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/. Health Care Syst Transit. Instead, they usually follow a countrys territorial structure, i.e. Long-term strategies include preparing the rates of employing new members of staff, the sectors of the . As the name suggests, it exists in addition to and along the other main pooling arrangements, as outlined above. 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. 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. 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. Cookies policy. Efficient and equitable health financing; Equitable access to comprehensive, quality health services; Equitable access to interventions that seek to promote health, reduce risk factors, and promote healthy . [http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/swaziland/swaziland_nhssp_ii_draft_zero_29_aug_2014.pdf. K]NiGe(T&k,JTNeu@#KWB&@XxDXw-2^ctyc9d"E@yk3'1V-o PKW em2VK: From these two institutional design aspects, we need to distinguish the level of prepaid funding, which is not considered in this classification. Health Financing. 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]. trailer Mathauer I, Behrendt T. State budget transfers to health insurance to expand coverage to people outside formal sector work in Latin America. Complementary insurance for user charges complements coverage of the public system by covering all or part of the residual costs (e.g. This is a protocol of a study that will aim to assess health financing system progress towards achieving UHC in Iran. 0000079977 00000 n However, we recognize that any classification is a simplification of reality and does not substitute for a country-specific analysis of pooling arrangements. Geneva: World Health Organization; 2017. the allocation of pooled funds to health service providers [1]. 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. 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. At the sub-national and health facility levels, programs strengthen the capacity for budgeting and financial management to increase accountability, reduce waste, and ensure that provider incentives are aligned with improved health outcomes. Mathauer I, Kutzin J. Londoo JL, Frenk J. 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. Results The Kenyan health sector relies heavily on out-of-pocket payments. Taken quite literally, perhaps no country has only one single pool. We provide a simple classification of country pooling arrangements and discuss the specific ways that fragmentation manifests in each and the typical challenges with respect to universal health coverage objectives associated. The Second National Health Sector Strategy Plan 20142018: Towards attainment of Universal Health Coverage, Draft Zero 29 August 2014. Gottret P, Schieber G. A practitioners guide health financing revisited. Policy note. 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 care administration professionals develop payment plans for patients, negotiate contracts with providers, draft policies, and ensure overall compliance. PubMed territorially distinct pools; (3.) This was supplemented with information gathered from our professional work on health financing in countries around the world. Improved equity in service use and financial protection involve expanding risk pooling, and as such pooling is a policy objective in itself. Thomson S. What role for voluntary health insurance? To understand the key challenges to health systems. Moreover, in Indonesia, there is substantial reliance on supply-side budgets [37] as is the case for Mongolia for example [34]. Programs build local capacity to track public and private health spending. Terms and Conditions, "The purpose of health financing is to make funding available, as well as to set the right financial incentives to providers, to ensure that all individuals have access to effective public health and personal health care" (WHO 2000: 95). Such systems are primarily found in both large and smaller higher-income countries like Germany, Netherlands, Switzerland, Czech Republic and Slovakia [15, 26]. Washington DC: World Bank; 2004. Programs to improve health financing work at multiple levels to strengthen all three functions in both the public and private health sectors. Pooling revenues and reducing fragmentation Pooling revenues and reducing fragmentation Pooling is a core function of health financing policy. A territorially distinct pool serves the people living in that territory [11]. Advances in health economics and health services research, volume 21. 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. Moreover, in France, there is a shift towards compulsory complementary coverage, which employers have to buy for their employees since 2016 (with exceptions for various employee groups) [56]. First, there are higher administrative costs of having multiple pooling/purchasing agencies rather than one, which can raise system-wide costs. Many others receive poor quality of services even when they pay out-of-pocket. IM, PS and JK developed the outline and framework. 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. 2019;97:33548. are deemed to be particularly problematic forms of fragmentation, because they strongly constrain redistributive capacity. Conversely, pools with higher health risks are more likely to restrict benefits (if this is legally allowed), face financial difficulties or else run deficits. Community based health insurance: how can it contribute to progress towards UHC? PubMed Health Policy. 0000079954 00000 n Valuable comments from Ke Xu, Matthew Jowett, Fahdi Dkhimi, Susan Sparkes, Aurelie Klein and Julius Murke are gratefully acknowledged. 2023 BioMed Central Ltd unless otherwise stated. Structured pluralism: towards an innovative model for health system reform in Latin America. 