DESK REVIEWS | 02.02. Health system financing

DESK REVIEW | 02.02. Health system financing

The Brazilian health system is financed through taxes, social contributions (taxes for special programmes), out-of-pocket spending, and employers’ healthcare contributions (Paim et al., 2011). The financing of the SUS is funded by the public sector through three levels of governance (federal, states, and municipalities) and it is guaranteed by the Federal Constitution of 1988 (Presidency of Republic of Brazil, 1988). Funding for the SUS comes from tax revenues and social contributions of the federal government, and from state, and municipal budgets (Paim et al., 2011). The federal government is the main financing body and follows a calculation based on GDP that reveals the percentage to be invested in SUS per year (Presidency of Republic of Brazil, 2012, p. 141).

According to the Law N. 141 (2012), states and municipalities must invest a minimum of 12% and 15% of their revenue in SUS, respectively (Presidency of Republic of Brazil, 2012). However, funding for the SUS has not been enough to ensure adequate or stable financial resources for the public system (Paim et al., 2011). The private health sector is financed both by the SUS (via services contracted-out by the public health system) and by private sources such as individuals who make out-of-pocket payments for private health services and employer’s healthcare contributions. Data show that in 2017, private health services accounted for 66.8% of families’ health-related expenditure (Brazilian Institute of Geography and Statistics, 2019a).

References:

Brazilian Institute of Geography and Statistics. (2019a). Conta-satélite de saúde: Brasil: 2010-2017. https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101690

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

Presidency of Republic of Brazil. (1988). Federal Constitution of Brazil. http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm

Presidency of Republic of Brazil. (2012). Lcp 141. http://www.planalto.gov.br/CCIVIL_03/LEIS/LCP/Lcp141.htm

Projeto de Lei do Senado n° 74, de 2014. (2014). https://www25.senado.leg.br/web/atividade/materias/-/materia/116394

Household health expenditures comprised 54.3% (including insurance contributions) of THE in 2017-2018 (NHSRC, 2021). Out-of-pocket (OOP) expenditures contributed to 48.8% of THE in 2017-2018 (NHSRC, 2021). Government health expenditures comprised 40.8% of THE in the same period (NHSRC, 2021).

Of the Current Health Expenditure, Union Government and State Government’s share is Rs.60,442 crores (12%) and Rs.90872 crores (18.1%) respectively in 2017-2018 (NHSRC, 2021). Local bodies’ share is Rs.4965 crores (1%), Households share (including insurance contributions) about Rs.3,008,225 crores (61.4%, OOPE being 55.1%) (NHSRC, 2021). Enterprises contribution (including insurance contributions) is Rs.26,335 crores (5.3%), NGOs is Rs.7,936 crores (1.6), and funding from external donors contributes to about Rs.2955 crores (0.6%) in 2017-2018 (NHSRC, 2021).

References:

National Health System Resource Centre (NHSRC). (2021). National Health Accounts-Estimates for India: 2017-2018. Ministry of Health and Family Welfare, Government of India. Available from: https://nhsrcindia.org/sites/default/files/2021-11/National%20Health%20Accounts-%202017-18.pdf

The NIHS/BPJS is a single quasi-government entity and the biggest single-payer system globally (Agustina et al., 2019, pp.76,88). The system is financed from three sources. First, contributing members pay insurance premiums. Second, for non-contributing members the insurance premiums are covered by the government of Indonesia. Third, additional revenue is received from income tax, tobacco tax, district-level payments as well as grants from overseas development agencies (Agustina et al., 2019, p.88). However, a World Bank report maintains that despite reform, out of pocket spending for health continues to be one of the main financing mechanisms of the health care system (World Bank, 2016b, p.4).

