Pre course module principles and objectives-en
-
Upload
julianedrews -
Category
Documents
-
view
276 -
download
0
Transcript of Pre course module principles and objectives-en
Dr Aviva Ron
-Senior Consultant
Public health and social health insurance-
The target is universal coverage
We are looking for the optimal health care financing strategy to reach that target
In the past:Government was responsible for health care - dual functions: Mandatory Regulation of health/health services Financing and provision of services
Health care was “free” in public facilities
In the present:Changing demography, health care costs (medical technology) can mean that Government needs more than it’s own
revenues. “Free” health care financed by government may then be
limited to what government can afford, and is willing to allocate for health care.
In most developing countries:Government spending on health is low
User fees are gradually introduced in public facilities –but do not cover all current expenditures
External funds are often the major source of funding Covers support to Ministry of Health to
specific facilities and programmesCovers some health care for the poor
Household out-of-pocket spending at the time of use becomes the major source of payment
And in periods of economic crises –less money is available for health care at government and household level
Low-Income Countries HaveWeak Capacity to Raise Revenues
To
tal
Go
ve
rnm
en
t R
eve
nu
es
as
% G
DP
0
20
40
60
80
100
Per capita GDP (Log scale)
10,000 100,0001,000100
Governments in many countries often raise less than 5% of GDP in public revenues; and
Total health expenditure (THE) per capita: < 10$ per capita in 13 countries 10-20$ in 25 countries 20-50$ in 28 countries > 2000$ in 16 countries Norway and Switzerland >$4000 USA >5000$ Commission on Macroeconomics and
Health – recommended a minimum of $35 per capita.
Cambodia 86.2 Percent Congo DR 80.2 “ Guinea Bissau 80.2 “ “ Lao PDR 75.5 Malaysia 73.8 Mongolia 91.1 “ Philippines 78.2 Saudi Arabia 28.6 “ Tanzania 81.1 “ Trinidad & Tobago 72.6 “ Turkey 69.9 Viet Nam 74.2“
Governments introduce user charges in public facilities to generate revenue into their own health care facilities
Governments promote private health services:To relieve the public financial burdenTo reduce provision of public servicesTo respond to changes in patient
preferencesBut - often without adequate regulation!
Governments look for more external aid, without adequate concern for sustainability
Total health expenditure is less than 5% GDP
Out-of-pocket spending reaches 70% of totalhealth expenditure (THE)
Around 10% of the population is covered by prepayment and risk-sharing schemes
Vulnerable populations have no assured social assistance/safety nets to access health care
Analyse the current situation regarding revenues and expenditures on health care
Improve efficiency in health services – avoid duplication, rationalize where appropriate, through planning based on agreed policies and sound information
Look for more stable/sustainable funding sources for all population sectors, including the vulnerable populations
Define the goals in a reasonable time frame
Reach an appropriate level of health spending by government, through efficiencies and investment in health
Keep out-of-pocket spending below 30% of total
Cover at least 90% of the population by prepayment and risk pooling schemes
Cover almost 100% of the population through social assistance/social safety nets
Basically there are three options:1. Increase in government budget for “free” health care
from general taxation revenues – and/or more external funds
2. Household financing - out-of-pocket payments Direct payments of user fees to public providers as well as user fees to private (for-profit) providers
3. Prepayment - health insurance schemes with risk-poolingContributions paid by workers, employers, government, or by the household Mechanisms to cover the non-contributing/vulnerable populations through risk-pooling schemes - Moving from charity to equity
The strategy will usually be a mix of at least 2 of the 3
These options differ with respect to the:
• Stability, equity and efficiency
• Fairness of financing and cost-sharing by the population
• Risk sharing and fund pooling
.
How much is now spent on health care?How much is spent by government?Can government spend more on health?
What are the sources of government revenue?Income tax of registered enterprises and workers – how many earners pay income tax? - how large is the unregistered /informal economy? Property and other taxesRevenue from service taxes – including state-owned authoritiesRevenue from natural resources/other sources
If the tax base/government revenue are growing: Are there competing social sector demands on tax revenues? Should priority be given to health services? Or other social services/public goods?Does increased public expenditure fit current economic reform measures?
Which health services should government give priority to– public or personal,
infrastructure and equipment, training?
To what extent can/should the government rely on external funds for health care?
If the user fees are high: - they may deter parts of the population (especially the poorest) from using health care; - they may lead to delays in seeking care; - direct payment through user fees may encourage unnecessary or inappropriate provision of services (lack of controls between provider and consumer/patient).- the fee (set amount) may be regressive - higher burden for lower income households- families may fall below the poverty level
If the fees are low – (even below the cost of services)- The yield is low and may not even justify
collection costs
If there are exemptions from fees in public facilities :- "unjustified" exemptions are encouraged- exemptions may not be respected by different providers, different levels of care - exempted patients may not be welcomed as there is no remuneration for these patients!
The protection which society provides for its members through a series of public measures, against the economic and social distress that otherwise would be caused by the stoppage or substantial reduction of earnings resulting from sickness, maternity, employment injury, unemployment, invalidity, old-age and death.
- To ensure greater stability in funding for health care - To be more equitable and reduce poverty, if the mechanisms truly spreads risks of illness and the subsequent health care costs throughout the community:
– To avoid high and unpredictable payment – To enable fairness of financing, and– To reach solidarity and optimal pooling in the
population– To provide revenue for under-funded public
health facilities
Social security systems who appreciate the value of adding health care as a short-term benefit – and potential for savings in disability allowances
Employers – faced with increasing burdens to cover occupational illness and accidents: Private commercial insurance is too
expensive Need to deal with non-work related illness
and accidents when these are not covered by other sources
Can be more efficient and cost-effective:Pooled funds enable more efficient purchasing of health services through negotiations with providers for populations – not for individuals
Negotiated and predictable payment to providers can encourage provider efficiency opportunities
Protection against the hazards of paying for services:
When the time of use is usually unpredictable
When the volume of service and costs are unpredictable
When the user has limited capacity to control costs
When income may be reduced due to ill-health Patient and family members
When the financial burden of the health care payment at the household level may require the sale of assets, and sources of household income
The burden may be too high for individuals or families
Family structure/composition is changing, priorities and responsibilities are changing
Some families have multiple needs, both acute and chronic
Savings cannot provide the solution and have other purposes in current socio-economic conditions
Social insurance – requiring contributions from households/insured persons
Social assistance – protected by the state for those who cannot contribute from their own incomes