FinancingFinancing Financing is the process by which Financing is the process by which

revenues are collectedrevenues are collected from primary from primary and secondary sources, and secondary sources, accumulatedaccumulated in in fund pools and fund pools and allocatedallocated to provider to provider activities. The activities. The financing functionfinancing function itself itself can usefully be divided further into can usefully be divided further into three sub-functions: three sub-functions:

Revenue collection Revenue collection Fund pooling Fund pooling PurchasingPurchasing

Revenue CollectionRevenue Collection Revenue collection is the first sub-Revenue collection is the first sub-

function of health system financing. function of health system financing. Although it is common to distinguish Although it is common to distinguish between resources that come from between resources that come from householdshouseholds, , firmsfirms, , governmentsgovernments, and , and donor agencies. It is important to realize donor agencies. It is important to realize that that all funds that are used for health all funds that are used for health services ultimately come from services ultimately come from householdshouseholds or external donors. or external donors.

The money provided by governments The money provided by governments comes from:comes from:

taxes paid by households directly (e.g. taxes paid by households directly (e.g. income and sales taxes);income and sales taxes);

taxes paid by households indirectly taxes paid by households indirectly through purchasing imports (tariffs); andthrough purchasing imports (tariffs); and

taxes paid by households indirectly taxes paid by households indirectly through purchasing domestically produced through purchasing domestically produced goods (etc. sales taxes, employer goods (etc. sales taxes, employer contribution to social security)contribution to social security)

There are several mechanisms for There are several mechanisms for revenue collection which can be revenue collection which can be out-out-of-pocket, prepaid, or externalof-pocket, prepaid, or external::

""Out-of-pocketOut-of-pocket" expenditures " expenditures includeinclude fees that cover the fees that cover the entire entire cost of a servicecost of a service; ; user feesuser fees that are that are complemented by publicly supported complemented by publicly supported health facilities and salaries for health facilities and salaries for personnel; or personnel; or copaymentscopayments that are that are part of an insurance program;part of an insurance program;

""PrepaidPrepaid" expenditures include " expenditures include voluntary insurance premiums (as in community-voluntary insurance premiums (as in community-

based health insurance or private health based health insurance or private health insurance); insurance);

compulsory insurance premiums (as in universal compulsory insurance premiums (as in universal health insurance systems); health insurance systems);

payroll taxes (as in countries with social security payroll taxes (as in countries with social security institutions); institutions);

general taxes (as in national health services); and general taxes (as in national health services); and earmarked taxes (specific taxes set aside for earmarked taxes (specific taxes set aside for

supporting health services).supporting health services).

External grantsExternal grants are funds that are are funds that are donated or contributed by foreign donated or contributed by foreign governments, international agencies governments, international agencies or individuals. Though governments or individuals. Though governments are private entities.are private entities.

What makes for a good collection system?What makes for a good collection system? A good collection system contributes to improved A good collection system contributes to improved

health conditions by generating enough resources health conditions by generating enough resources to adequately finance the health system. But to adequately finance the health system. But collection systems also affect a variety of other collection systems also affect a variety of other social goals, namely: social goals, namely:

solidarity (fairness in paying for the health solidarity (fairness in paying for the health services relative to income); services relative to income);

financial protection (giving individuals claims on financial protection (giving individuals claims on the health system that protect them from the health system that protect them from catastrophic health expenditures in case of catastrophic health expenditures in case of illness); andillness); and

accountability (responsible use of collected funds). accountability (responsible use of collected funds).

Mobilizing financial resources is Mobilizing financial resources is affected by affected by how those paying how those paying see their contributions linked see their contributions linked to the benefits they receiveto the benefits they receive. . Hence, it is relatively easy to Hence, it is relatively easy to mobilize out-of-pocket spending in mobilize out-of-pocket spending in terms of services received, and much terms of services received, and much more difficult to “motivate” increases more difficult to “motivate” increases in general taxes. in general taxes.

Arguments in favor of distinguishing Arguments in favor of distinguishing health service financing from other health service financing from other forms of taxation or collection rely forms of taxation or collection rely primarily on arguments of a primarily on arguments of a political political or social natureor social nature. For example, . For example, some argue that it easier to increase some argue that it easier to increase revenue collection if citizens are told revenue collection if citizens are told that payments will that payments will be exclusively be exclusively reserved to fund health servicesreserved to fund health services..