The NIHS/BPJS system contracts primary care providers as well as hospital providers directly. Primary care providers are paid through a capitation system and advance payments, while secondary providers (hospitals) are reimbursed through diagnosis-based group (CBG) tariffs allocated by the Ministry of Health (Agustina et al., 2019, pp.76,88). The direct contracting system enabled the NHIS to enrol 20,000 primary care providers, 907 public and 1,106 private hospitals as well as pharmacists, dispensaries, laboratories, and radiology centres (Agustina et al., 2019, p.89).

In terms of allocation of funding, it is clear that political emphasis lies on curative and rehabilitative care. The largest share of health expenditure accounts for hospital care (over 65%), with approximately 50% financing in-patient and 15% percent financing outpatient care. A further 20% of health expenditure support care in the Puskesmas and in private clinics. Less than one per cent of the budget are allocated for prevention and health promotion (World Bank, 2016b, p.5).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. Available at: http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

 

Health care in Kenya is financed through three main sources (Munge & Briggs, 2014):

  • Direct payments (out-of-pocket payments (OOP)): This forms the highest proportion out of the sources of health-care financing for public health expenditure and fully for private health expenditure,
  • Government expenditure (through taxation, employer schemes, health insurance etc.),
  • Donors

OOPs are charged for health care services in public and private health institutions and accounted for nearly 30% of the total expenditure on health, thus reducing access to care. However, recently there has been an increase in government investment to reduce the financial burden on the poor and vulnerable populations through abolishing user fees in public health facilities (e.g., Makueni County), the provision of free maternity and the introduction of a Health Insurance Subsidy Programme. Half of the total health budget is allocated to the three referral hospitals and the remaining resources are allocated to the 47 counties. Payments are provided in block grants, depending on the size of the population, poverty levels, land share etc. Apart from the county Departments of Health budget from the national government (forming 36.4% of the total budget), the counties also collect their own revenue through households (37.3%), donors (16.3%) and NGOs (10.1%) (Maina et al., 2016). Donor funding is mainly concentrated in areas with high HIV prevalence such as Siaya, Kisumu, Migori, Mombasa and Turkana (T. Maina et al., 2016). This funding is channelled either through the government budgetary system referred to as “on-budget” or through the extra-budgetary known as “off-budget” via donor administered programmes e.g. the World Bank Multi-Country HIV/AIDS Programme (MAP) or NGOs (KNASA & NACC, 2014). The private sector is mainly funded by donors through grants/programmes to NGOs, health insurance (Marek et al., 2005) and out-of-pocket payments.

References:

KNASA, & NACC. (2014). Kenya National Aids Spending Assessment Report for the Financial Years 2009/10-2011/12. https://unaids-test.unaids.org/sites/default/files/unaids/contentassets/documents/data-and-analysis/tools/nasa/20141017/kenya_2009_en.pdf

Maina, T., Akumu, A., & Muchiri, S. (2016). Kenya County Health Accounts: Summary of Findings from 12 Pilot Counties. Washington, DC. https://www.healthpolicyproject.com/pubs/7885_FINALSynthesisreportoftheCHA.pdf

Marek, B. T., Farrell, C. O., Yamamoto, C., & Zable, I. (2005). Trends and Opportunities in Public-private Partnerships to Improve Health Service Delivery in Africa. Human Development Sector Africa Region, The World Bank. https://documents1.worldbank.org/curated/en/480361468008714070/pdf/336460AFR0HDwp931health1service.pdf

Munge, K., & Briggs, A. H. (2014). The progressivity of health-care financing in Kenya. Health Policy and Planning, 29(7), 912–920. https://doi.org/10.1093/heapol/czt073

Each of the subsystems that form the health system in Mexico is financed differently. The IMSS and ISSSTE, the two main social security institutions for those in formal employment in the private and public sectors respectively, are financed based on a three-party funding scheme with fees provided by the employer, the employee, and the government; whereas public services provided by the MoH are funded entirely through general taxes. In addition, other institutions have their own health services and social security benefit schemes and financing such as the Navy and the Army (Armed Forces), and public companies such as PEMEX.

