《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2000_Health Systems：Improving performance_5 Who Pays for Health Systems?

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WHO PAYS FOR HEALTH SYSTEMS? HOW FINANCING WORKS 19, h care expenditures have risen from 3% of world GDP in 1948 7.9%in 97.This dramaticincrease in spending worldwide has prompted societies every where to look for health financing arrangements which ensure that people are not denie access to care because they cannot afford it. Providing such access to all citizens has lor been a comerstone of modern health financing systems in many countries. The main func tion of the health system is to provide health services to the population, and this chapter concentrates on health financing as a key to effective interaction between providers and citizens. It discusses the purpose of health financing, and the links between health financ ing and service delivery, through purchasing. The factors affecting the performance of health financing are also examined The purpose of health financing is to make funding available, as well as to set the right financial incentives for providers, to ensure that all individuals have access to effectiv lic health and personal health care. This means reducing or eliminating the possibility that an individual will be unable to pay for such care, or will be impoverished as a result of trying to do so To ensure that individuals have access to health services three interrelated functions of health system financing are crucial: revenue collection, pooling of resources, and purchas- g of interventions. The main challenges are to put in place the necessary technical, or- ganizational and institutional arrangements so that such interactions will protect people financially the fairest way possible, and to set incentives for providers that will motivate them to increase health and improve the responsiveness of the system. The three functions are often integrated in a single organization, and this is currently the case in many health systems in the world. Although this chapter discusses the three functions separately, it does not imply that an attempt should be made to separate them in different organizations There is, however, an increasing trend to introduce a separation between financing and provision. Revenue collection is the process by which the health system receives money from hous holds and organizations or companies, as well as from donors. Contributions by donors are discussed in Box 5. 1. Health systems have various ways of collecting revenue, such as gen eral taxation, mandated social health insurance contributions (usually salary-related and almost never risk-related), voluntary private health insurance contributions (usually risk elated), out-of-pocket payment and donations. Most high income countries rely heavily

Who Pays for Health Systems? 95 5 WHO PAYS FOR HEALTH SYSTEMS? HOW FINANCING WORKS ealth care expenditures have risen from 3% of world GDP in 1948 to 7.9% in 1997. This dramatic increase in spending worldwide has prompted societies everywhere to look for health financing arrangements which ensure that people are not denied access to care because they cannot afford it. Providing such access to all citizens has long been a cornerstone of modern health financing systems in many countries. The main function of the health system is to provide health services to the population, and this chapter concentrates on health financing as a key to effective interaction between providers and citizens. It discusses the purpose of health financing, and the links between health financing and service delivery, through purchasing. The factors affecting the performance of health financing are also examined. The purpose of health financing is to make funding available, as well as to set the right financial incentives for providers, to ensure that all individuals have access to effective public health and personal health care. This means reducing or eliminating the possibility that an individual will be unable to pay for such care, or will be impoverished as a result of trying to do so. To ensure that individuals have access to health services, three interrelated functions of health system financing are crucial: revenue collection, pooling of resources, and purchasing of interventions. The main challenges are to put in place the necessary technical, organizational and institutional arrangements so that such interactions will protect people financially the fairest way possible, and to set incentives for providers that will motivate them to increase health and improve the responsiveness of the system. The three functions are often integrated in a single organization, and this is currently the case in many health systems in the world. Although this chapter discusses the three functions separately, it does not imply that an attempt should be made to separate them in different organizations. There is, however, an increasing trend to introduce a separation between financing and provision. Revenue collection is the process by which the health system receives money from households and organizations or companies, as well as from donors. Contributions by donors are discussed in Box 5.1. Health systems have various ways of collecting revenue, such as general taxation, mandated social health insurance contributions (usually salary-related and almost never risk-related), voluntary private health insurance contributions (usually riskrelated), out-of-pocket payment and donations. Most high income countries rely heavily

