable but have a shortage of cash and. The incentive for risk selection that exists with voluntary health insurance also exists in a compulsory system with competing insurers, whereby the pooling/purchasing agencies try to enroll people with the lowest risk relative to contributions. Today, millions of people do not access services due to the cost. Health Financing in Ghana. To cite variations across countries of different income levels. Smith P. The role of markets and competition. 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. 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. All people have in principle access to the same benefits. -U+:V\GCs2C /L7w0X-O`>2h?! hbbd``b` "$8@B\HHo \Q u 88b``g T Hungary, Bull World Health Organ. Health Systems Financing: The path to universal coverage. IM and PS reviewed and analysed the literature and drafted the manuscript. Thomson S. What role for voluntary health insurance? Gottret P, Schieber G. A practitioners guide health financing revisited. As changes in the pooling arrangements are about redistribution of funds, this is ultimately also very political, and it is hence important to understand the feasibility and manage the political economy of pooling reforms. 814 0 obj <>stream All authors have read and approved the final manuscript. While the issue of segmentation first emerged in Latin America [43], it is not limited to that region. 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. Health financing - World Health Organization. This chapter provides background on demographic and epidemiological trends, the configuration of Ghana's health system, and health financing functions and health systems goals. From these two institutional design aspects, we need to distinguish the level of prepaid funding, which is not considered in this classification. 6. Int J Equity Health. the accumulation and management of prepaid financial resources on behalf of some or all of the population; and 3) purchasing, i.e. . 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. A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects? Provided by the Springer Nature SharedIt content-sharing initiative. 5. Int J Equity Health. !{~4nf0QMh92]Ta, *eIF 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. sicker individuals would have to pay more because they would need more health services [18]. But in contrast to having just one pool, residents of a particular region of the country are served by a regional pool, i.e. Heal Policy Plan. Overview Akerlof GA. the mobilization of resources for the health sector; 2) pooling, i.e. By Jonas May 13, 2021 5min read 4233 views. Mathauer I, Mathivet B, Kutzin J. 2019;97:33548. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. Health financing systems have a key role in achieving universal health coverage (UHC) across the globe. 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. 154 0 obj <> endobj Risk pooling in health care financing: the implications for health system performance. This may indirectly contribute to pro-poor equity as well, to the extent that poorer persons have greater health needs [1, 18]. (accessed 5 February 2019)]. Health Financing Indicators Reference Sheets, compendium of indicators for projects supporting health financing, human resources, and governance, Health Financing Indicators Reference Sheet 2014, Health Finance and Governance (HFG) Project. In the early 1990s, Thailand had a scheme for civil servants and another scheme for private sector employees. Geneva: World Health Organization; 2017. Taken quite literally, perhaps no country has only one single pool. 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. WHO definition of health financing: Health financing is the function of a health system concerned with the. 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