Classifications of Health Financing:

Transcription

1 SHA Revision Classifications of Health Financing: Units 9 and 10 First IHAT Draft 11 th Meeting of Health Accounts Experts Paris, 7-8 October

2 Overview Key components of the accounting framework for health financing: concepts, classifications, accounts, indicators Classification of Health Financing Schemes (ICHA-HF) Classification of Financing Sources (ICHA-FS) Feedback from the consultation process: advantages and disadvantages of the proposal Points for discussion 2

3 Requirements for the accounting framework for health financing To improve the analytical power of SHA different needs of countries / current vs. future needs To improve the comparability of health expenditure data together with other elements of SHA 2.0 To ensure feasibility of regular data reporting current vs. future possibilities 3

4 Main components of the accounting framework Key concepts and definitions providing a comprehensive framework Tools proposed for international data collection Classifications Accounts (allocation of resources; revenueraising) Key indicators

5 Main components of the accounting framework (cont.) Optional tools justified by different needs and capacity of countries future analytical needs 5

6 Key concepts Health financing schemes as the main building blocks of a country s health financing systems Financing agents: institutional units managing health financing schemes a financing scheme can be managed by one or more types of institutional units Financing sources: institutional units providing revenues Revenues of health financing schemes

7 Current framework Functions (HC) Financing sources (FS) Financing agents / schemes (HF) Providers (HP) Proposed framework Functions (HC) Financing Sources (FS) Types of revenues Financing schemes (HF) Financing agents Providers (HP)

8 Classifications Proposed for international data collection Classification of Health Financing Schemes: ICHA-HF Classification of Financing Sources: ICHA-FS Optional tools Classification of Financing Agents: ICHA-FA Classification of Revenues of Health Financing Schemes: ICHA-R potential tool for international data collection 8

9 Proposed tables for international data collection Financing sources HF FS Types of Revenues (*) HF R(*) Financing schemes HF HC Functions HF HP Providers */under discussion

10 Definition of Health Financing Schemes Health financing schemes are financing arrangements defined by their rules over mode of participation, basis for entitlement and coverage (who gets what); revenue-collection and pooling mechanisms ( and how it is financed) 10

11 Health financing schemes are managed by one or more institutional units, but are not themselves institutional units Financing schemes An example: financing schemes and institutional units Central government Institutional units (Financing agents) Social security funds Insurance corporations Non-profit Institutions Households Government funded schemes (programs) Compulsory social insurance Voluntary private insurance Foreign aid programmes Out-of-pocket payments

12 Classification of Health Financing Schemes: ICHA-HF HF.1 Social and compulsory private health financing schemes HF.1.1 Government funded schemes (with sub-categories ) HF.1.2 Social health insurance (with sub-categories) HF.1.3 HF.2 HF.2.1 HF.2.2 HF.2.3 HF.3 Compulsory private health insurance Voluntary private schemes (other than OOP) Voluntary health insurance (with sub-categories, including Voluntary Community-based insurance ) NPISHs- funded schemes Enterprises funded schemes (other than employer-based insurance) Households out-of-pocket payment (with sub-categories) HF.4 Rest of the World funded programmes 12

13 What are the main differences at the 1st level categories? HF.1: Social and compulsory private (health financing) schemes HF.2: Voluntary private schemes (other than OOP) HF.3: Household out-ofpocket payment HF.4: Rest of the world funded schemes Characteristics of financing schemes - aimed at ensuring access to basic health care for the whole society / large part / vulnerable groups - pre-paid arrangements; -private initiatives; -access to care is based on discretion of private actors. - households direct payment at the time of the use of services - resources are provided by RoW, - separate budget and management for the use of funds 13

14 HF.1 SHA 2.0 vs. SHA 1.0 Revised ICHA-HF SHA Manual (current Version 1.0) Social and compulsory private schemes HF.1 HF.1.1 Government funded schemes HF.1.1 HF Central government funded schemes HF General government General government excluding social security funds Central government HF State/regional/local government funded schemes HF HF State/provincial government Local/municipal government HF.1.2 Social health insurance HF.1.2 Social security funds HF HF HF.1.3 National health insurance (NHI) Social health insurance (excluding NHI) Compulsory private insurance 14

15 SHA 2.0 vs. SHA 1.0 HF.2 HF.2.1 HF HF HF HF HF HF.2.2 HF.2.3 Voluntary private schemes (other than OOP) Voluntary private health insurance Primary insurance coverage schemes Employer-based insurance Community-based insurance Other primary coverage schemes Complementary voluntary insurance schemes NPISHs funded schemes Enterprises funded schemes HF.2 HF.2.1 HF.2.2 HF.2.4 HF.2.5 Private sector Private social insurance Private insurance enterprises (other than social insurance) NPISHs (other than social insurance) Corporations (other than health insurance) 15