Also, many countries have pre-Also, many countries have pre-existing institutions, such as workers' existing institutions, such as workers' health insurance funds, that already health insurance funds, that already distinguish health service payments distinguish health service payments from other contributions. In such from other contributions. In such cases, countries may find it less costly cases, countries may find it less costly and/or politically easier to adapt or and/or politically easier to adapt or expand the existing mechanisms for expand the existing mechanisms for raising revenues. They includes;raising revenues. They includes;

EarmarkedEarmarked taxes taxes and and mandatory mandatory contributions dedicated to health contributions dedicated to health insurance. insurance. They can sometimes assure a They can sometimes assure a regular source of additional revenue for a regular source of additional revenue for a particular function, but they can also particular function, but they can also reduce flexibility over time in allocating reduce flexibility over time in allocating public funds to the best possible use; public funds to the best possible use;

{{VaghfVaghf} } So-called So-called "sin taxes""sin taxes" which have two which have two

additional characteristics; additional characteristics;

On the one handOn the one hand, studies have shown , studies have shown that "sin" taxes are effective in that "sin" taxes are effective in reducing reducing the demandthe demand for harmful substancesfor harmful substances, , such as tobacco and alcohol, by raising the such as tobacco and alcohol, by raising the price closer to its true social cost and price closer to its true social cost and increasing the price faced by consumers; increasing the price faced by consumers;

On the other handOn the other hand, if these taxes , if these taxes become an important source of revenues, become an important source of revenues, they can generate a conflict of interests they can generate a conflict of interests for public officials.for public officials.

Payroll taxesPayroll taxes, along with many other , along with many other forms of mandatory contribution, can forms of mandatory contribution, can be an effective way to generate be an effective way to generate resources for the health sector for resources for the health sector for several reasons: they can be several reasons: they can be inexpensive to administerinexpensive to administer and and they they can be utilized to pursue can be utilized to pursue redistributive aimsredistributive aims. .

Redistribution tends to be limited, as; Redistribution tends to be limited, as;

Contributions are levied against labor Contributions are levied against labor income and normally do not touch income and normally do not touch returns to capital; and returns to capital; and

it is also limited to a relatively it is also limited to a relatively privileged part of the workforce in privileged part of the workforce in many developing countries because many developing countries because the formal sector, on which such the formal sector, on which such mandates are placed, is generally mandates are placed, is generally small.small.

Since the health sector may utilize a Since the health sector may utilize a significant amount of domestic resources, it significant amount of domestic resources, it is important to be aware that is important to be aware that revenue revenue collection for health services may collection for health services may create problems for other parts of create problems for other parts of public policypublic policy. For example, in small open . For example, in small open economies where growth of labor economies where growth of labor productivity is modest, productivity is modest, taxing labor may taxing labor may reduce employment, or lead to greater reduce employment, or lead to greater informalisation of the economy, or tax informalisation of the economy, or tax evasion, quality reduction evasion, quality reduction

Therefore collection policies that rely on taxes or Therefore collection policies that rely on taxes or mandatory contributions need to address issues mandatory contributions need to address issues common to all fiscal revenue mechanisms, such as: common to all fiscal revenue mechanisms, such as:

the most effective marginal tax and contribution the most effective marginal tax and contribution rates; rates;

ease of evasion ease of evasion positive and negative incentives to enhance positive and negative incentives to enhance

compliance; compliance; discrimination in collection discrimination in collection relative importance of taxes or contributions based relative importance of taxes or contributions based

on labor, land, capital; or trade andon labor, land, capital; or trade and disincentive effects of user fees or co-payments. disincentive effects of user fees or co-payments.

Most countries choose to link collection with Most countries choose to link collection with solidarity and financial protection and solidarity and financial protection and therefore aim to collect from therefore aim to collect from contributors contributors in proportion to their capacity to payin proportion to their capacity to pay. . To the extent that a country chooses to link To the extent that a country chooses to link these goals, the literature supports three these goals, the literature supports three general policy recommendations. general policy recommendations.