The World Health Report Box 5. 1 The importance of donor contributions in revenue collection and purchasing in developing countries Donor contributions, as a source countries, rly in Africa, de- Most aid comes in the form of and procedures, rather than con- of revenue for the health system, pend on donors for a large share of projects, which are separately devel- centrating on strategic steward- are of key importance for some total expenditure on health. The oped and negotiated between each ship and health programm developing countries. The absolute fraction can be as high as 40% donor and the national authorities. implementation. Donors and gov- amounts of such aid have been (Uganda in 1993)or even 849 Although by no means unsuccess- ernments are increasingly seeing large in recent years in Angola, (Gambia in 1994)and exceeds 20% ful, international cooperation the need to move away from a Bangladesh, Ecuador, India, Indo- in 1996 or 1997 in Eritrea, Kenya, The through projects can lead to frag- project approach towards wider esia, Mozambique, Papua New Lao People's Democratic Republic mentation and duplication of effort, programme support to long-term uinea, the United Republic of and Mali. Bolivia, Nicaragua, the particularly when many donors are strategic development that is in- Tanzania and several eastern Eu- United Republic of Tanzania and involved, each focusing on their own tegrated into the budgetary pro ropean countries, but in the Zimbabwe have obtained 10% to geographical or programme priori- ess of the country. In this respect larger countries aid is usually only 20% of their resources for health ties. Such an approach forces sector-wide approaches have a small share of total health from donors in one or more recent national authorities to devote sig- been effective in countries such as spending or even of govemment years. nificant amounts of time and effort Bangladesh, Ghana and Pakistan expenditure. In contrast, several to dealing with donors' priorities I Cassels A, Janovsky K. Better health in developing countries: are sector-wide approaches the way of the future? The Lancet,1998,352:1777-1779 on either general taxation or mandated social health insurance contributions. In contrast, low income countries depend far more on out-of-pocket financing: in 60% of countries at incomes below $1000 per capita, out-of-pocket spending is 40% or more of the total whereas only 30% of middle and high income countries depend so heavily on this kind of financing (see Table 5.1) In most social insurance and voluntary private insurance schemes, revenue collection and pooling are integrated in one organization and one purchasing process For organiza tions relying mainly on general taxation, such as ministries of health, collecting is done by the ministry of finance and allocation to the ministry of health occurs through the govern ment budgetary process. Pooling is the accumulation and management of revenues in such a way as to ensure that the risk of having to pay for health care is borne by all the members of the pool and no each contributor individually Pooling is traditionally known as the"insurance function within the health system, whether the insurance is explicit (people knowingly subscribe to a scheme)or implicit (as with tax revenues). Its main purpose is to share the financial risk associated with health interventions for which the need is uncertain. In this way it differs from collecting, which may allow individuals to continue bearing their own risks from their own pockets or savings. When people pay entirely out of pocket, no pooling occurs Table 5.1 Estimated out-of-pocket share in health spending by income level, 1997 Estimated share in total expenditure on health(%) (USS at exchange rate) Under 20 20-29 30-39 40-49 50-59 60 and over Total 10 19 1000-9999 18 73 15 8 All income classes 42 Source who national health accounts estimates income unknown for three countries

96 The World Health Report 2000 on either general taxation or mandated social health insurance contributions. In contrast, low income countries depend far more on out-of-pocket financing: in 60% of countries at incomes below $1000 per capita, out-of-pocket spending is 40% or more of the total whereas only 30% of middle and high income countries depend so heavily on this kind of financing (see Table 5.1). In most social insurance and voluntary private insurance schemes, revenue collection and pooling are integrated in one organization and one purchasing process. For organizations relying mainly on general taxation, such as ministries of health, collecting is done by the ministry of finance and allocation to the ministry of health occurs through the government budgetary process. Pooling is the accumulation and management of revenues in such a way as to ensure that the risk of having to pay for health care is borne by all the members of the pool and not by each contributor individually. Pooling is traditionally known as the “insurance function” within the health system, whether the insurance is explicit (people knowingly subscribe to a scheme) or implicit (as with tax revenues). Its main purpose is to share the financial risk associated with health interventions for which the need is uncertain. In this way it differs from collecting, which may allow individuals to continue bearing their own risks from their own pockets or savings. When people pay entirely out of pocket, no pooling occurs. Table 5.1 Estimated out-of-pocket share in health spending by income level, 1997 (number of countries in each income and expenditure class) Estimated annual Estimated share in total expenditure on health (%) per capita income (US$ at exchange rate) Under 20 20–29 30–39 40–49 50–59 60 and over Total Under 1000 7 10 9 7 11 19 63 1000–9999 16 18 23 15 8 8 88 10 000 and over 19 7 4 5 0 2 37 All income classes 42 35 36 27 19 29 188 Source: WHO national health accounts estimates: income unknown for three countries. Box 5.1 The importance of donor contributions in revenue collection and purchasing in developing countries Donor contributions, as a source of revenue for the health system, are of key importance for some developing countries. The absolute amounts of such aid have been large in recent years in Angola, Bangladesh, Ecuador, India, Indonesia, Mozambique, Papua New Guinea, the United Republic of Tanzania and several eastern European countries, but in the larger countries aid is usually only a small share of total health spending or even of government expenditure. In contrast, several countries, particularly in Africa, depend on donors for a large share of total expenditure on health. The fraction can be as high as 40% (Uganda in 1993) or even 84% (Gambia in 1994) and exceeds 20% in 1996 or 1997 in Eritrea, Kenya, The Lao People‘s Democratic Republic and Mali. Bolivia, Nicaragua, the United Republic of Tanzania and Zimbabwe have obtained 10% to 20% of their resources for health from donors in one or more recent years. Most aid comes in the form of projects, which are separately developed and negotiated between each donor and the national authorities. Although by no means unsuccessful, international cooperation through projects can lead to fragmentation and duplication of effort, particularly when many donors are involved, each focusing on their own geographical or programme priorities. Such an approach forces national authorities to devote significant amounts of time and effort to dealing with donors’ priorities and procedures, rather than concentrating on strategic stewardship and health programme implementation. Donors and governments are increasingly seeing the need to move away from a project approach towards wider programme support to long-term strategic development that is integrated into the budgetary process of the country. In this respect, sector-wide approaches have been effective in countries such as Bangladesh, Ghana and Pakistan.1 1 Cassels A, Janovsky K. Better health in developing countries: are sector-wide approaches the way of the future? The Lancet, 1998, 352:1777–1779