16 SHA 2.0 vs. SHA 1.0 Revised ICHA-HF SHA Manual (current Version 1.0) HF.3 HF.3.1 HF.3.2 HF.3.3 Household out-of-pocket payment Out-of-pocket excluding cost sharing Cost sharing: Government schemes and compulsory health insurance Cost sharing: voluntary schemes HF.2.3 HF HF HF Private household out-of-pocket expenditure Out-of-pocket excluding cost sharing Cost sharing: central government Cost sharing: State /provincial government HF Cost sharing: Social security funds HF Cost sharing: other private l insurance HF All other Cost sharing HF.4 Rest of the world funded schemes HF.3 Rest of the world 16

17 Allocation of resources (purchasing): What information is provided by SHA? How much is spent on - main types of services & goods (HCxHF); - main disease or beneficiaries categories, or - to main types of providers (HPxHF) under the particular financing schemes; (Optional tools): What institutional units (financing agents) carry out the purchasing under the particular financing schemes (HFxFA; HFxFAxHC; HFxFAxHP) 17

18 Definition of Financing Sources Financing Sources are institutional units from which health financing schemes collect / receive their revenues (through specific mechanisms, e.g., contributions to insurance, premiums paid, foreign grant, voluntary transfer, etc.). Government is treated as a financing source for government funded health financing schemes. Households are considered the financing source of outof-pocket payments 18

19 Classification of Financing Sources FS.1. FS.2 FS.3 FS.4 FS.5 FS.1.1 FS.1.2 FS.1.3 FS.1.4 General Government Corporations Households Central government State/Regional government Local government All Other Government Units Non-profit institutions serving households (NPISHs) Rest of the World 19

20 Differences to current version of FS categories The revised ICHA-FS does not contain the category Private sector Under JHAQ, FS.2: Private sector. However, the meaning of private is ambiguous in this context (Corporations and Households contribute to both public funds and private funds ) FSxHF: revenues raised in a given period may be greater / smaller than the expenditure on health services and goods (HFxHC) 20

21 Revenue collection and pooling: What information is provided by SHA (2.0)? How much revenue; (i) from which institutional units of the economy (HFxFS) (ii) in what ways (HFxR*); are raised for the particular financing schemes (HFxRxFS**) */potential tool for international data collection **/optional tools 21

22 Public versus private Current use of terms is ambiguous: What do the terms of Public expenditure (OECD HD) and Expenditure by general government (SHA tables) refer to? Sources? Contribution mechanisms? Institutional units (collecting revenues / purchasing)? Financing arrangements? 22

23 Public versus private Proposed interpretations 1) From the perspective of financing schemes Public and compulsory private expenditure (can be 2 separate categories); and Voluntary private expenditure 2) From the perspective of compulsory versus voluntary contribution mechanisms Public and compulsory private funds spent on health care (can be 2 separate categories) and private funds spent on health care 23

24 Health spending from public, compulsory private and private funds Revenues of financing schemes Major expenditure aggregates R.1 Non-earmarked revenues of Government Public funds spent on health care R.2 Social insurance contributions R.3 Grants R.4 Subsidies R.5 Government transfer to NPISHs R.6. Compulsory private Insurance premiums Compulsory private funds spent on health care R 7. Voluntary private Insurance premiums Private funds spent on health care R 8 Households disposable income and saving (used for OOP) R.9 Voluntary transfers (other than grants) R.10 Other revenue (not elsewhere classified) 24

25 Optional tools Classification of Financing Agents: ICHA-FA Classification of Revenues of Health Financing Schemes: ICHA-R Optional tables HF x FA; HC x HF x FA; HP x HF x FA Expenditure by diseases, age and gender and Health Financing Schemes HF x R; HFxFSxR Sectoral accounts 25

26 Proposed optional tables HF FS HF HF HF FA HC Functions HF R (*) HFxFA Financing sources Types of Revenues (*) Financing schemes Financing agents HF R FS HF R CA HF FA HP Collecting agents HF HP Providers

27 Advantages of the proposed framework The revised framework: adequately reflects the complex and changing systems of health financing; eliminates the ambiguity regarding some of the ICHA-HF categories in SHA 1.0; distinguishing government funded schemes (as a health financing scheme) and government as institutional unit new tools for country-specific analysis; and sufficiently flexible to accommodate future changes 27

