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Designing Health Financing System to Achieve Universal Coverage Ke Xu Health Systems Financing World Health Organization November 2008, Shanghai 1| Health System Financing Universal Coverage as a Policy Objective defined as everyone having access to appropriate care when they need it and at affordable cost implies financial risk protection and equity of access associated with equity in financing ( contribution according to ability to pay) Resolution "Sustainable Health Financing, Universal coverage and Social Health Insurance" May 2005. Geneva 2| Health System Financing Three Dimensions of Universal Coverage 3| Health System Financing Universal Coverage Getting the Mix Right Revenue collection Collect funds (taxes or contributions) efficiently and equitably 4| Health System Financing Pooling Costs are shared by all and not borne by people when they are ill wealthy & healthy subsidize the poor & sick Purchasing Buy or provide effective health interventions Incentives for efficiency Revenue Collection Sustainability Is the money collected in an equitable way? Equity How much I pay and how much others pay? 5| Health System Financing Does the collected sufficient? Efficiency How to collect a sufficient amount of money with minimum administrative cost? Health Financing Mechanisms Financing mechanisms Tax-based financing Health care services Health System Financing 1. General tax or other revenue Social health insurance 2. Payroll tax Other prepayment schemes 3. Contribution or premium Out-of-pocket payments 6| Financing sources External resource Household 4. Direct payment Natural resource revenue Revenue Collection Generally a mix of different types of revenue collection mechanisms co-exist: – Tax based funding • General taxation, earmark taxes – Compulsory insurance • Payroll tax and contribution • Formal and informal sector employees • Dependants – Voluntary insurance 7| Health System Financing Social Health Insurance- Constrain Factors •Income level and growth •The structure of the economy •The distribution of the population •Administrative capacity •Solidarity •Stewardship 8| Health System Financing Funds Pooling How far can solidarity go ? – – – How many pools-risk adjustment/ risk-equalisation? – – – One pool (Korea, Turkey) Multiple pools (Germany, Netherland, Switzerland…) Fragmentation and segmentation How should tax-based funding be channeled? – – – 9| What level of cross-subsidies from rich to poor and from healthy to ill? Any role for supplementary or complementary health insurance ? Should opt-out be allowed (Latin America, Germany)? To provider (Latin American countries)-low price services To insurance funds- low insurance premium To consumers (cash transfer)- to purchase services or insurance Health System Financing 15 8 3 1 .3 .1 .03 .01 % of households with catastrophic expenditure (logarithm) Proportion of households with catastrophic expenditures vs. share of out-of-pocket payment in total health expenditure 3 5 8 14 22 37 out-of-pocket payment in total health expenditure % (logarithm) OECD others 61 100 Purchasing Strategic purchasing Provider payment mechanisms Outpatient service Inpatient service Drugs High-tech medical equipments No over provision 11 | Health System Financing Benefit package design Differentiate cost sharing among different services and drugs No over utilization By Pia Schneider: Provider Payment Reforms: Lessons from Europe and America for South Eastern Europe 12 | Health System Financing The Design Features of Benefit Package Risk protection Budget constrain The size of benefit package Width The number of services 13 | Health System Financing Depth Cost-sharing Structure What services and how much OOP Components by Quintiles (Korea, 2007) 100% 80% 60% 40% 20% 0% 1 2 drug 14 | Health System Financing 3 equipment 4 5 service to tal Catastrophic Expenditure by Different Payments (Korea) 35% 30% 25% 20% outpatient 15% inpatient dental 10% drug 5% 0% 2003 15 | Health System Financing 2004 2005 2006 2007 Percentage of Households Reporting Non-zero Inpatient Expenditure (Korea, 2007) 6 % of households 5 4 3 2 1 0 1 2 3 4 quintiles 16 | Health System Financing 5 Total Stages of Coverage and Organisational Mechanisms Universal Coverage •Tax-based financing Intermediate stages of coverage Absence of financial protection Out-of-pocket spending 17 | Health System Financing Mixes of community cooperative and enterprise based health insurance, other private health insurance, SHI type coverage for specific groups and limited tax based financing •Social health insurance •Mix of tax-based and various types of health insurance How Long It Takes to Reach Universal Coverage? Time (in years) between first social protection Costa Rica 20 Republic of Korea 26 Japan 36 UK 36 Austria 79 Belgium 118 Germany 127 law and universal coverage 18 | Health System Financing Summary 1. Achieving universal coverage takes time, a long-term vision is important 2. Revenue collects through equitable and efficient ways 3. Increase prepayment and reduce out-of-pocket payment 4. Improve financial risk protection through an appropriate benefit package 5. Improve service quality and control cost through a set of provider payment mechanisms. 19 | Health System Financing Thank you for your attention!