Who Pays for Health St For public health activities and even for aspects of personal health care- such as health check-ups- for which there is no uncertainty or the cost is low, funds can go directly from collecting to purchasing. This is an important consideration with regard to the regulation of mandatory pooling schemes, as consumer preferences for insurance packages often focus on interventions of high probability and low cost(relative to the household capacity to pay), although these are best paid for out of current income or through direct public subsi dies for the poor. poling reduces uncertainty for both citizens and providers. By increasing and stabiliz- ing demand and the flow of funds, pooling can increase the likelihood that patients will be able to afford services and that a higher volume of services will justify new provider invest Purchasing is the process by which pooled funds are paid to providers in order to deliver a specified or unspecified set of health interventions. Purchasing can be performed pas sively or strategically Passive purchasing implies following a predetermined budget or sir ply paying bills when presented. Strategic purchasing involves a continuous search for the best ways to maximize health system performance by deciding which interventions should be purchased, how, and from whom. This means actively choosing interventions in order to achieve the best performance, both for individuals and the population as a whole, by means of selective contracting and incentive schemes. Purchasing uses different instruments for paying providers, inchuding budgeting. Recently, many countries, including Chile (1, 2), Hungary (3), New Zealand(4, 5), and the United Kingdom(6-8), have tried to introduce an active purchasing role within their public health systems PREPAYMENT AND COLLECTION Traditionally, most policy discussions regarding health system financing centre around the impact of public versus private financing on health system performance. Chapter 3 clarifies the central role of public financing in public health For personal health care, how ever, it is not the public-private dichotomy that is most important in determining health system performance but the difference between prepayment and out-of-pocket spending Thus, private financing, particularly in developing countries, is largely synonymous with out-of-pocket spending or with contributions to small, voluntary and often highly frag- mented pools. In contrast, public or mandatory private financing(from general taxation or from contributions to social security) is always associated with prepayment and large pools The way policy-makers organize public financing or influence private financing will affect four key determinants of health system financing performance: the level of prepayment the degree of spreading of risk; the extent to which the poor are subsidized; and strategic A health system where individuals have to pay out of their own pockets for a substantial part of the cost of health services at the moment of seeking treatment clearly restricts access to only those who can afford it, and is likely to exclude the poorest members of societ (9-12). Some important health interventions would not be financed at all if people had pay for them, as is the case for the public good type of interventions discussed in Chapter 3 (13). Fairness of financial risk protection requires the highest possible degree of separation between contributions and utilization. This is particularly so for interventions that are high cost relative to the household's capacity In addition to affording protection against having to pay out of pocket and acing barriers to access, prepayment makes it possible to spread the financial risk among

Who Pays for Health Systems? 97 For public health activities and even for aspects of personal health care – such as health check-ups – for which there is no uncertainty or the cost is low, funds can go directly from collecting to purchasing. This is an important consideration with regard to the regulation of mandatory pooling schemes, as consumer preferences for insurance packages often focus on interventions of high probability and low cost (relative to the household capacity to pay), although these are best paid for out of current income or through direct public subsidies for the poor. Pooling reduces uncertainty for both citizens and providers. By increasing and stabilizing demand and the flow of funds, pooling can increase the likelihood that patients will be able to afford services and that a higher volume of services will justify new provider investments. Purchasing is the process by which pooled funds are paid to providers in order to deliver a specified or unspecified set of health interventions. Purchasing can be performed passively or strategically. Passive purchasing implies following a predetermined budget or simply paying bills when presented. Strategic purchasing involves a continuous search for the best ways to maximize health system performance by deciding which interventions should be purchased, how, and from whom. This means actively choosing interventions in order to achieve the best performance, both for individuals and the population as a whole, by means of selective contracting and incentive schemes. Purchasing uses different instruments for paying providers, including budgeting. Recently, many countries, including Chile (1, 2), Hungary (3), New Zealand (4, 5), and the United Kingdom (6–8), have tried to introduce an active purchasing role within their public health systems. PREPAYMENT AND COLLECTION Traditionally, most policy discussions regarding health system financing centre around the impact of public versus private financing on health system performance. Chapter 3 clarifies the central role of public financing in public health. For personal health care, however, it is not the public–private dichotomy that is most important in determining health system performance but the difference between prepayment and out-of-pocket spending. Thus, private financing, particularly in developing countries, is largely synonymous with out-of-pocket spending or with contributions to small, voluntary and often highly fragmented pools. In contrast, public or mandatory private financing (from general taxation or from contributions to social security) is always associated with prepayment and large pools. The way policy-makers organize public financing or influence private financing will affect four key determinants of health system financing performance: the level of prepayment; the degree of spreading of risk; the extent to which the poor are subsidized; and strategic purchasing. A health system where individuals have to pay out of their own pockets for a substantial part of the cost of health services at the moment of seeking treatment clearly restricts access to only those who can afford it, and is likely to exclude the poorest members of society (9–12). Some important health interventions would not be financed at all if people had to pay for them, as is the case for the public good type of interventions discussed in Chapter 3 (13). Fairness of financial risk protection requires the highest possible degree of separation between contributions and utilization. This is particularly so for interventions that are high cost relative to the household’s capacity to pay. In addition to affording protection against having to pay out of pocket and, as a result, facing barriers to access, prepayment makes it possible to spread the financial risk among