28 Is the implementation feasible? ICHA- HF the proposed changes are in accordance with solutions in national data reporting (e.g., Netherlands, Slovakia) several countries: changes required only in the names of categories ICHA-FS no important changes compared to JHAQ Implementation of optional tools Depends on countries needs and capacity 28

29 Questions for discussion (Unit 9: ICHA-HF) 1. Are the main purposes of the SHA framework for health financing adequately defined? 2. The paper proposes the following key concepts: (i) health financing schemes (ii) financing (purchasing) agents;(iii) financing sources, (iv) revenues of health financing schemes. Is this an adequate starting point for the accounting framework? 3. Are the main proposed categories of ICHA-HF appropriate? Are there any financial arrangements of countries that cannot be brought under any of these categories? 4. Do the proposed tables provide sufficient information concerning the allocation of resources of the main financing sub-systems? 5. Should household out of pocket include /exclude cost-sharing? 29

30 Questions for discussion (Unit 10: ICHA-FS) 5. Are the main proposed categories of the Classification of Financing Sources appropriate? 6. Does the FSxHF table provide sufficient information concerning the revenue-raising of the main financing sub-systems? 7. Would you propose to also collect data for the type of revenues of the health financing schemes (HFx R table)? 8. Is there a need for guidance on how to deal with multiple intermediation of sources such as the flows of funds passing through several institutions before reaching the schemes? 9. What other issues would be useful to present in Unit 10? 30

31 Questions for discussion (Optional tools) Are the main proposed categories of the Classification of Financing Agents appropriate? May the optional HF x FA and HC x HF x FA tables provide useful information for national analysis? Are the main proposed categories of the Classification of Revenues of Financing Schemes appropriate? May the optional HF x R table provide useful information for national analysis? Are the sectoral accounts (see Annex 4) useful additional tools for country-specific analysis? Are the tools proposed for accounting international assistance adequate and sufficient? What other issues would be useful to present among the optional accounting tools? 31

32 Thank you for your attention! 32

33 Additional slides 33

34 Definition of financing agent A financing agent is an institutional unit managing one or more financing schemes: collects revenues and / or purchases services under rules of the given health financing scheme(s). Included are households as financing agent for out-of-pocket payments. 34

35 FA.1. FA.1.1 FA FA FA FA FA.1.2 FA.1.3 FA.1.9 FA.2 FA.2.1 FA.2.2 FA.3 FA.3.1 FA.3.2 FA.4 FA.5 Classification of Financing Agents (ICHA-FA) General Government Central government Ministry of Health Other Ministries and public units (belonging to central government) National Health Service Agency National Health Insurance Agency State /Regional / Local government Social insurance funds All other general government units Insurance corporations Commercial insurance companies Mutual and other non-profit insurance organisations Corporations (other than insurance corporations) Health management and provider corporations Corporations (other than providers of health services) Non-profit Institutions serving households (NPISHs) Households FA.6 FA.6.1 FA.6.2 FA.6.3 Rest of the World International organisations Foreign governments Other foreign entities 35

36 Definition of Revenues The revenue of health financing schemes is an increase in the funds of health financing schemes through specific contribution mechanisms. The categories of revenues are the types of contribution mechanisms, that is, the types of the ways through which funds of financing schemes are collected from financing sources 36

37 Classification of Revenues of financing schemes (ICHA-R) R.1 Non-earmarked revenues of Government (domestic, foreign) R.2 Social insurance contributions (with sub-categories) R.3 Grants R.3.1 Grants from foreign governments R.3.2 From international organisations R.3.3 From other general government unit R.4. Compulsory private Insurance premiums R 5. Voluntary private Insurance premiums R 6 Households disposable income R.7 Other revenue (with sub-categories) R.7.3 Voluntary transfers other than grants R Domestic Voluntary transfers R Foreign Voluntary transfers R.7.4 Miscellaneous and unidentified revenues

38 Types of insurance schemes Social insurance Compulsory private insurance Voluntary insurance National Health Insurance Agency Types of insurer organisations Sickness funds Insurance companies x x x x x x x x x Corporations * */E.g., Including Non-profit Institutions engaged in market production, HMOs, Employer-based organisations x 38

39 Accounting for the different roles of government

40 HF.1 and HF.2: Main differences compared to the current ICHA-HF Revised ICHA-HF Current ICHA-HF HF.1 Financing schemes aimed at ensuring access to basic care for the whole / majority (or most vulnerable groups) of society Regardless whether managed by government units or private enterprises HF.2 Voluntary schemes Regardless whether managed by government units or private enterprises General Government Institutional units of government and social security funds on all levels of government Private sector All institutional units which do not belong to the government 40

