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Budgeting in Health Care System and Health Care Financing
Presenter: Dr. Vaishnavi CGuide: Dr. Chethana TDept of Community MedicineMSRMC, Bangalore
6/20/2016
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Contents
Introduction
Budgeting in Health care
Definition,
Need
Types
Approaches
Procedure
Challenges
Union budget 2016-17
12th five year plan
Health Care Financing
Definition
Principles
Sources
Models
Criteria
Trends of financing
Financing in India
NHA
Conclusion & References6/20/2016
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Introduction
Government – to provide affordable, equitable,
accessible and quality health care
Progress towards a healthier nation - close correlation of
health sector with economy
Health care expenditure requires a significant
contribution from the government
Countries that need the largest health advances are
precisely those spending the least on health
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IntroductionPublic health expenditure - component for the
provisioning of health facilities
*Definition–
“recurrent and capital spending from government
budgets, external borrowings and grants and social
health insurance funds”
*Source: World Bank- Health Systems Financing
6/20/2016
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Financial Control in Health Settings
Proper accounting system for funds, equipment
Laid down standards of performance against which actual
performance would be measured
Tools of control:
Budget
Hospital cost control
Financial statement analysis
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Source: Health Systems Financing- Toolkit on monitoring health systems strengthening, WHO
6/20/2016
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Budgeting in health care system
‘Budget’ - French word “Bougette”
- leather ‘pouch’ or leather bag
Public sector invention
Anticipated receipts & available resources of an
organisation during the given year
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‘Budget System’ was introduced
in India on 7th April, 1860. James
Wilson the first Indian Finance
Member delivered the budget
speech expounding the Indian
financial policy as an integral
whole for the first time
History of budget in India
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Post independence, the first
budget was presented on
November 26, 1947 by India's
first Finance Minister Sri
R.K. Shanmugham Chetty.
History of budget in India
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Budget:
Definition:
“A statement of future plans described in quantitative
and monetary terms, for a specific period of time, which
is usually one year in case of financial budgets”
Source: Union Budget 2016-17. Ministry of Finance, GOI. http://www.unionbudget.nic.in/
6/20/2016
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Need for Budget
Need for proper budgeting arises to allocate scarce
resources to various governmental activities
Planned expenditure and accurate foresight of
earnings are sine-qua-non
Has to be based on the long term strategy & focus on
future
All health care professionals should have a sound
knowledge of budgeting and health care financing
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Types of Budgets
Time-based Budgets
• Long term• Short term• Current• Rolling (Progressive)
Function-based budgets
• Capital based (Planned)• Operational (Non-Plan)• Research budgets
Flexibility-based budgets
•Fixed budgets•Flexible budgets
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Approaches to budgeting in health care
3 approaches to budgeting:
1. Incremental approach
2. Performance budgeting
3. Zero Based Budgeting (ZBB)
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1. Incremental approach
› Previous year’s expenditure is applied to the next year
with additional components
› Only the increment over the previous year’s budget is
actually justified for the present duration
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Advantages:
Easy to prepare, less preparation time and lower
preparation costs
Easy to understand & prevents conflict
Disadvantages:
wasteful expenditures and priorities are not ascertained
Alternative better options are not considered
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2. Performance budgeting
Presents the actual operations undertaken department-
wise & evaluation of actual performance of the
organisation
Periodic performance reports is prepared which
compares the budgeted actual performance with the aim
to detect any deviations at the earliest possible.
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3. Zero Based Budgeting (ZBB)
Must review the existing & old programs, especially
which involve a high degree of discretionary costs
Justification that the activity proposed is essential, cost
effective is required
No activity or action is financed simply because it was
done in the past and the entire program must be justified
each time a budget is being drawn up.
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Advantages of ZBB:
Based on cost benefit analysis
Strictly based on priority of programs/ actions
Identifies areas of wasteful expenditure
Limitations:
Planning requires greatest effort and time
Less applicable for those activities which do not have a
direct cost-benefit relationship
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Advantages of budgeting
Effective means of communicating future organizational plans to all people, in monetary and financial terms
Pre-decided and approved budget serves as an effective benchmark for monitoring ongoing operations
Reduces wastage and losses by identifying wasteful expenditures well in advance and rectifying them.