The World Health Report members of a pool, as discussed later in the chapter. Individual out-of-pocket financing does not allow the risk to be shared in that way. In other words, as already proposed by The world health report 1999 (14), there has to be prepayment for effective access to high-cost personal care. The level of prepayment is mainly determined by the predominant revenue collection mechanism in the system. General taxation allows for maximum separation between con tributions and utilization, while out-of-pocket payment represents no separation. Why then is the latter so generally used, particularly in developing countries?(15) The answer is that separation of contributions from utilization requires the agencies onsible for collection to have very strong institutional and organizational capacity. These attributes are lacking developing countries. Thus, although the highest possible level of prepayment is desirable, it is usually very difficult to attain in low income settings where institutions are weak. Relying on prepaid arrangements, particularly general taxa- tion, is institutionally very demanding. General taxation, as the main source of health fi nancing, demands an excellent tax or contribution collecting capacity. This is usually associated with a largely formal economy, whereas in developing countries the informal sector is often predominant. While general taxation on average accounts for more than 40% of GDP in OECD countries, it accounts for less than 20% in low income countries. All other prepayment mechanisms, including social security contributions and volun- tary insurance premiums, are easier to collect, as the benefit of participating is linked to actual contributions. In most cases, participation in social insurance schemes is restricted to formal sector workers who contribute through salary deductions at the workplace. This makes it easier for the social security organization to identify them, collect contributions and possibly exclude them from benefits if no contribution is made. Similarly, identification and collection is easier for voluntary health insurance and community pooling arrange ments. Nevertheless, such prepayment still requires large organizational and institutional capacity compared to out-of-pocket financing In developing countries, therefore, the objective is to create the conditions for revenue collecting mechanisms that will increasingly allow for separation of contributions from utilization In low income countries, where there are usually high levels of out-of-pocket expenditure on health and where organizational and institutional capacity are too weak to make it viable to rely mainly on general taxation to finance health, this means promoting job-based contribution systems where possible, and facilitating the creation of community ased prepayment schemes. Evidence shows (16, 17), however, that although the latter are an improvement over out-of-pocket financing, they are difficult to sustain and ments to improve the targeting of public subsidies in health. In middle income countries, with more formal economies, strategies to increase prepayment as well as pooling arrange bution systems, as well as increasing the share of public financing, particularly for the poor. Although prepayment is a cornerstone of fair health system financing, some direct con tribution at the moment of utilization may be required in low income countries or settings to increase revenues where prepayment capacity is inadequate. It can also be required in the form of co-payment for specific interventions with a view to reducing demand. Such an approach should only be used where there is clear evidence of unjustified over-utilization of the specific intervention as a result of prepayment schemes (moral hazard). The use of Co-payment has the effect of rationing the use of a specific intervention but does not have the effect of rationalizing its demand by consumers. When confronted with co-payments

98 The World Health Report 2000 members of a pool, as discussed later in the chapter. Individual out-of-pocket financing does not allow the risk to be shared in that way. In other words, as already proposed by The world health report 1999 (14), there has to be prepayment for effective access to high-cost personal care. The level of prepayment is mainly determined by the predominant revenue collection mechanism in the system. General taxation allows for maximum separation between contributions and utilization, while out-of-pocket payment represents no separation. Why then is the latter so generally used, particularly in developing countries? (15). The answer is that separation of contributions from utilization requires the agencies responsible for collection to have very strong institutional and organizational capacity. These attributes are lacking in many developing countries. Thus, although the highest possible level of prepayment is desirable, it is usually very difficult to attain in low income settings where institutions are weak. Relying on prepaid arrangements, particularly general taxation, is institutionally very demanding. General taxation, as the main source of health financing, demands an excellent tax or contribution collecting capacity. This is usually associated with a largely formal economy, whereas in developing countries the informal sector is often predominant. While general taxation on average accounts for more than 40% of GDP in OECD countries, it accounts for less than 20% in low income countries. All other prepayment mechanisms, including social security contributions and voluntary insurance premiums, are easier to collect, as the benefit of participating is linked to actual contributions. In most cases, participation in social insurance schemes is restricted to formal sector workers who contribute through salary deductions at the workplace. This makes it easier for the social security organization to identify them, collect contributions and possibly exclude them from benefits if no contribution is made. Similarly, identification and collection is easier for voluntary health insurance and community pooling arrangements. Nevertheless, such prepayment still requires large organizational and institutional capacity compared to out-of-pocket financing. In developing countries, therefore, the objective is to create the conditions for revenue collecting mechanisms that will increasingly allow for separation of contributions from utilization. In low income countries, where there are usually high levels of out-of-pocket expenditure on health and where organizational and institutional capacity are too weak to make it viable to rely mainly on general taxation to finance health, this means promoting job-based contribution systems where possible, and facilitating the creation of community or provider-based prepayment schemes. Evidence shows (16, 17), however, that although the latter are an improvement over out-of-pocket financing, they are difficult to sustain and should be considered only as a transition towards higher levels of pooling or as instruments to improve the targeting of public subsidies in health. In middle income countries, with more formal economies, strategies to increase prepayment as well as pooling arrangements include strengthening and expanding mandatory salary-based or risk-based contribution systems, as well as increasing the share of public financing, particularly for the poor. Although prepayment is a cornerstone of fair health system financing, some direct contribution at the moment of utilization may be required in low income countries or settings to increase revenues where prepayment capacity is inadequate. It can also be required in the form of co-payment for specific interventions with a view to reducing demand. Such an approach should only be used where there is clear evidence of unjustified over-utilization of the specific intervention as a result of prepayment schemes (moral hazard). The use of co-payment has the effect of rationing the use of a specific intervention but does not have the effect of rationalizing its demand by consumers. When confronted with co-payments