We could not find precise estimates about that. However, based on data from the National Regulatory Agency for Private Health Insurances and Plans (ANS – Agência Nacional de Saúde Suplementar), we estimated that by the end of 2018, around 77% of the population were not covered by private health insurance (National Regulatory Agency for Private Health Insurances and Plans, 2019b).

References:

National Regulatory Agency for Private Health Insurances and Plans, M. (2019b). Caderno de Informação da Saúde Suplementar: Beneficiários, operadoras e planos. Março 2019. https://www.gov.br/ans/pt-br/arquivos/acesso-a-informacao/perfil-do-setor/dados-e-indicadores-do-setor/informacoes-gerais/total-cad-info-jun-2019.pdf

Less than 20% of the population was covered by any form of health insurance in 2014, based on the National Sample Survey (71st round) of household data (National Sample Survey Office (NSSO), 2015). An estimate of the National Health Profile (Central Bureau of Health Intelligence (CBHI), 2019), states that about 48 crore individuals were covered by any health insurance in 2017-2018, which is about 37.2% of the population. A more recent National Family Health Survey (NFHS-5) 2019-2021, found that 41% of households with any usual member was covered under a health insurance/financing scheme. In principle, all citizens are eligible to receive health services in tax-financed public facilities (Gupta, 2020). In practice, there are major supply side constraints that limit access to public facilities, resulting in high out-of-pocket expenditures at private facilities by households (Gupta, 2020).

References:

Central Bureau of Health Intelligence (CBHI). (2019). National Health Profile. Ministry of Health & Family Welfare, Government of India. Available from http://www.cbhidghs.nic.in/showfile.php?lid=1147

Gupta, I. (2020). India | Commonwealth Fund. Commonwealthfund.org. Retrieved from: https://www.commonwealthfund.org/international-health-policy-center/countries/india.

National Sample Survey Office (NSSO). (2015). Key Indicators of Social Consumption in India Health -NSS 71st Round. Ministry of Statistics and Programme Implementation, Government of India. Available from https://www.thehinducentre.com/resources/article7378862.ece

It is estimated that 16 per cent of the Indonesian population was not covered by health insurance in 2017. The NIHS covered 70 per cent of the population and approximately 14 per cent of the population were covered through private health insurance (Agustina et al., 2019, p.90).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

75% of the population in Kenya is not covered under any health (insurance) and typically relies fully on out of pocket expenses (Kenya Healthcare Federation and Task Force Health Care, 2016). Those who are not insured tend to have lower education, live in rural and remote areas, unemployed and are more likely to be women (Kazungu and Barasa, 2017).

References:

Kazungu, J. S., & Barasa, E. W. (2017). Examining levels, distribution and correlates of health insurance coverage in Kenya. Tropical Medicine & International Health, 22(9), 1175–1185.  https://doi.org/10.1111/tmi.12912

Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya. http://khf.co.ke/wp-content/uploads/2018/03/2016-Kenyan-Healthcare-Sector-Report.pdf

According to INEGI, 17.3% of total population in 2015 was not covered by health insurance (INEGI, 2015a). People who are not affiliated to any social security institution (IMSS, ISSSTE, etc.) or public insurance mechanism (Seguro Popular) by law could access MoH services. However, it is frequent that only in the case of acute problems (heart attack) or accidents they would access these and most likely solve minor issues within the private sector, such as consultations within pharmacies in the private sector or private sector physicians, which can be found in most places, but this doesn’t necessarily equal optimal and quality care.

References:

INEGI. (2015a). Encuesta Intercensal 2015 Estados Unidos Mexicanos. Instituto Nacional de Estadística y Geografía, 1, 85–90.

In 2004 Kenya adopted a uniform user fee policy “the 10/20” policy to generate revenue at the lower-level facilities. Standardized fees were set at a flat rate of 10 Kenya shillings in dispensaries (table 2) and 10 Kenya shillings in health centres (table 2). Any fees are waived for people requiring treatment for malaria, tuberculosis, and sexually transmitted diseases, for children under 5 years old, for births and antenatal care (ANC) services and for people from poor households. However, clear guidelines on laboratory fees inclusion and criteria to identify patients from poor households were missing from the policy.