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Advantages of budgeting
Budgets through participation, encourage & develop team spirit and collective responsibility towards excellence.
Basis for assessing performance of senior managers in any organisation
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Procedure of Budgeting in India
Ministry of Finance – Shri Arun Jaitley
Department of Economic Affairs (Secretary - Shri Shaktikanta Das)
Budget Division (Joint secretary)
The finance secretary, revenue secretary, secretary of Economic Affairs & Planning Commission - determine the contour of the budget.
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Execution of the budget
Enactment of the budget
Execution of the budget
Parliamentary control over finance
•Compilation and co-ordination of the estimates •Scrutinized by the Planning Commission
Presenting the budget to Lok Sabha and Rajya Sabha
Ministries are authorized to draw the necessary amounts And spend them
Ensuring that the money has been spent for the purpose stated by it
Procedure of Budgeting
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Key challenges to health care budgeting in India
Public expenditure on healthcare to be increased from 1.3
(2014) per cent to 5 per cent of the GDP to match the
global average expenditure
A robust plan for effective utilisation of existing budgets
so that public expenditure is fully utilised
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Key challenges to health care budgeting in India
High burden of out - of-pocket expenditure (OOP) in
India
Hospital bed density - 0.9 per 1,000 persons*
0.7 doctors per 1,000 patients*
Focus on geriatric care
Shortage of medical institutions and with majority
present in urban areas
Technology promotion
Source: Health Systems Financing- World Bank Report6/20/2016
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Twelfth Five Year Plan
Allocation three times greater than 11th five year plan
expenditure
Share of healthcare – 2.5% of GDP
Focuses on providing universal healthcare, strengthening
healthcare infrastructure, promoting research and
enacting strong regulations for the healthcare sector
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Budget allocation to health care (USD billion)
Source: Planning commission-http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_vol2.pdf
6/20/2016
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Union Budget 2016-17: Vikas ka budget
Allotments: Total: 31,300 Cr ( 1.58% of total)*
Medical, Public Health and Family Welfare (Rs.
5188.63 cr)
Rs.2077.55 cr for major central and medical
institutions
Rs.384 cr for medical education, training and
research
Rs.252.70 cr towards Ayurveda, Yoga and
Naturopathy Siddha and Homoeopathy.
Source: Union Budget 2016-Ministry of finance, GoI6/20/2016
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Budget 2016-17 contd...
New health protection scheme - health cover up to one
lakh per family.
Prime Minister’s Jan Aushadhi Yojana- 3000 stores
‘National Dialysis Services Programme’ under National
Health Mission through PPP mode
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Budget 2016-17 contd...
Social Security and Welfare (Rs. 1,329.60 cr):–
Rs. 760.16 cr for pension and other benefits to freedom
fighters,
Rs. 61.03 cr for child and women welfare and
Rs. 67 cr for the welfare and empowerment of persons
with disabilities.
Census, Surveys and Statistics- Rs808.81 cr
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Union Budget Proposal 2016-17
1.5%
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Shortfalls
Increasing the public expenditure as proposed by 12th
five year plan to over 2.5 per cent - not been met
Long way in achieving universal health coverage from
burgeoning healthcare costs
Efforts to reduce the manpower and skill gap were also
missing from the budget
Reforms in health care sector is necessary6/20/2016
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Guidance for strengthening public expenditure management
Strengthened budget formulation process
Enhanced government capacity for efficient public
expenditure management and monitoring
To generate expenditure priorities and arbitrate between
competing needs for scarce resources and reflect
government policy objectives
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Health care financing
Financing is the most critical of all determinants of a health
system
WHO – “function of a health 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”
to ensure that all individuals have access to effective public
health and personal health care
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Principles of a health financing system
• Have to be collected equitably and efficiently
Revenue collection
• costs of health care are shared by all and not borne by individualsPooling
• Used to buy or provide health interventions that are allocatively and technically efficient
Purchasing
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Action 1:
Establishing the vision
Action 2:
Situational
analysis
Action 3:
Financial
assessmentAction
4: Constrai
nt assessme
nt
Action 5:
Strategy for
change
Action 6:
Implementation
Action 7:
Monitoring and
Evaluation
Decision Process of Health Financing
Source: Health systems financing-The path to universal coverage - WHO
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Models of healthcare financing
Beveridge model