Countries should try to minimize large out-Countries should try to minimize large out-of-pocket payments by minimizing out-of-of-pocket payments by minimizing out-of-pocket finance generally, or by using pocket finance generally, or by using prepayment to cover large expenses so that prepayment to cover large expenses so that out-of-pocket spending is not catastrophic.out-of-pocket spending is not catastrophic.

Countries who choose to link collection with Countries who choose to link collection with solidarity and financial protection should try to solidarity and financial protection should try to collect funds through progressive means -- collect funds through progressive means -- unless those instruments affect the capacity unless those instruments affect the capacity to generate and apply fundsto generate and apply funds. .

Finally, policies should aim to reduce links Finally, policies should aim to reduce links between contributions and the between contributions and the ability to access ability to access and utilize health servicesand utilize health services (paying attention, (paying attention, again to the impact on generating funds. When again to the impact on generating funds. When the link between payment and access to benefit the link between payment and access to benefit diminishes, the ability to mobilize funds and diminishes, the ability to mobilize funds and enforce accountability may be weakened.enforce accountability may be weakened.

With voluntary prepayment, evasion is not a With voluntary prepayment, evasion is not a serious problem; serious problem;

mutual trust can be built between managers and mutual trust can be built between managers and members; members;

accountability can be enforced through the accountability can be enforced through the individual's ability to withdraw if they are individual's ability to withdraw if they are dissatisfied; anddissatisfied; and

payments can be scaled to capacity to pay. payments can be scaled to capacity to pay. However, However, voluntary prepayment generates a voluntary prepayment generates a

variety of problems unless strong regulatory variety of problems unless strong regulatory mechanisms are put in placemechanisms are put in place. Some of these . Some of these problems include differential access to health problems include differential access to health services and, in the case of insurance schemes, services and, in the case of insurance schemes, adverse selection and risk selection adverse selection and risk selection

Analyzing and setting Analyzing and setting collection policiescollection policies

A first step in any policy discussion requires A first step in any policy discussion requires collecting, disaggregating and analyzing collecting, disaggregating and analyzing the sources of health sector spending so as the sources of health sector spending so as to understand who pays and under what to understand who pays and under what conditions (e.g mandatory or voluntary), conditions (e.g mandatory or voluntary), and not just how much is paid. In many and not just how much is paid. In many cases this requires information about:cases this requires information about:

the general tax and mandatory contribution the general tax and mandatory contribution systems, even if the health system has little systems, even if the health system has little influence over them;influence over them;

Cont…Cont…

out-of-pocket spending, its out-of-pocket spending, its distribution across the population distribution across the population and over time, what it is spent on, and over time, what it is spent on, who is paid, and why people rely on who is paid, and why people rely on this method of obtaining services;this method of obtaining services;

the incidence of catastrophic the incidence of catastrophic spending; and spending; and

financial incentives faced by payers financial incentives faced by payers and payees, alikeand payees, alike

Fund poolingFund pooling

Good pooling contributes to improve Good pooling contributes to improve health conditions by sharing resources health conditions by sharing resources effectively between individuals so that effectively between individuals so that people can get access to services when people can get access to services when needed. Pooling of funds means that needed. Pooling of funds means that financial resources in the pool are no financial resources in the pool are no longer tied to a particular contributor. longer tied to a particular contributor. Healthy people will necessarily pay in Healthy people will necessarily pay in more to the pool than they receive in more to the pool than they receive in terms of health services, while the terms of health services, while the unhealthy will receive more. unhealthy will receive more.

Pooling is distinct from revenue Pooling is distinct from revenue collection. For example, fees paid at collection. For example, fees paid at time of service and medical savings time of service and medical savings accounts pay funds into the health accounts pay funds into the health system but do not pool resources system but do not pool resources across individuals.across individuals.

There are many different forms There are many different forms of pooling. Some common of pooling. Some common

examples include:examples include: Integrated public providers (e.g. the UK and Costa Integrated public providers (e.g. the UK and Costa

Rica)Rica) Single Payer systems (e.g. Canada)Single Payer systems (e.g. Canada) Social Security systems (e.g. Western Europe & Social Security systems (e.g. Western Europe &

Latin America)Latin America) Competing insurers (e.g. US, Colombia, and Competing insurers (e.g. US, Colombia, and

Switzerland)Switzerland) Voluntary health insurance (e.g. Vietnam, Voluntary health insurance (e.g. Vietnam,

Thailand)Thailand) Community-Based Health Insurance (e.g. Community-Based Health Insurance (e.g.