As a result, adherence to this policy was minimal with:

  • patients paying for services at private shops that could have been free (but may not have been available at the facility)
  • health facilities loading expenses associated with free services on other non-free services
  • patients paying more than the specified amount due to:
    1. the facilities’ need for revenue
    2. the lack of strategies to compensate facilities for lost revenue or lack of awareness of the policy (Onsomu et al., 2014; Opwora et al., 2015).

It is estimated that out of pocket expense contribute to 26.1% out of the total health expenditure (World Health Organization, 2017b). In 2018, about  7% of households in Kenya faced catastrophic expenditures due to OOP payments (Salari et al., 2019). Furthermore,  75% of the population is not covered under any health insurance and typically relies on out of pocket expenses to cover the cost of care (Kenya Healthcare Federation and Task Force Health Care, 2016). However, it is the goal of the UHC, currently under trial, to tackle the high out-of-pocket costs by ensuring that citizens can access good quality and affordable (without paying out of their own pockets) basic health services (Wangia & Kandie, 2018).

References:

Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya. http://khf.co.ke/wp-content/uploads/2018/03/2016-Kenyan-Healthcare-Sector-Report.pdf

Onsomu, D., Muthaka, G., Mwabu, O., Nyanjom, A., Dutta, T. M., Maina, C. B., & Muchir, S. (2014). Public Expenditure Tracking Survey in Kenya, 2012 (PETS-Plus). Washington, DC. https://www.healthpolicyproject.com/pubs/479_KenyaPETSPlusReportFINAL.pdf

Opwora, A., Waweru, E., Toda, M., Noor, A., Edwards, T., Fegan, G., … Goodman, C. (2015). Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue. Health Policy and Planning, 30(4), 508–517. https://doi.org/10.1093/heapol/czu026

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6). https://doi.org/10.1136/bmjgh-2019-001809

Wangia, E., & Kandie, C. (2018). Policy brief: Refocusing on quality of care and increasing demand for services; Essential elements in attaining universal health coverage in Kenya. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2019/01/UHC-QI-Policy-Brief.pdf

World Health Organization. (2017b). Primary Health Care Systems (PRIMASYS): Case Study from Kenya, abridged version. Geneva. https://www.who.int/alliance-hpsr/projects/Alliance-PRIMASYS-Kenya-comprehensive.pdf

Brazil is undergoing a socio-political and economic transition. Since 2018, Brazil is under a new government, which has been adopting austerity measures that are likely to affect the SUS. Some estimates show impacts that might be linked to these measures on healthcare of the population, such as: increased infant mortality, worsened regional disparity regarding infant mortality, increased inequalities regarding the Family Health Strategy (FHS) coverage and among mothers who regularly attend antenatal care centres. Changes in FHS coverage are likely to affect smaller municipalities disproportionately, given the stronger dependence of small municipalities on primary healthcare (Castro et al., 2019). So far, no comprehensive plan for the future exists. While the Constitutional Amendment Proposal Number 241 (PEC 241), approved in 2016, limits public expenditures and consequently affects the SUS, the Ministry of Health has strengthened the Primary Healthcare by expanding the number of working hours and the quantity of primary healthcare units. However, it is still too early to assess possible changes in the financing of the health system.

References:

Castro, M. C., Massuda, A., Almeida, G., Menezes-Filho, N. A., Andrade, M. V., Noronha, K. V. M. de S., Rocha, R., Macinko, J., Hone, T., Tasca, R., Giovanella, L., Malik, A. M., Werneck, H., Fachine, L. A., & Rifat, A. (2019). Brazil’s unified health system: The first 30 years and prospects for the future. Lancet Health Public. https://www.abrasco.org.br/site/wp-content/uploads/2019/07/PIIS0140673619312437.pdf

India has a semi-federal governance structure. Public responsibilities are shared either by the Union or the States or both. Health is a State subject in India. Thus, Union and State strategies for health might align, differ, or co-adapt. Government spending on health is mainly based on budget allocations as part of the annually announced Union (Central) budget as well as state budget allocations and central transfers to states.

