Key performance indicators for the implementation of social health insurance

Several low- and middle-income countries are interested in extending their existing health insurance for specific groups to eventually cover their entire populations. For those countries interested in such an extension, it is important to understand what characterises a well performing social health insurance scheme. This article provides a simple framework to analyse key performance issues related to the functions of health financing within the context of social health insurance. The framework first illustrates how performance in the health financing functions of revenue collection, pooling and purchasing affects the realisation of health financing targets of resource generation, optimal resource use and financial accessibility of health services for all. Then, within each health financing function, key performance issues and associated measurable indicators are developed. 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. In doing so, policy makers can come closer to achieving universal coverage -- access to appropriate healthcare for all at an affordable cost -- the ultimate goal of social health insurance.     

The desirability and feasibility of scaling up community health insurance in low-income settings--lessons from Armenia

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling-up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders.     

Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia

Based on a household survey conducted in Tbilisi, Georgia, in 2000, this paper examines current patterns of health care-seeking behaviour and the extent of out-of-pocket payments. Results show that health care services are a financial burden and that private (out-of-pocket) payment creates financial barriers to accessing health services. Members of the poorest households are less likely to seek care than people from more affluent households, and devote a higher share of household monthly expenditure to health care. Households have adopted various strategies to overcome these financial barriers, but the strategies are likely to contribute to both declining economic status and worsening health outcomes. The paper provides an evidence base to help direct future policy reform in Georgia. Government needs to: (1) prioritize public financing of services for the poor, in particular through amending the Basic Benefit Package so that it better reflects the needs of the poor; (2) promote the quality and utilization of primary care services; (3) address the issue of rational drug use; and (4) consider mobilizing out-of-pocket payments on a pre-paid basis through formal or community-based risk pooling schemes.     

Health care financing in Asia: key issues and challenges

This article examines the major elements of health care financing such as financial risk protection, resource generation, resource pooling, and purchasing and payment; provides key lessons; and discusses the challenges for health care financing systems of Asian countries. With the exception of Japan, Korea, Taiwan, and Thailand, most health care systems of Asia provide very limited financial risk protection. The role of public prepaid schemes such as tax and social health insurance is minimal, and out-of-pocket payment is a major source of financing. The large informal sector is a major challenge to the extension of population coverage in many low-income countries of Asia, which must seek the optimal mix of tax subsidy and health insurance for universal coverage. Implementation of effective payment systems to control the behavior of health care providers is also a key factor in the success of health care financing reform in Asia.     

Regulating private health insurance to serve the public interest: policy issues for developing countries

Private health insurance plays a large and increasing role around the world. This paper reviews international experiences and shows that private health insurance is significant in countries with widely different income levels and health system structures. It contrasts trends in private health insurance expansion across regions and highlights countries with particularly important experiences of private coverage. It then discusses the regulatory approaches and policies that can structure private health insurance markets in ways that mobilize resources for health care, promote financial risk protection, protect consumers and reduce inequities. The paper argues that policy makers need to confront the role that private health insurance will play in their health systems and regulate the sector appropriately so that it serves public goals of universal coverage and equity.     

Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: A study of policy barriers and opportunities in Cambodia

Reaching out to the poor and the informal sector is a major challenge for achieving universal coverage in lesser-developed countries. In Cambodia, extensive coverage by health equity funds for the poor has created the opportunity to consolidate various non-government health financing schemes under the government's proposed social health protection structure. This paper identifies the main policy and operational challenges to strengthening existing arrangements for the poor and the informal sector, and considers policy options to address these barriers. Conducted in conjunction with the Cambodian Ministry of Health in 2011–12, the study reviewed policy documents and collected qualitative data through 18 semi-structured key informant interviews with government, non-government and donor officials. Data were analysed using the Organizational Assessment for Improving and Strengthening Health Financing conceptual framework. We found that a significant shortfall related to institutional, organisational and health financing issues resulted in fragmentation and constrained the implementation of social health protection schemes, including health equity funds, community-based health insurance, vouchers and others. Key documents proposed the establishment of a national structure for the unification of the informal-sector schemes but left unresolved issues related to structure, institutional capacity and the third-party status of the national agency. This study adds to the evidence base on appropriate and effective institutional and organizational arrangements for social health protection in the informal sector in developing countries. Among the key lessons are: the need to expand the fiscal space for health care; a commitment to equity; specific measures to protect the poor; building national capacity for administration of universal coverage; and working within the specific national context.     