41 Example: Health expenditure by financing schemes and financing agents (optional table) HF.1.1 Financing scheme Financing agent County A Country B Government funded schemes (programs ) total 30 5 FA. Ministry of Health 20 Other Ministries 5 NPISHs 5 HF.1.2 Compulsory social insurance total 60 FA.1.4 social security funds 40 FA.3 private insurance companies 20 HF.2.1 Voluntary private insurance total 5 10 FA.3 private insurance companies 5 8 FA.1.4 social security funds 2 HF.3 Households out-of-pocket payment FA.4 Households HF.4 Foreign aid programmes total 15 FA.5 NPISHs (Domestic) 5 FA.1.3 government units 5 FA.5 Foreign NGOs 5

42 Examples for indicators: revenue collection and pooling Share of domestic revenues of Government to current expenditure & gross capital formation Share of grants from international organisations in revenues of government funded schemes Share of foreign voluntary transfers in revenues of government funded schemes / NGOs health programmes Share of government funded schemes (programs), compulsory social insurance, compulsory private insurance, voluntary health insurance, out-of-pocket payments and other private schemes in total current expenditure 42

43 Examples for indicators: allocation of resources Current expenditure by compulsory social insurance (on key healthcare functions) Current expenditure by compulsory social insurance, executed by social security agency Current expenditure by compulsory social insurance, executed by for-profit insurance companies Expenditure on prevention by government funded schemes Expenditure on prevention by government funded schemes, executed by local governments Expenditure on prevention by government funded schemes, executed by NGOs 43

44 Health expenditure by function, financing schemes and financing agent (extract) (optional table) Financing scheme Financing agent Inpatient services Medical goods Preventi on Administ ration HC.I HC.5 HC.6 HC.7 HF.1. 1 Government funded schemes (programs) IS.1.2 IS.5 Local government units NGOs HC.6x HF.1.1 x IS.1.2 HC.6x HF.1.1 x IS.5 HF.1. 2 Compulsory social insurance IS.1.4 IS.3 Social security funds Private insurance companies HC.Ix HF.1.2 X IS.1.4 HC.Ix HF.1.2 X IS.3 IS.5 NGOs HC.6.x HF.4. x IS.5 HF.4 Foreign aid programs) IS.1.3 IS.6 Government units Foreign NGOs HC.6.x HF.4. x IS.6

45 General government units Central government All other public units Corporations Households NPISHs Rest of the world Revenues of Financing Schemes (HF) by Financing Sources (FS) FS.1 FS.1.1 FS.1.3 FS.2 FS 4 FS.5 FS.6 HF.1.1 HF.1.1 General government funded schemes Compulsory social health insurance HF.1.2 Compulsory private insurance HF.2.1 Voluntary private insurance HF.2.4 HF.2.5 HF.3 HF.4 Non-profit institutions serving households Corporations (other than health insurance) Private households out-of-pocket exp. Rest of the world 45

46 Government non-earmarked revenues Social contributions Grants from foreign government Grants from other general government units Compulsory private Insurance premiums (including MSA) Voluntary private Insurance premiums (including MSA) Households disposable income Other revenue Total revenues Total Domestic sources Total Foreign sources Revenues of financing subsystems (HF) by types of revenues (R R.1 R.2 R.3.1 R.3.3 R.4 R.5 R.6 R.7 R.1-7 HF.1 HF.1.1 HF.1.2. HF.1.3 HF.2 HF.2.1. HF.2.2 HF.2.3 HF.3 HF.4 Government and compulsory health insurance Government funded schemes Compulsory social health insurance Compulsory private health insurance Voluntary health schemes (other than OOP) Voluntary private insurance NPISH health programs Corporation health programs Households out-of-pocket payment Rest of the world health programs 46

47 Accounting for International assistance and loans Major forms of transactions: Foreign revenues of health financing sub-systems: (1) grants and voluntary transfers (other than grants) earmarked for health (2) non-earmarked grants and voluntary transfers (other than grants) Loans (changes in financial assets / liabilities), which may: (3) balance the general government budget (4) finance a special health-related programme (e.g., healthspecific loan given by the World Bank)

48 Accounting for international assistance R.1 Non-earmarked revenues of Government: domestic (R.1.1) R.1.2 Non-earmarked revenues of Government: foreign (??) R.2 Social insurance contributions (with sub-categories) R.3 Grants R.3.1 R.3.2 R.3.3 Grants from foreign governments From international organisations From other general government unit R.7 Other revenue (with sub-categories) R.7.3 R R Voluntary transfers other than grants Domestic Voluntary transfers Foreign Voluntary transfers Total domestic revenues Total foreign revenues

49 Accounting for international assistance