A scheme launched by the Government of India in 2018 is the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY), which is part of the Ayushman Bharat programme. This scheme is designed to have a defined benefit cover of Rs. 5 lakh per family per year (National Health Portal, 2019). Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private impanelled hospitals across the country (National Health Portal, 2019). It is an entitlement-based scheme with entitlement decided based on deprivation criteria in the Socio-Economic Caste Census database (National Health Portal, 2019).

The Ayushman Bharat flagship programme brings together initiatives of the National Health Insurance (PMJAY) and the Health and Wellness Centres (HWCs) (National Health Portal, 2019). The programme is based on tax-based financing and thus, critically depends on the Centre’s allocations to the programme.

References:

National Health Portal. (2019). Ayushman Bharat Yojana. Government of India. Available from: https://www.nhp.gov.in/ayushman-bharat-yojana_pg

Yes. The Ministry of Health in Indonesia pursues a five-step Strategic Plan (2015-2019). The key aspects on the agenda are the ‘revitalization of community health centres (puskesmas)’, continuation of care, and ‘specific solutions for specific health problems’. Planned changes to the financing strategy have only been outlined for community health centres. The Ministry of Health declared the aim to ‘increase […] the budget for facilities and support for puskesmas’ but it did not explicitly outline how this will be approached (Claramita et al., 2017, p.9). The Ministry of Health further states the aim to reduce ‘household burden [due] to finance health services’ from 37 per cent to 10 per cent (Ministry of Health Republic of Indonesia, 2015a, p.45).

References:

Claramita, M., Syah, N. A., Ekawati, F. M., Hilman, O., & Kusnanto, H. (2017). Primary Health Care Systems (PRIMASYS): Comprehensive case study from Indonesia. World Health Organization. https://www.who.int/alliance-hpsr/projects/AHPSR-PRIMASYS-Indonesia-comprehensive.pdf

Ministry of Health Republic of Indonesia. (2015a). Ministry of Health Regulation No. 67/2015 on Geriatric Services in Public Health Center (Permenkes No. 67/2015 Tentang Penyelenggaraan Pelayanan Kesehatan Lanjut Usia Di Pusat Kesehatan Masyarakat). Kementrian Kesehatan Indonesia, 1–140.

The new initiative for the country is to move towards universal coverage (funded by the World Bank). A pilot has been rolled out in 4 counties (described under 2.01.03.01). It is planned to roll out cover for all households by 2022 to guarantee access to equitable, affordable, and high-quality health and related services for all citizens. Other financing strategies by the government in addition to the UHC are through taxation and health insurance contributions (to cover basic essential services). The contributions are discussed in 1.04.01 under social protection schemes. General tax revenue is 30% of value added tax which is charged at 16%. Import and excise duty each account for 10% of the total revenue while corporate tax for companies ranges between 20% and 37.5% depending on the company’s existence. A proportion of the taxes are allocated to health care in Kenya (Chuma & Okungu, 2011). These financing mechanisms translate direct household payments into prepayment so that OOP are kept at a minimum (Njuguna & Pepela, 2019).