Who Pays for Health St people, particularly the poor, will reduce the amount of services demanded(even to the extent of not demanding a service at all) but will not necessarily be more rational in distin guishing when to demand services or which services they need to demand. Therefore, us ing user charges indiscriminately will indiscriminately reduce demand, hurting the poor in particular. Free-of-charge services do not translate automatically into unjustified over-utilization of services. Services that are free of direct charge are in reality not necessarily free or afford able, particularly for the poor, because of other costs associated with seeking health care, such as the cost of medication(when not available free of charge), under-the-table pay- ments, transportation, or time lost from work (18, 19) Given its potentially negative impact on necessary services, especially for the poor, co- payment should not be chosen as a source of financing except for low-cost relatively pre- dictable needs. Rather, it can be used as an instrument to control over-utilization of specific interventions(when such over-utilization is evident) or to implicitly exclude services from a benefit package when explicit exclusion is not possible Because of the desirability of sepa rating contributions from utilization, out-of-pocket payment should not be used unless no other alternative is available. All prepaid arrangements are preferable, except for low-cost interventions for which the administrative costs involved in prepayment arrangements mig not be worthwhile SPREADING RISK AND SUBSIDIZING THE POOR POOLING OF RESOURCES Pooling is the main way to spread risks among participants. Even when there is a high degree of separation between contributions and utilization, prepayment alone does not guarantee fair financing if it is on an individual basis only- that is, via medical savings accounts. Individuals would then have limited access to services after their savings were exhausted. It is claimed for medical savings accounts, which have been implemented in Singapore and in the United States, that they reduce moral hazard and give consumers the incentive to buy services more rationally, but while there is evidence of reduced expendi ture and of substantial savings among those who receive tax benefits and can afford to save (20), there is no evidence of more rational purchasing And individual financing fosters fee- for-service payment and makes it harder to regulate the quality of provision( 21). Peopl with a high risk of having to use services, such as the sick and the elderly, would be denied access because they could not save enough from their income. On the other hand, the healthy and the young, whose risk is usually low, might prepay for a long time without needing the services for which they had saved. In this case, mechanisms allowing for cross- subsidies from the young and healthy to the sick and old would benefit the former without damaging the latter. Thus, systems as well as people benefit from mechanisms that not only increase the degree of prepayment for health services, but also spread the financial risk among their members Ithough prepayment and pooling are a significant improvement over purely out-of- pocket financing, they do not take questions of income into account. As a result of large pools, society takes advantage of economies of scale, the law of large numbers, and subsidies from low-risk to high-risk individuals. Pooling by itself allows for equalization of contributions among members of the pool regardless of their financial risk associated with service utilization. But it also allows the low-risk poor to subsidize the high-risk rich Soci eties interested in equity are not indifferent to who is subsidized by whom. Therefore, health

Who Pays for Health Systems? 99 people, particularly the poor, will reduce the amount of services demanded (even to the extent of not demanding a service at all) but will not necessarily be more rational in distinguishing when to demand services or which services they need to demand. Therefore, using user charges indiscriminately will indiscriminately reduce demand, hurting the poor in particular. Free-of-charge services do not translate automatically into unjustified over-utilization of services. Services that are free of direct charge are in reality not necessarily free or affordable, particularly for the poor, because of other costs associated with seeking health care, such as the cost of medication (when not available free of charge), under-the-table payments, transportation, or time lost from work (18, 19). Given its potentially negative impact on necessary services, especially for the poor, copayment should not be chosen as a source of financing except for low-cost relatively predictable needs. Rather, it can be used as an instrument to control over-utilization of specific interventions (when such over-utilization is evident) or to implicitly exclude services from a benefit package when explicit exclusion is not possible. Because of the desirability of separating contributions from utilization, out-of-pocket payment should not be used unless no other alternative is available. All prepaid arrangements are preferable, except for low-cost interventions for which the administrative costs involved in prepayment arrangements might not be worthwhile. SPREADING RISK AND SUBSIDIZING THE POOR: POOLING OF RESOURCES Pooling is the main way to spread risks among participants. Even when there is a high degree of separation between contributions and utilization, prepayment alone does not guarantee fair financing if it is on an individual basis only – that is, via medical savings accounts. Individuals would then have limited access to services after their savings were exhausted. It is claimed for medical savings accounts, which have been implemented in Singapore and in the United States, that they reduce moral hazard and give consumers the incentive to buy services more rationally, but while there is evidence of reduced expenditure and of substantial savings among those who receive tax benefits and can afford to save (20), there is no evidence of more rational purchasing. And individual financing fosters feefor-service payment and makes it harder to regulate the quality of provision (21). People with a high risk of having to use services, such as the sick and the elderly, would be denied access because they could not save enough from their income. On the other hand, the healthy and the young, whose risk is usually low, might prepay for a long time without needing the services for which they had saved. In this case, mechanisms allowing for crosssubsidies from the young and healthy to the sick and old would benefit the former without damaging the latter. Thus, systems as well as people benefit from mechanisms that not only increase the degree of prepayment for health services, but also spread the financial risk among their members. Although prepayment and pooling are a significant improvement over purely out-ofpocket financing, they do not take questions of income into account. As a result of large pools, society takes advantage of economies of scale, the law of large numbers, and crosssubsidies from low-risk to high-risk individuals. Pooling by itself allows for equalization of contributions among members of the pool regardless of their financial risk associated with service utilization. But it also allows the low-risk poor to subsidize the high-risk rich. Societies interested in equity are not indifferent to who is subsidized by whom. Therefore, health