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. Seinfeld J, Montaez V, Besich N. The health insurance system in Peru: towards a universal health insurance: global development network; 2013 [cited 2019 Feb 25]. 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]. 2013;91(8):60211. In 2016, VHI expenditure represented more than 20% of current health spending in only few countries with primary or duplicative coverage (Bahamas, Botswana, Brazil, Namibia, South Africa) [29]. On the other hand, competition among insurance pools creates an incentive for pool managers to cream skim, i.e. 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. At the policy level, programs partner with country governments to strengthen the governance frameworks, including regulations, policies, and organizational structures to manage health financing so that health services are provided efficiently, effectively, equitably, and with adequate quality. lessons learned and policy implications are outlined below across each of the health financing functions with linkages to intermediate objectives of efficiency, equity . Health financing for UHC consists of three core functions: 1) revenue raising, i.e. (Accessed on 25 February 2018)]. 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. Spending wisely: buying health services for the poor. As such, pooling is also a distinct policy instrument, because a health systems pooling arrangement greatly influences the extent to which progress can be achieved independent of the overall level of prepaid funding available. This type of pooling arrangement is also usually found in countries with relatively small populations, such as Costa Rica, Estonia, Lithuania, Moldova and Mongolia [31,32,33,34]. Article 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. 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. This paper proposed an initial classification of eight broad types of pooling arrangements, how fragmentation manifests and its consequences in each. World Health Organization. Brussels: European Observatory on Health Systems and Policy; 2010. p. 299326. complementary or supplementary voluntary health insurance. Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. The Netherlands: health system review. hmo6 Mathauer I, Mathivet B, Kutzin J. What are the three main functions of health financing? 1: World Health Organization, 2015. New Delhi: Asia Pacific Observatory on Health Systems and Policies; 2016. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. Health financing policy brief no. 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. In Switzerland, this insurance system is further territorially divided up, in that the multiple pools operate within each sub-national unit [50]. 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. 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. There are also some concerns, however. 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. Latin American development forum. 1.2.1. Article The eleven essential functions of health systems are based on assessing the health status of the population and ill health factors, . 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. 2014;16(1). 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. Berkshire: Open University Press; 2005. van de Ven WP, Beck K, Van de Voorde C, Wasem J, Zmora I. In: Chernichovsky D, Hanson K, editors. Department of Health and Human Services However, there are limitations to this classification, because the full reality is much more complex. Soors W, Devadasan N, Durairaj V, Criel B. Pools may be organized as territorially distinct. and (7.) Agency's Mandate and Functions Mandate. Wahshginton DC: World Bank; 2005. agencies that manage pools (typically insurance schemes) compete for members. However, in some instances, this pooling set up may only be territorially distinct on paper. "Health system financing is an essential component of UHC but progress toward UHC also requires coordinated actions across the pillars of the health system with particular attention to strengthening human resources for health." Health system financing health topic 0000012340 00000 n it is the function of a system concerned with the mobilization, accumulation, and allocation of money to cover the health needs of the people, individually and collectively, in the health system. Heal Policy Plan. 0000002224 00000 n In: Kutzin J, Cashin C, Jakab M, editors. Health system review. Article Resource allocations also need to take into account differences in sub-national revenue raising capacity across the different territorial units [38]. 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 . Kutzin J, Shishkin S, Bryndov L, Schneider P, Hrobo. Int J Equity Health. Today, millions of It concentrates on patient flows as well as the organization and delivery of all services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health. Geneva: World Health Organization; 2008. Revenue collection is how health systems raise money from households, businesses, and external sources. A desciptive framework for country-level analysis for health care financing arrangements. 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. Privacy 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 Mathauer I, Theisling M, Mathivet B, Vilcu I. Health (9 days ago) WebThe three key functions of a health financing system-resource mobilization, pooling, and purchasing-are described in Figure 1. 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 complex structure of Australia's . As such, this type of pooling arrangement, if and when it has an effective risk adjustment mechanism that deters risk selection efforts, can act as a virtual single pool (due to the flows between the pools). voluntary health insurance). 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). Purchasing health services for universal health coverage: how to make it more strategic? 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. 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