References:

Chuma, J., & Okungu, V. (2011). Viewing the Kenyan health system through an equity lens: implications for universal coverage. International Journal for Equity in Health, 10(1), 22. https://doi.org/10.1186/1475-9276-10-22

Njuguna, D., & Pepela, W. (2019). A Case for Increasing Public Investments in Health: Raising Public Commitments to Kenya’s Health Sector. Nairobi, Kenya. https://sparc.africa/wp-content/uploads/2020/01/Kenya-Health-Financing-Policy-Brief.pdf

One of the main campaign promises was to end the fragmented nature of the health system and work towards a single universal health system. As of January 2020, the government eliminated the 2003 health reform (Seguro Popular) from national laws and government agencies with the objective of generating a sole, centralised health system with integrated public financing and delivery, while reducing private participation. To this end, President Lopez Obrador (referred to by his initials, AMLO) created the Institute of Health and Wellbeing, INSABI (Instituto de Salud para el Bienestar), but to date (July 2020), no real changes have been implemented. A first study of the proposed reform notes large challenges, many that should have been overseen before implementation, and summarises their findings in five lessons: First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government’s restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization” (Reich, 2020).

References:

Reich, M. R. (2020). Restructuring Health Reform, Mexican Style. Health Systems & Reform, 6(1), e1763114. https://doi.org/10.1080/23288604.2020.1763114

The Ministry of Planning (Ministério do Planejamento, in Portuguese) (International Budget Partnership, 2018).

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

 

The federal structure of the country and the recognition of health as a state subject implies that both centre and the states decide how much should be spent on health. States depend on central funds for many of the health programmes. While most of the taxation powers are with the central government (for example income tax), the bulk of spending on health is done by the states. Thus, transfer of resources from the central government to the states is a critical part of the overall financing arrangement, and the Finance Commission – set up every 5 years to indicate principles of allocation of divisible taxes as well as the share between central government and the states – is a key entity that recommends how much additional funds should be allocated to the states and how these should be distributed across states. However, recommendations of the Finance Commission are not binding for the central government (Finance Commission India, n.d.; MoHFW, 2017).

References:

Finance Commission India. (n.d.). Finance Commission. Government of India. Available from:  https://fincomindia.nic.in/

Ministry of Health and Family Welfare. (2017). National Health Policy. Government of India. Available from: https://www.nhp.gov.in/nhpfiles/national_health_policy_2017.pdf

The World Bank suggests that health care spending has been ‘accorded a generally low priority’ in Indonesia given that expenditure of total government budget amounted only to 4.7 per cent, which is lower than that of neighbouring countries such as the Philippines, China, and Thailand (World Bank, 2016b, p.4). In 2015, the Government of Indonesia passed legislation that requires 5 per cent of the national budget to be allocated to the health sector. This target was reached by 2016. In addition, district governments must spend 10 per cent of their budget on health-related issues (Agustina et al., 2019, p.85). Despite these allocations, spending on health in Indonesia is comparatively low (3% of GDP) in comparison to other LMICs and other countries in the Association of Southeast Asian Nations (Agustina et al., 2019, p.85).

In an effort to provide communities with greater ability to respond to local needs, the Village Law (Law Number 6/2014) and a law to strengthen the role of provinces (Law Number 23/2014) have been enacted.  The Village Law regulates the transfer of an estimated one billion rupiahs per village to 77,548 villages. These funds may also contribute to improvement of community-based healthcare and lifestyle interventions. The law strengthening the role of the provinces creates a closer link between provincial governors and central governments and offers an opportunity for provinces to be responsible for monitoring Minimum Service Standards in health care. Besides monitoring activities, provinces can impose sanctions on district/city level to enforce adherence to Minimum Service Standards (Ministry of Health Republic of Indonesia, 2015b, p.36).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

The President of the Republic of Indonesia. (2014). Law of the Republic of Indonesia Number 6 of 2014 concerning village https://www.kemenkeu.go.id/sites/default/files/pdf-peraturan/16.pdf

The President of the Republic of Indonesia. (2014). Law of the Republic of Indonesia Number 23 of 2014 about local government http://extwprlegs1.fao.org/docs/pdf/ins160168.pdf

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. Available at: http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

 

The national government is funded through various channels and allocates specific proportions to each Ministry. The Ministry of Finance sets 3-year budget ceilings for each sector rather than each sector submitting a budget request based on actual needs. The Ministry of Health (MoH) then distributes the funds through the county Health Management Boards in each county (Nyakundi et al., 2011).