The World Health Report financing, in addition to ensuring cross-subsidies from low to high risk(which will happen in any pool, unless contributions are risk-related), should also ensure that such subsidies (see Figure 5.1) Health systems throughout the world attempt to spread risk and subsidize the poor through various combinations of organizational and technical arrangements(22). Both risk and income-related cross-subsidies could occur among the members of the same pool, for example in single pool systems such as the Costa Rican social security organization and the ational health service in the UK, or via government subsidies to a single or multiple pool In practice, in the majority of health systems, risk and income cross-subsidization oc curs via a combination of two approaches: pooling and government subsidy. Cros subsidization can also occur among members of different pools (in a multiple pool system via explicit risk and income equalization mechanisms, such as those being used in the social security systems of Argentina(23), Colombia(24)and the Netherlands(25). In these countries, the existence of multiple pools allows members of pools to have different risk and income profiles Without some compensatory mechanisms, such arrangements would offer incentives for pooling organizations to select low risks, and to exclude the poor and the sick Even under single pool organizations, decentralization, unless accompanied by equali zation mechanisms for resource allocation, may result in significant risk and income differ- ences among decentralized regions. Brazil has introduced compensatory mechanisms in the allocation of revenues from the central government to the states to reduce such differ- ences(26) Table 5.2 shows four country examples of different arrangements for spreading risk and subsidizing the poor. Some organizational arrangements are less efficient than others in ensuring that these two objectives are achieved, particularly if the arrangements facilitate fragmentation, creating numerous small pools. Collecting, pooling, purchasing and provi- Figure 5.1 Pooling to redistribute risk, and cross-subsidy for greater equity (arrows indicate flow of funds) Contribution Net transfer Utilization bsid

100 The World Health Report 2000 financing, in addition to ensuring cross-subsidies from low to high risk (which will happen in any pool, unless contributions are risk-related), should also ensure that such subsidies are not regressive (see Figure 5.1). Health systems throughout the world attempt to spread risk and subsidize the poor through various combinations of organizational and technical arrangements (22). Both riskand income-related cross-subsidies could occur among the members of the same pool, for example in single pool systems such as the Costa Rican social security organization and the national health service in the UK, or via government subsidies to a single or multiple pool arrangement. In practice, in the majority of health systems, risk and income cross-subsidization occurs via a combination of two approaches: pooling and government subsidy. Crosssubsidization can also occur among members of different pools (in a multiple pool system) via explicit risk and income equalization mechanisms, such as those being used in the social security systems of Argentina (23), Colombia (24) and the Netherlands (25). In these countries, the existence of multiple pools allows members of pools to have different risk and income profiles. Without some compensatory mechanisms, such arrangements would offer incentives for pooling organizations to select low risks, and to exclude the poor and the sick. Even under single pool organizations, decentralization, unless accompanied by equalization mechanisms for resource allocation, may result in significant risk and income differences among decentralized regions. Brazil has introduced compensatory mechanisms in the allocation of revenues from the central government to the states to reduce such differences (26). Table 5.2 shows four country examples of different arrangements for spreading risk and subsidizing the poor. Some organizational arrangements are less efficient than others in ensuring that these two objectives are achieved, particularly if the arrangements facilitate fragmentation, creating numerous small pools. Collecting, pooling, purchasing and proviFigure 5.1 Pooling to redistribute risk, and cross-subsidy for greater equity (arrows indicate flow of funds) Pooling (across equal incomes) Risk Low High Subsidy (across equal risks) Income Low High Contribution Net transfer Utilization