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out‐of‐pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.     

Financial preconditions for successful community initiatives for the uninsured

Community-based initiatives are increasingly being implemented as a strategy to address the health needs of the community, with a growing body of evidence on successes of various initiatives. This study addresses financial status indicators (preconditions) that might predict where community-based initiatives might have a better chance for success. We evaluated five community-based initiatives funded by the Communities in Charge (CIC) program sponsored by the Robert Wood Johnson Foundation. These initiatives focus on increasing access by easing financial barriers to care for the uninsured. At each site, we collected information on financial status indicators and interviewed key personnel from health services delivery and financing organizations. With full acknowledgment of the caveats associated with generalizations based on a small number of observations, we suggest four financial preconditions associated with successful initiation of CIC programs: (1) uncompensated care levels that negatively affect profitability, (2) reasonable financial stability of providers, (3) stable health insurance market, and (4) the potential to create new sources of funding. In general, sites that demonstrate successful program initiation are financially stressed enough by uncompensated care to gain the attention of local healthcare providers. However, they are not so strained and so concerned about revenue sources that they cannot afford to participate in the initiative. In addition to political and managerial indicators, we suggest that planning for community-based initiatives should include financial indicators of current health services delivery and financing organizations and consideration of whether they meet preconditions for success.     

基于ILO筹资模型的儿童口腔保险筹资水平研究——以四川省城镇职工家庭儿童为例

目的 估计四川省城镇职工家庭0~18岁儿童口腔保险的筹资水平,为儿童口腔保险的开展和政策制定部门提供参考意见。 方法 利用ILO模型对某专科口腔医院儿童口腔科7个月的门诊电子病历数据,结合全国第三次口腔流行病调查数据、国家卫计委等统计数据进行分析。 结果 将儿童口腔疾病诊断数据划分为3个等级,1级是预防性治疗,级别越高治疗程度越复杂。为了提高预防性治疗的使用率,预防性治疗100%的报销。按照级别越低报销程度越高的思路进行分级报销。利用ILO模型测算出2015年四川城镇儿童口腔保险筹资水平为每个儿童家庭缴纳保费125.04元/年,可以建立以预防为主的儿童口腔保险。 结论 结果显示较低的年费用就可以支撑以预防为主的儿童口腔保险的开展,建议卫生政策制定部门尽快将儿童口腔疾病纳入到基本医疗保险,可以更有效的保障儿童口腔健康。     

The role of community-based health insurance within the health care financing system: a framework for analysis

There is increasing advocacy for community-based health insurance (CBHI) schemes as part of a broader solution to health care financing problems in low-income countries, but to date there is very limited understanding of how CBHI schemes interact with other elements of a health care financing system. This paper aims to set out a preliminary conceptual framework for understanding such interactions, and highlights the kind of research questions raised by such a framework. A basic conceptual map of a CBHI scheme is developed, and extensions added to this map that incorporate (1). effects upon non-members of schemes, (2). government subsidies to providers, (3). government subsidies to schemes, and (4). issues raised by the existence of multiple risk-pooling schemes in a particular context. The utility of a broader approach to analyzing/assessing CBHI schemes is illustrated through examination of two policy issues, namely (1). coordination of CBHI risk pools and government risk pools, and (2). equity implications of CBHI schemes and the role of government subsidies in such schemes. It is concluded that there is a strong need for empirical work to explore how CBHI schemes and the broader health care financing system interact, and that even if individual schemes achieve their own objectives (in terms of equity, efficiency etc.), this does not necessarily imply that such objectives will be achieved at the system level.