References:

Nyakundi, C. K., Teti, C., Akimala, H., Njoya, E., Brucker, M., Nderitu, R., & Changwony, J. (2011). Health Financing in Kenya: The case of RH/FP. Nairobi, Kenya. https://silo.tips/download/kenya-health-financing-in-t-h-e-c-a-s-e-o-f-r-h-f-p

The Ministry of Finance (Secretaria de Hacienda y Credito Publico) is in charge of presenting the Federal Public Budget to the legislative branch for its review and approval.

The Constitution of 1988 defines the key planning and budgeting instruments as: (a) the Pluriannual Plan (Plano Plurianual – PPA), which is formulated over the first year of a presidential mandate and covers a period of 4 years; (b) the Law of Budgetary Guidelines (Lei de Diretrizes Orçamentárias – LDO) to be passed every year to define the key parameters and policy directives that will orient budget formulation; and (c) the annual Budget Law (Lei Orçamentária Anual – LOA). The PPA is meant to define objectives and targets for national, regional, and sectoral government plans and programs, while LDOs and LOAs are supposed to translate these into yearly priorities and activities. The Ministry of Planning reviews and updates the budget for health as part of the process for formulating the PPA. At the beginning of each PPA cycle, the ministry of planning defines the programs that outline the government’s agenda for each area of public policy, including health policies (International Budget Partnership, 2018). 

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

 

The central government presents its budget estimates for each of the sectors, including the health sector, in its Annual Financial Statement (traditionally in February) – also called the Union Budget of India. The budget is prepared mainly in the Ministry of Finance after detailed consultations with major stakeholders, including other ministries. Thus, the Ministry of Health and Family Welfare’s inputs are critical. However, the National Institute for Transforming India (NITI) Aayog (the policy think tank of the government, which provides technical advice to both central and state governments), which replaced the former Planning Commission, also plays an important role especially in terms of new initiatives and can influence the budget, including the health budget (Government of India, 2018a).

References:

Government of India. (2018a). NITI Aayog holds Dialogue on Health System for New India. Available from: http://pib.nic.in/newsite/PrintRelease.aspx?relid=186039

Every five years, the Ministry of National Development Planning (BAPPENAS) issues a medium-term national spending plan (Rencana Pengeluaran Jangka Menengah Nasional (RPJMN)). Based on this and taking into consideration the macroeconomic framework as well as the president’s instructions, the ministries, including the Ministry of Health have to submit an annual work plan (Rencana Kerja Pemerintah (RKP)), along with their budget to the Ministry of Finance. The combined budgets are then discussed and approved by the legislative body (Dewan Perwakilan Rakyat (DPR)). This process occurs annually between October and November for the following year (Kementrian Keuangan, 2015).

The previous RPJMN covered the years 2014 to 2019. From 2020 onwards the RPJMN 2020-2024 will be the reference for upcoming budgets (Kementrian PPN/BAPPENAS, 2019).

References:

Kementrian Keuangan. (2015). Pedoman Proses Perencanaan, Penganggaran, dan Pelaksanaan APBN. http://www.anggaran.depkeu.go.id/content/publikasi/buku pedoman perencanaan.pdf

Kementrian PPN/BAPPENAS. (2019). Rancangan Teknokratik Rencana Pembangunan Jangka Menengah Nasional 2020 – 2024.

Half of the total national health budget is allocated to three referral hospitals while resource allocation to the 47 counties is provided in block grants and is based on a resource allocation formula that takes into consideration factors such as the population, poverty levels, land share etc. The counties then decide the amount to be allocated to health. (Health Policy Project, 2016). Although the proportion of total government budget allocation to health (national and county) has increased over the past few years (7% in Financial Years (FYs) 2017/18 to 9.2% in FYs 2018/19) (Ministry of Health, 2018), it is still below the Abuja Declaration level of 15% .