Who Pays for Health St sion imply flows of funds from sources to providers through a variety of organizations, which may perform only one, or several of these tasks. Figure 5. 2 illustrates the structure of health system financing in four countries which differ greatly in the degree to which there is formal pooling of funds and purchasing rather than consumers paying directly to pro- Large pools are better than small ones because they can increase resource availability for health services. The larger the pool, the bigger the share of contributions that can be allo- cated exclusively to health services. A large pool can take advantage of economies of scale in administration and reduce the level of the contributions required to protect against certain needs, while still ensuring that there are sufficient funds to pay for services. Given that needs vary unpredictably, the estimation for an individual could be unaffordably large By reducing this uncertainty, the pool is able to reduce the amount set aside as a financial reserve to deal with variations in the health expenditure estimates for its members. It can then use the funds released for more and better services Fragmentation of the pool-in other words, the existence of too many small org . of all tions involved in revenue collection, pooling and purchasing -damages performance of all three tasks, particularly pooling. In fragmented systems, it is not the number of existing pools and purchasers that matters, but that many of them are too small. In Argentina, prior to the 1996 reforms, there were more than 300 pooling organizations(Obras Sociales Nacionales) for formal sector workers and their families, some with no more than 50 000 members. The administrative capacity and financial reserves required to ensure financial viability for the small ones, together with the low wages of their beneficiaries, guaranteed that their benefit packages were very limited. A similar problem occurs with community Table 5.2 Approaches to spreading risk and subsidizing the poor: country cases Country System Spreading risk Subsidizing the poor Multiple pools: multiple Intra-pool via non-risk-related Intra-pool and inter-pool: salary inter-pool via a related contribution plus explicit organizations, municipal health central risk equalization fund. subsidy paid to the systems and Ministry of Health Mandated minimum benefit poor to join social security; supply package for all members of all side subsidy via the Ministry of Health and municipal systems Netherlands Multiple pools: predominantly Intra-pool via non-risk-related private competing social insurance contribution and inter-pool via excluding the rich. organizations. central risk equalization fund. Republic of Korea Two main pools: national health Intra-pool via non-risk-related insurance and the Ministry of contribution. supply side subsidy via the Health Ministry of Health and national cit single benefit package for health insurance from Ministry of National health insurance health expenditures of any Public subsidy for insurance for the member poor and farmers Zambia Single predominant formal pool: Intra-pool, implicit single benefit Intra-pool via general taxation Ministry of Health/Central Board of package for all in the Ministry of Supply side subsidy via Health Health System and at state level. Ministry of Health Financed via general taxes

Who Pays for Health Systems? 101 sion imply flows of funds from sources to providers through a variety of organizations, which may perform only one, or several of these tasks. Figure 5.2 illustrates the structure of health system financing in four countries which differ greatly in the degree to which there is formal pooling of funds and purchasing, rather than consumers paying directly to providers without any sharing of risks. Large pools are better than small ones because they can increase resource availability for health services. The larger the pool, the bigger the share of contributions that can be allocated exclusively to health services. A large pool can take advantage of economies of scale in administration and reduce the level of the contributions required to protect against uncertain needs, while still ensuring that there are sufficient funds to pay for services. Given that needs vary unpredictably, the estimation for an individual could be unaffordably large. By reducing this uncertainty, the pool is able to reduce the amount set aside as a financial reserve to deal with variations in the health expenditure estimates for its members. It can then use the funds released for more and better services. Fragmentation of the pool – in other words, the existence of too many small organizations involved in revenue collection, pooling and purchasing – damages performance of all three tasks, particularly pooling. In fragmented systems, it is not the number of existing pools and purchasers that matters, but that many of them are too small. In Argentina, prior to the 1996 reforms, there were more than 300 pooling organizations (Obras Sociales Nacionales) for formal sector workers and their families, some with no more than 50 000 members. The administrative capacity and financial reserves required to ensure financial viability for the small ones, together with the low wages of their beneficiaries, guaranteed that their benefit packages were very limited. A similar problem occurs with community Table 5.2 Approaches to spreading risk and subsidizing the poor: country cases Country Colombia Netherlands Republic of Korea Zambia System Multiple pools: multiple competing social security organizations, municipal health systems and Ministry of Health. Multiple pools: predominantly private competing social insurance organizations. Two main pools: national health insurance and the Ministry of Health. National health insurance, however, only covers 30% of total health expenditures of any member. Single predominant formal pool: Ministry of Health/Central Board of Health. Spreading risk Intra-pool via non-risk-related contribution and inter-pool via a central risk equalization fund. Mandated minimum benefit package for all members of all pools. Intra-pool via non-risk-related contribution and inter-pool via central risk equalization fund. Intra-pool via non-risk-related contribution. Explicit single benefit package for all members. Intra-pool, implicit single benefit package for all in the Ministry of Health System and at state level. Financed via general taxes. Subsidizing the poor Intra-pool and inter-pool: salaryrelated contribution plus explicit subsidy paid to the insurer for the poor to join social security; supply side subsidy via the Ministry of Health and municipal systems. Via risk equalization fund, excluding the rich. Salary-related contribution plus supply side subsidy via the Ministry of Health and national health insurance from Ministry of Finance allocations. Public subsidy for insurance for the poor and farmers. Intra-pool via general taxation. Supply side subsidy via the Ministry of Health