Bismarck Model
National Health
Insurance Model
The Out of Pocket Model
Source: Health Systems financing. Report - World Bank. 6/20/2016
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Sources of health care financing
The tax-based public sector
Out of Pocket Expenditure
Insurance- social, community- based, private
External financing
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Borrowing
Corp Tax
Income tax
Service tax
Nondebt capital
Customs
Sources of tax based Income (%) – India 2015-16
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Out of Pocket ExpenditureSimplest form
Main financer of health services in India is individual
household
Consequences:
Lower the access to health care
Impoverish the households
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Insurance
Most complex mechanism of financing health care
Objective - manage the revenues equitably and
efficiently allowing for subsidies from healthy to
unhealthy, rich to poor and productive workers to
dependents
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• Employees State Insurance Scheme (ESIS) and the Central Government Health Services (CGHS)
Social Health Insurance (SHI)
• Generally preferable to out of pocket expenditure
• Increase financial protection and access
Private Health Insurance
• Not-for-profit prepayment plans Community Health Insurance
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Criteria for choosing the financing system
Risk pooling
EquityEconomic Effects
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45OOP 80%40%
20%
Health system financing trends:
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Health care financing in India
Health sector - high maternal and child mortality, dual
burden of communicable & non-communicable diseases
Hospitalization for major illness is a cause of
indebtedness for all income groups
Inability of the poor to access good health care
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Private Public Others
Debt financing Annual govt budget for
rural health
Foreign
donations
Foreign direct
investment
Annual govt budget for
urban health
PPP project
funding
External
commercial
borrowing
Govt. funding for
community programmes
Individual investors Govt. sponsored
schemes
Avenues of Health care financing- India
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Factors influencing health care financing in India
Demography data
Economic Recession
Expectations from health care
Drive for Equity
Changing disease pattern
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Health financing issues in India
Low level of public health expenditure
18% - no access to OPD services*
40% have to sell their assets or borrow to pay the bill*
A mismatch between policy and practice – eg. NACO,
RNTCP
Weak absorption capacity in the government
Budgeting - not functional
Source: NSSO- 2011
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Indicators (2014) Value (US$)
Total Health Expenditure (THE) - % (GDP) 5
General Government Health Expenditure
(GGHE) as % of Total Health Expenditure
30
Private Health Expenditure (PvtHE) as % of
Total Health Expenditure (THE)
70
Health expenditure series. Global health expenditure database. WHO
Financial indicators in health care-India
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Indicators (2014) Value (US$)
Out of Pocket Expenditure (OOP) as % of
Total Health Expenditure (THE)
62
General Government Health Expenditure
(GGHE) as % of GDP
1.2
Total expenditure on health 97,140
million
General government expenditure on health 29,177
million
Source: Health expenditure series. Global health expenditure database. WHO
Financial indicators in health care-India
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Fig: Trends in centre-state share % in TPHE on health
Source: National Health Profile - 20156/20/2016
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53Source: National Health Profile - 2015
Fig: Composition of public expenditure on medical and public health
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National Health Accounts (NHA)
Consistent, comprehensive information of all the
resources that flow through the country’s health system
over time
Standard management tool for situation analysis,
planning, monitoring and evaluation purposes
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NHA address four basic sets
of questions:
where do resources come
from
where do they go
what kinds of services and
goods do they purchase
whom do they benefit
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Six dimensions are considered:
Financing sources
Financing agents
Providers
Functions
Cost of Factors of Production
Beneficiaries
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Conclusion
Countries have to move forward faster to develop
equitable and efficient institutional structures, revenue-
raising mechanisms and spending prioritizations
To become more efficient and equitable in the use of
resources
Need for constant re-evaluation and adjustment
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References Hanlon JJ, Pickett GE. Public Health – Administration and
Practice. 8th ed.USA: Times Mirror; 1979.p.
Sathe VP, Doke PP. Epidemiology and management of
HEALTH CARE. 4th ed. Mumbai (INDIA): Vora Medical
Publications;2014.p.
Detels R, Beaglehole R, Lansang MA, Gulliford M. Oxford
Textbook of Public Health. 2nd ed. United Kingdom: Oxford
University press;2001.p.