Senegal, Bangladesh) Senegal, Bangladesh)

There are four important There are four important characteristics of pooling:characteristics of pooling:

its scopeits scopethe number of poolsthe number of poolswhether or not its mandatorywhether or not its mandatoryand the degree of competition. and the degree of competition.

Financing Health Financing Health CareCare

های -- -- فعالیت مالی تامین برای پول های چگونه فعالیت مالی تامین برای پول چگونهاسفاده مورد چگونه و شود می فراهم اسفاده بهداشتی مورد چگونه و شود می فراهم بهداشتی

) تخصیص ) گیرد می (قرار تخصیص ) گیرد می ..قرار

پرداخت - - های مکانیزم یا ان چگونگی و ها پرداخت پرداخت های مکانیزم یا ان چگونگی و ها پرداختاست مالی تامین سکه دوم است روی مالی تامین سکه دوم ..روی

یک عملکرد در چشمگیری اثرات مالی یک تامین عملکرد در چشمگیری اثرات مالی تامین. سیستم سیستم دارد . بهداشتی دارد بهداشتی

: که کند می که : تعیین کند می تعیین است موجود پول مقدار است چه موجود پول مقدار چه کشد می دوش بر را مالی بار کسی کشد چه می دوش بر را مالی بار کسی چه ) دارد ) بعهده را صندوق مالی منابع کنترل کسی ( چه دارد ) بعهده را صندوق مالی منابع کنترل کسی چه شوند می کاسه یک و اوری جمع ها ریسک شوند چگونه می کاسه یک و اوری جمع ها ریسک چگونه میتوانند سالمت های مراقبت های هزینه ایا میتوانند و سالمت های مراقبت های هزینه ایا و

خیر یا شوند خیر کنترل یا شوند کنترل

: خود نوبه به ها متغیر :این خود نوبه به ها متغیر این - مردم سالمت مردم - وضعیت سالمت وضعیت - درمانی های هزینه برابر در که درمانی - گروههایی های هزینه برابر در که گروههایی

فقر) خط زیر تا شوند حمایت باید فقر) کاتاستروفیک خط زیر تا شوند حمایت باید کاتاستروفیکو و نیافتند نیافتند

- های مراقبت به مختلف گروههای های - دسترسی مراقبت به مختلف گروههای دسترسیرا را سالمت سالمت

. کنند می .تعیین کنند می تعیین

- وجود مالی مسایل برای جادویی حل راه وجود - هیچ مالی مسایل برای جادویی حل راه هیچندارد.ندارد.

) ( - خارجی کمکهای بجز اعتبارات و پول خارجی - ) ( همه کمکهای بجز اعتبارات و پول همهمی تامین مردم سوی از مستقیم غیر و می مسقیم تامین مردم سوی از مستقیم غیر و مسقیم

شود.شود.: از - متاثر مالی منابع تامین روش :انتخاب از - متاثر مالی منابع تامین روش انتخاب - اجتماعی اجتماعی - ارزشهای ارزشهای - سیاسی سیاسی - فضای فضای

مالی تامین مالی روشهای تامین :: روشهای

عمومی - - عمومی درامد درامداجتماعی - - اجتماعی بیمه بیمهخصوصی - - خصوصی بیمه بیمه

مستقیم - - های مستقیم پرداخت های پرداخت

شود * * می گرفته بکار روشها این از ترکیبی ها کشور از خیلی شود در می گرفته بکار روشها این از ترکیبی ها کشور از خیلی . .در

- - ( فقط : عمومی درامد ) انگلیس فقط : عمومی درامد بیمه% “ بیمه% “ 7676انگلیساجتماعیاجتماعی

خصوصی “ 12% “ 12% خصوصی بیمه های% 1010بیمه پرداخت های% و پرداخت و22مستقیم مستقیم % ).% ).