Who Pays for Health Systen 103 pooling arrangements in developing countries. Although an improvement over out-of- pocket financing, their size and organizational capacity often threatens their financial sustainability(16, 17). Predominantly out-of-pocket financing represents the highest de gree of fragmentation. In such a case, each individual constitutes a pool and thus has to pay for his or her own health services Larger is better for pooling and purchasing. But economies of scale show diminishing returns and, beyond a critical size, marginal benefits may be negligible. The argument for large pools is therefore not an argument for single pools when multiple pools can exist without fragmentation, and when their size and financing mechanisms allow for adequate spreading of risk and subsidization of the poor. Health system policy with regard to pooling needs to focus on creating conditions for the development of the largest possible pooling arrangements. Where a particular country for the moment lacks the organizational and institutional capacity to have a single pool or large pools for all citizens, policy-makers and donors should try to create the enabling conditions for such pools. Meanwhile, policy-makers should promote pooling arrange ments whenever possible, as a transitional stage towards the future aggregation of pools Even small pools or pools for segments of the population are better than pure out-of pocket financing for all Opposing or neglecting such arrangements until the capacity ex- ists for the establishment of an effective single pool has two drawbacks. It deprives consumer of improved protection. And it may prevent the state from regulating such initiatives and teering them towards future large or single pool arrangements. Introducing regulations such as community rating(adjusting for the average risk of a group), portable employ- ment-based mum benefit packages(access to the same services in all pools), in addition to protecting members of the pools, may pave the way for larger pooling in the future or low income economies where the formal sector is small, this means promoting pooling at the community level. Communities'lack of trust in local pooling organization might be a limiting factor, but such initiatives offer an important opportunity for interna tional cooperation whereby donors act as guarantor for the community and help create the necessary organizational and institutional capacity For middle income developing coun- establishing a large pool or enacting regulation to specify a minimum size of pool for finan ial viability, as well as regulating pooling initiatives in a way that will facilitate consolida tion in the future However, competition among pools is not entirely bad. It can increase the responsive- ss of pooling organizations to their members and provide an incentive for innovation. It can also offer incentives for reducing costs( to increase market share and profits), for exam- ple through mergers, as in the reform of the quasi-public health insurance organizations (Obras Sociales) in Argentina in 1996. Lack of competition meant that the administrators were little concerned about high administrative costs and small benefits for their member as they had in any case a captive group of contributors. Competition and the resulting mergers, together with explicit subsidies for low-income beneficiaries, have allowed I bers of small pools to join larger pools and obtain better benefits for the same level of contributions Despite its potential benefits, pooling competition poses significant problems to health ystems, particularly in selection behaviour by both pooling organizations and consumers Mandatory participation(that is, all eligible members must join the pooling organization) gnificantly reduces the scope of selection behaviour but does not totally eliminate the

Who Pays for Health Systems? 103 pooling arrangements in developing countries. Although an improvement over out-ofpocket financing, their size and organizational capacity often threatens their financial sustainability (16, 17). Predominantly out-of-pocket financing represents the highest degree of fragmentation. In such a case, each individual constitutes a pool and thus has to pay for his or her own health services. Larger is better for pooling and purchasing. But economies of scale show diminishing returns and, beyond a critical size, marginal benefits may be negligible. The argument for large pools is therefore not an argument for single pools when multiple pools can exist without fragmentation, and when their size and financing mechanisms allow for adequate spreading of risk and subsidization of the poor. Health system policy with regard to pooling needs to focus on creating conditions for the development of the largest possible pooling arrangements. Where a particular country for the moment lacks the organizational and institutional capacity to have a single pool or large pools for all citizens, policy-makers and donors should try to create the enabling conditions for such pools. Meanwhile, policy-makers should promote pooling arrangements whenever possible, as a transitional stage towards the future aggregation of pools. Even small pools or pools for segments of the population are better than pure out-ofpocket financing for all. Opposing or neglecting such arrangements until the capacity exists for the establishment of an effective single pool has two drawbacks. It deprives consumers of improved protection. And it may prevent the state from regulating such initiatives and steering them towards future large or single pool arrangements. Introducing regulations such as community rating (adjusting for the average risk of a group), portable employment-based pooling (insurance that a worker keeps when changing jobs) and equal minimum benefit packages (access to the same services in all pools), in addition to protecting members of the pools, may pave the way for larger pooling in the future. For low income economies where the formal sector is small, this means promoting pooling at the community level. Communities’ lack of trust in local pooling organizations might be a limiting factor, but such initiatives offer an important opportunity for international cooperation whereby donors act as guarantor for the community and help create the necessary organizational and institutional capacity. For middle income developing countries, this means both encouraging the creation of pools and, where possible, either directly establishing a large pool or enacting regulation to specify a minimum size of pool for financial viability, as well as regulating pooling initiatives in a way that will facilitate consolidation in the future. However, competition among pools is not entirely bad. It can increase the responsiveness of pooling organizations to their members and provide an incentive for innovation. It can also offer incentives for reducing costs (to increase market share and profits), for example through mergers, as in the reform of the quasi-public health insurance organizations (Obras Sociales) in Argentina in 1996. Lack of competition meant that the administrators were little concerned about high administrative costs and small benefits for their members, as they had in any case a captive group of contributors. Competition and the resulting mergers, together with explicit subsidies for low-income beneficiaries, have allowed members of small pools to join larger pools and obtain better benefits for the same level of contributions. Despite its potential benefits, pooling competition poses significant problems to health systems, particularly in selection behaviour by both pooling organizations and consumers. Mandatory participation (that is, all eligible members must join the pooling organization) significantly reduces the scope of selection behaviour but does not totally eliminate the

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