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Chapter 6 An outcome-oriented health sector

6.4 Funding and allocation of resources for health services and care

6.4.1 Financial resources

Level of financing

Adequate financial resources are a prerequisite for the operation of health services and the delivery of care. Health expenditure as a percentage of GNP depends largely on the economic status of a country, and varies from 3.1% to 10.7% across the Region. Clearly, in some countries of the Region the absolute level of public spending on health is simply inadequate to meet anything like the population’ s reasonable requirements. In many countries, health promotion and disease prevention are inadequately funded. All too often, measures aimed at containing costs have been targeted at patients and users of the health system, rather than at health care institutions and providers.

The trends in the Region indicate the likelihood that additional resources and investments will be directed towards meeting human development needs, especially in health, education and culture.

Health care is part of a continuum of investing in health.

Resources can be released if steps are taken to focus attention on the quality of care and on planning and managing the whole health sector, weighing up the relative values of health promotion, disease prevention, diagnosis/treatment, rehabilitation and care. These resources can then be used to fund some of the new investments that will be required to apply more effective (but often expensive) new technologies and to care for increasing numbers of elderly people.

Sources of funding

Sources of funding vary from country to country, ranging from tax-based to insurance-based systems. There is a considerable debate about how best to fund services so as to maintain universal access and financial sustainability. Most often, a mix of these systems is seen. The countries in the eastern part of the Region have largely implemented tax-based systems, although some are in the process of introducing health insurance. Other countries, especially in the south of the Region, are moving from insurance-based systems to tax-based ones.

Private insurance schemes are often operated in a way that corrodes social solidarity through the use of individual risk rating – a particularly pernicious type of cover. In such cases, the basis of payments by an individual to the health insurance company takes the form of risk-adjusted premiums that reflect his or her health status. A system based on competition between private health insurers will violate the principles of equity and solidarity if insurers seek to select good risks.

Allocation of financial resources

Resources should be allocated in the light of a society’ s needs and priorities. Choices have to be made between geographical areas and services and between particular forms of treatment, and about whether to provide innovative or expensive procedures.

132 HEALTH21: the health for all policy framework for the WHO European Region

In response to concerns about how best to allocate financial resources to facilities and services so as to maximize health gain and reduce costs, several countries have started to examine priority-setting in a more systematic and explicit way in recent years. Setting priorities involves several levels of decision, ranging from those to do with overall funding of health services in relation to other competing claims for resources, to those related to the treatment of individual patients. A number of countries in the Region have moved from integrated models of service provision towards separating public, or quasi-public, third-party payers from providers.

Geographical allocation of resources mostly does not correspond to need. Especially in the eastern part of the Region, infrastructure-based norms are more likely to encourage excess provision than respond to actual needs.

Provider payments

At present, three different systems are used by countries in the European Region to pay primary care physicians – salary, capitation (i.e. an annual amount per person for whom the physician has permanent responsibility) and fee-for-service. Allowances to reward good practice can be combined with any of these three systems. Each has its advantages and disadvantages, and none of them alone can meet all the policy objectives.

Providers of secondary and tertiary care should be paid to contain costs and ensure value for money in terms of health. Traditional approaches to paying hospitals (based on inputs or intermediate outputs such as beds, rather than on outcomes) are not a convenient means of ensuring that these aims are attained, and retrospective hospital payment systems based on service volume are open-ended, making it difficult to control costs and utilization.

TARGET17 – FUNDING HEALTH SERVICES AND ALLOCATING RESOURCES

BY THE YEAR 2010, MEMBER STATES SHOULD HAVE SUSTAINABLE FINANCING AND RESOURCE ALLOCATION MECHANISMS FOR HEALTH CARE SYSTEMS BASED ON THE PRINCIPLES OF EQUAL ACCESS,COSTEFFECTIVENESS,SOLIDARITY,AND OPTIMUM QUALITY.

In particular:

17.1 spending on health services should be adequate, while corresponding to the health needs of the population;

17.2 resources should be allocated between health promotion and protection, treatment and care, taking account of health impact, cost–effectiveness and the available scientific evidence;

17.3 funding systems for health care guarantee universal coverage, solidarity and sustainability.

Sustainable funding for health services

The level of financial resources required to operate a health service is impossible to specify in absolute terms, and it is not easy to correlate that level of funding with a country’ s health experience. Certainly the amount should be affordable by the country and enough to meet the needs of both health promotion and the provision of effective and high quality care. These objectives are simply stated but much more difficult to reconcile in practice. Nevertheless, a comparative analysis of current European experience suggests that 7–10% of GDP may provide for a reasonable spread of health system capacity and performance, dependent of course on an adequate overall level of national GDP. Furthermore, in most countries expenditure trends over time ought to show an increase in the share of resources allocated to health promotion and disease prevention, and to PHC.

It should be noted that this range is indicative only; individual countries must determine the best level based on their economic resources, their health experience, and their need for health promotion and the provision of effective and high-quality care.