- - ( فقط : عمومی درامد ) هند فقط : عمومی درامد بیشتر% 7070و% و% 2020هند بیشتر% یا یاازاز

از کمتر و مستقیم از پرداختهای کمتر و مستقیم دیگر% 1010پرداختهای دیگر% از از..منابعمنابع

عملکرد - - بهبود برای مالی استراتژی انتخاب عملکرد در بهبود برای مالی استراتژی انتخاب در نظامنظام

باشد نظر مطمح باید باشد بهداشتی نظر مطمح باید ::بهداشتی

اجتماعی -1 -1 اقتصادی اجتماعی توسعه اقتصادی توسعه

مالی -2 -2 مالی ظرفیت ظرفیت

اندازی -3 -3 راه اندازی قابلیت راه قابلیت

و -4 -4 سیاسی پذیری مسولیت و و پاسخگویی سیاسی پذیری مسولیت و ......پاسخگویی

اجتماعی -1 -1 و سیاسی و اقتصادی اجتماعی توسعه و سیاسی و اقتصادی ::توسعهنمی - - ان با مرتبط سازمان و مالی تامین نمی ساختار ان با مرتبط سازمان و مالی تامین تواندتواندساختار

. برای انچه باشد یکسان جا همه برای و جا . همه برای انچه باشد یکسان جا همه برای و جا همهکاربردی است ممکن کنیا در دارد کارایی کاربردی انگلیس است ممکن کنیا در دارد کارایی انگلیس

باشد باشد نداشته ..نداشتهبا - - زیادی میزان به ملت یک مالی منابع اوری جمع با توان زیادی میزان به ملت یک مالی منابع اوری جمع توان

ان سرانه ان درامد سرانه درامددارد دارد همبستگی ..همبستگی

--

خانوار - - خدمات خرید برای تقاضا و پرداخت ظرفیت خانوار درامد، خدمات خرید برای تقاضا و پرداخت ظرفیت درامد،تعیین تعیین را را

کند کند می ..می

کند - - می روشن را مالیاتی درامدهای و مالیات پایه کند درامد، می روشن را مالیاتی درامدهای و مالیات پایه ..درامد،

دهد - - می بدست ها یارانه تنظیم برای ای دهد پایه می بدست ها یارانه تنظیم برای ای ..پایه

باشد - - داشته نقشی تواند می نیز اجتماعی های بیمه باشد برای داشته نقشی تواند می نیز اجتماعی های بیمه ..برای

نبود صورت در و بحران شرایط در بیمارستان مدیریت نبود سناریوی صورت در و بحران شرایط در بیمارستان مدیریت سناریویکافی مالی کافی منابع مالی منابع

هزینه مراکز مهار و جویی هزینه صرفه مراکز مهار و جویی صرفه – ( ارائه جهت موجود فضاهای بیمارستان زمین از استفاده جدید خدمات ارائه ) – ایجاد جهت موجود فضاهای بیمارستان زمین از استفاده جدید خدمات ایجاد

).... -.... و پزشکی اقالم و لوازم فروش و تجاری و رفاهی متنوع ....(خدمات -.... و پزشکی اقالم و لوازم فروش و تجاری و رفاهی متنوع خدمات( داوطلب نیروهای از )استفاده داوطلب نیروهای از ((NGONGOاستفاده قسمتها برخی کاربری قسمتها تغییر برخی کاربری تغییر بخشها برخی بخشها ادغام برخی ادغام ( الیه چند متمول بیماران برای و خاص بیماریهای برخی برای ها تعرفه الیه ) افزایش چند متمول بیماران برای و خاص بیماریهای برخی برای ها تعرفه افزایش

) خدمات (کردن خدمات کردن خیرین کمک خیرین جذب کمک جذب) ( گذاری سپرده سود بیمارستان حسابهای در پول خواب از (جلوگیری ( گذاری سپرده سود بیمارستان حسابهای در پول خواب از جلوگیری پرداختها کردن پرداختها الترونیک کردن الترونیک شرعی وجوهات شرعی جذب وجوهات جذب – – ( سوزنی طب درمان گیاهی درمان پزشکی جانشین خدمات اندازی سوزنی ) – – راه طب درمان گیاهی درمان پزشکی جانشین خدمات اندازی راه

درمانهای ....(درمانهای ....( تخت چرخش افزایش و بیمار اقامت طول تخت کاهش چرخش افزایش و بیمار اقامت طول کاهش ها اسقاطی ها فروش اسقاطی فروش

باید به تداوم کلیه سیاستهای فوق توجه داشت باید به تداوم کلیه سیاستهای فوق توجه داشت