Health Systems Financing- World Bank [Online] 2016 [Cited on
2016 Jun 10];Available from:URL: http://web.worldbank.org/6/20/2016
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References Balwar R, Vaidya R, Tilak R, Guptha RK, Kunte R. Textbook of Public
Health and Community Medicine. 1st ed. Department of community
medicine, AFMC, Pune in collaboration with WHO India office.New
Delhi (India); 2009. p.
Schieber G, Baeza C, Kress D, and Maier M. Financing Health Systems
in the 21st Century [online] 2006 [Cited on 2016 Jun 2] ];Available
from:URL: http://www.ncbi.nlm.nih.gov/books/NBK11772
Health Systems Financing - Toolkit on monitoring health systems
strengthening. World Health Organisation [Online] 2008 [Cited on 2016
Jun 4];Available
from:URL:http://www.who.int/healthinfo/statistics/toolkit_hss/EN_PD
F_Toolkit_HSS_Financing.pdf
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References Budget in parliament- procedure. Ministry of Finance, GoI
[online] [Cited on 2016 Jun 2];Available from:URL: http://www.parliamentofindia.nic.in/ls/intro/p4.htm
BUDGET MANUAL- 2016-17. Ministry Of Finance. Department Of Economic Affairs, Budget Division, New Delhi [online] 2016 [cited on 2016 Jun 10];Available from: http://finmin.nic.in/the_ministry/dept_eco_affairs/budget/Budget_Manual.pdf
Srinivasan R. Health Care in India – Vision 2020, Issues and Prospects – Planning Commission. Planning Commission. Nic [Online] 2012 [Cited on 2016 Jun 10];Available from: URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714944/
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Financing and Delivery of Health Care Services in India. National Commission on Macroeconomics and Health. Ministry Of Health And Family Welfare Government Of India & WHO [Online] 2005 [ Cited on 2016 Jun 4];Available from: URL: http://www.who.int/macrohealth/action/Background%20Papers%20report.pdf
Healthcare Union Budget 2016- Post-Budget sectoral point of view. Health Care. KPMG- India [Online] 2016 Mar [Cited on 2016 Jun 10];Available from:URL: https://www.kpmg.com/IN/en/services/Tax/unionbudget2016/Documents/Healthcare.pdf
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Expenditure on Health in India. National Institute of Public Finance and Policy (NIPFP) [online] 2012 May [Cited on 2016 Jun 4];Available from:URL: http://www.nipfp.org.in/media/medialibrary/2013/08/health_estimates_report.pdf
Healthcare Infrastructure and Services Financing in India- Challenges. Indian Chamber of Commerce [Online] 2012 Sep [Cited on 2016 Jun 10];Available fom:URL:https://www.pwc.in/assets/pdfs/publications2012/healthcare_financing_report_print.pdf
Kurian OC. Financing Healthcare for all in India: Towards a Common Goal. OXFAM India [Online] 2015 [Cited on 2016 Jun 4];Available from: URL: https://www.oxfamindia.org/sites/default/files/WP-Financing-Healthcare-for-All-In-India-29-05-2015-EN_0.pdf6/20/2016
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References Adedigba MA. Health Care Costs and Comparison of
Different Methods Of Financing Health Care. Organisation of African Unity [online] 2011 [Cited on 2016 Jun 4];Available from:URL http://www.oauife.edu.ng/wp-content/uploads/2013/05/Health-Care-financing-by-Adedigba.doc
National Health Accounts 2004-05. National Health Accounts Cell. MoHFW-GoI [online] 2004 [2016 Jun 4];Available from:URL: http://planningcommission.nic.in/reports/genrep/health/National_Health_Account_04_05.pdf
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Health financing for universal coverage- Health financing country diagnostic. A foundation for national strategy development. WHO [Online] 2010 [Cited on 2016 Jun 10]; Available from:URL: http://www.who.int/health_financing/tools/diagnostic/en/
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Approaches To Budget Reform. World Bank Report. [Online] 2012 [Cited on 2016 Jun 6];Available from:URL: http://siteresources.worldbank.org/INTPEAM/Resources/part3.pdf
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It is well enough that people do not understand the
monetary system, for if they did, there would be a
revolution before tomorrow morning
- HENRY FORD
THANK YOU
6/20/2016