Collective funding and solidarity

Regardless of the main method of funding used, governments, as the elected representatives of the people, have the responsibility of ensuring solidarity and universal access to health services, as well as of containing overall costs. Governments may have different positions, for instance as the main source of funds (in countries with taxation-based arrangements) or as the regulator of contributions (in countries with social insurance systems). In both cases, however, their role in ensuring universal access and solidarity is crucial and should not be diminished.

Measures should be taken to promote collective funding, whether by insurance or taxation, to ensure solidarity and “risk pooling”. A core concern in countries engaged in transforming their funding systems is to balance the principle of solidarity with increasing pressures to introduce competition mechanisms, which are considered to promote quality of care and efficient use of resources. In terms of solidarity, sizeable out-of-pocket payments at the point of use are the most regressive form of payment for health care, since they represent a greater share of income for the poor who are also higher consumers of care. Collective experience indicates that no funding reforms should be introduced that would directly damage solidarity.

Where countries in transition to a market economy are switching to social insurance-based financing, the introduction of such a system should be done with care, to ensure that the complex institutional and technological structures required to manage a new system really do function as they should.

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MARKETS AND HEALTH CARE

Available evidence from both western and eastern Europe indicates that unfettered markets are not compatible with the nature of health as a social good. Market mechanisms in health care are likely to be more successful, financially and operationally, if they are focused on hospitals and physicians; in contrast, efforts to create competition among multiple private insurers or to require increased co-payments from patients have been notably less successful.

For the application of market mechanisms to service providers to work well, the State needs to steer and regulate these relationships. While the mix of public/private ownership of provider institutions varies greatly across Europe, both efficiency and equity require consistent and stable State regulation.

Source: Saltman, R.B & Figueras, J. European health care reform.Analysis of current strategies. Copenhagen, WHO Regional Office for Europe, 1997 (WHO Regional Publications, European Series, No. 72).

Resource allocation according to need

The evidence suggests that a strategic approach to resource allocation and priority-setting is needed, in order to coordinate decision-making at different levels, and this should start with a discussion and a decision on the values and principles to be applied when determining need and selecting priorities. A debate (involving government, health service and care providers, the public and patients) on the ethical, political and social questions that need to be addressed must precede any decision on the rationing of resources. Any rationing of access to necessary services should be preceded by a thorough scrutiny of the overall organization and of the cost and effectiveness of the services and care provided.

Needs-based resource allocation formulae have been introduced into some countries in the western part of the Region and are now being developed in some countries in the eastern part, in particular regarding the geographical allocation of resources and services.

Contracting is a mechanism that offers an alternative to traditional models of resource allocation, binding third-party payers and providers to explicit commitments and generating the economic motivation to meet these commitments. Four major reasons have been put forward for introducing contractual relationships into tax-based systems, based on the long experience of health insurance systems:

to encourage decentralization

to improve the performance of providers

to improve the planning of health service and care development

to improve management.

Contracts can support equity if, through needs assessment, resources are allocated as a priority explicitly to disadvantaged population groups. The role of governments should be to ensure equity, in order to avoid over-emphasizing profitable, rather than effective, services.

Provider payments to create incentives for quality Paying primary health care providers

Payment systems for PHC providers should contribute to achievement of the best possible health outcomes. An optimum payment system for PHC providers should also ensure the following:

financial management of the different components of PHC within a country’ s total health care expenditure; a balanced package of health promotion, disease prevention, treatment, and rehabilitative services; a free choice of health care provider (nurse, physician, hospital) for all individuals; a structure of fair rewards for practitioners which recognizes workload and professional merit;

acceptance of health care providers’ responsibility for and accountability to the population and responsiveness to the needs of the community, the family and the individual; promotion of close collaboration among health care providers; and a democratic system of decision-making. Finally, the system should allow purposeful, flexible management aimed at achieving continuous quality development and greater cost–effectiveness.

Mixed payment systems, with a prospective component based on capitation together with fee-for-service for selected items, seem to be more successful in controlling costs at the macro level, while ensuring both patient and provider satisfaction and achieving efficiency and quality at the micro level. The tools available for management include the use of different incentives to influence patterns of care (e.g. to offer more preventive services) and ensure equitable distribution of primary care providers throughout the country.

Paying for secondary and tertiary care

Prospective budgeting has evident merits: it limits expenditure to funding a given level of service provision that is determined in advance for a defined period. A prospective budgeting system can be recommended if it incorporates the use of case-mix controls and output measures. Classification systems based on diagnosis or on the characteristics of the patients can be used to better analyse cost structures, evaluate hospital performance and quality of care, and make comparisons between hospitals in terms of costs and quality, as well as in negotiating contracts between hospitals and those purchasing services.

Alternatively, a volume-based approach can be made to work by using prospective pricing and contracting or planning agreements for agreed levels of service provision. In this way, hospitals can be obliged to achieve specific objectives of cost control and effective resource utilization, stimulating them to review and adjust their current organization, staffing levels and internal resource allocation.

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