1. Insurance as a Sub-Function of Finance

2. Relations between functions and objectives of a health system Stewardship (oversight) Financing (collecting, pooling And purchasing) Creating resources (investment And training) Delivering services (provision) Responsiveness (to non-medical expectations) Fair (financial) contribution Health Functions the system performsObjectives of the system

3. Sub-functions of health system financing To ensure that individuals have access to health services, three interrelated sub- functions of health system financing are crucial:  Revenue collection  Pooling of resources  Purchasing of interventions

4. Revenue Collection Is the process by which the health system receives money from house-holds and organizations or companies, as well as from donors.

5. Different ways of collecting Revenues General taxation Mandated social health insurance contributions (usually salary-related and almost never risk-related) Voluntary private health insurance contributions (usually risk-related) Out-of-pocket payment Donations

6. Pooling 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).

7. Pooling or Collecting The main purpose of pooling is to share the financial risk associated with health interventions for which the need is uncertain Collecting 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

8. Pooling for which interventions? For those activities for which there is no uncertainty or the cost is low (e.g. check-ups), funds can go directly from collecting to purchasing. Consumer preferences for insurance packages often focus on interventions of high probability and low cost, although these are best paid for out of current income or through direct public subsidies for the poor.

9. Pooling and uncertainty Pooling reduces uncertainty for both citizens and provider.

10. Purchasing Purchasing is the process by which pooled funds are paid to providers in order to deliver a specified or unspecified set of health interventions; there are two main type of purchasing: 1.Passive purchasing 2.Strategic purchasing

11. Health insurance Health insurance is a health financing mechanism that involves both pre- payment and risk pooling.

12. Pre-payment: Collection and management of revenues so that contributions for the health care system are collected from individuals prior to (and independently from) the utilisation by individuals of health services.

13. Pooling: Collection and management of revenues in such a way to ensure that the risk of having to pay for health care is borne by all members of the pool and not by each contributor individually.

14. Alternative options for financing health care systems. Prepayment NoYes Pooling No Out of Pocket Payment Medical Saving Accounts Yes Spontaneous Charity Health Insurance

15. Alternative options for financing health care systems. Prepayment NoYes Pooling No Out of Pocket Payment Medical Saving Accounts Yes Spontaneous Charity Health Insurance

16. Alternative options for financing health care systems. Prepayment NoYes Pooling No Out of Pocket Payment Medical Saving Accounts Yes Spontaneous Charity Health Insurance

17. Alternative options for financing health care systems. Prepayment NoYes Pooling No Out of Pocket Payment Medical Saving Accounts Yes Spontaneous Charity Health Insurance

18. Alternative options for financing health care systems. Prepayment NoYes Pooling No Out of Pocket Payment Medical Saving Accounts Yes Spontaneous Charity Health Insurance

19. Health insurance Health insurance can be defined as a way to distribute the financial risk associated with the variation of individuals’ health care expenditures by pooling costs over time (pre- payment) and over people (pooling).

20. Factor of income: subsiding the poor 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.

21. Importance of Direction of Subsidy  Health 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 (from the poor to the rich)

22. Pooling to redistribute risk, cross-subsidy for greater equity Contribution Net Transfer Utilization Low Risk High Risk Subsidy across equal incomes Subsidy across equal risks Low Income High Income

23. Poolng Pooling Across Time: Prepayment Pooling Across People: –Healthy to ill subsidy –Rich to poor subsidy

24. Financing Organizations  Collecting, pooling, purchasing and provision imply flows of funds from sources to providers through a variety of organizations, which may perform only one, or several of these tasks.

25. Health Policy and Insurance  Health system policy with regard to pooling needs to focus on creating conditions for the development of the largest possible pooling arrangements.

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