During the financial year 2014/15, 38 of the 47 counties allocated at least 15% of the total county budget to health, with a larger share of the health budget given to conditions with a high burden (Health Policy Project, 2016). These allocations increased from 27% in FY 2016/17 27.2% in FY 2017/18 which is still below the pre-devolution level of 35% (Health Policy Plus, 2019). In Kenya, the financial year begins on 1st July of the present calendar year and ends on 30thth June of the following year. The budget making process in each county is a cycle (each cycle contains four financial quarters of three months each) with four quarters as follows (Githinji, 2019):

  • First Quarter (1st July to 30th September): Each county treasury to issue every county department and the public with a circular on the budget process guidelines for the following financial year
  • Second Quarter (1st October to 31st December): The county treasury tables the county budget reviews before the county assembly and the county governments to publish first quarter implementation reports.
  • Third Quarter (1st January to 31st March): The county governments publicize and publish second quarter implementation reports. The county treasury tables, publishes, and publicizes the County Fiscal Strategy Paper for approval by the county assembly.
  • Fourth Quarter (1st April to 30th June): The county governments publicize and publish third quarter implementation reports and the county treasury submits the budget estimates to the county assembly who will pass the appropriation bill.
References:

Githinji, G. (2019). The County government budget process in Kenya. https://afrocave.com/county-government-budget-process/#the-budget-process-for-county-governments-in-kenya

Health Policy Plus. (2019). Kenya’s Health Sector Budget An Analysis of National and County Accounts for Fiscal Year 2018/19. Washington DC. http://www.healthpolicyplus.com/ns/pubs/11306-11586_KenyaBudgetAnalysis.pdf

Health Policy Project. (2016). Health Financing Profile: Kenya. Washington DC. https://www.healthpolicyproject.com/pubs/7887/Kenya_HFP.pdf

Ministry of Health. (2018). National and county health budget analysis FY 2018/19. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/11306-11563_NationalandCountyBudgetAnalysis.pdf

While each sub-system has a particular process for planning and allocating funds, as with all policies and programmes financed with public funds, the budget process starts in June with the elaboration of the Annual Operation Programmes (Programa Operativo Annual, POA). These plans are presented by sector or Ministry to the Ministry of Finance, which makes the ultimate decisions on how funds are allocated. This gets integrated into the Federal Budget (Presupuesto de Egresos de la Federación, PEF) initiative that then goes to Congress for final approval. According to the Budget and Expenditure Legislation, the Federal Budget initiative has to be submitted no later than September 8 of each year to the Chamber of Deputies, which has the exclusive power to approve it no later than November 15 and then be published in the Official Gazette of the Federation no later than 20 calendar days after its approval (Ley Federal de Presupuesto y Responsabilidad Hacendaria).

The budget to be spent on health follows a “transfer system” and priorities are set independently by each of the different government levels (federal government, states and municipalities) (Brazilian Ministry of Health, 2019m).

References:

Brazilian Ministry of Health. (2019m). Sobre o FNS. http://portalfns.saude.gov.br/sobre-o-fns

 

The previous description clearly indicates that priority setting itself is a complex exercise and depends on the central government, the states, and also on the NITI Aayog. There are programmes that are centrally sponsored, but responsibility for implementation lies with the states. The states also set their priorities and implement several programmes where the Centre does not play any role. However, since the states depend on the central budget allocation for much of their funding, ultimately, the total amount of funding for the health sector –which comes from the states’ own revenues and central transfers – does affect how the priorities get implemented.

The priorities for funding are set by the Ministry of Health based on the RPJMN as mentioned above. For the RPJMN 2020-2024, one of the directions of policy and strategy is to increase access and quality of health service and to work towards universal health coverage with an emphasis on the strengthening of primary care. This was to be achieved through several action plans, including those focusing on disease control for HIV/AIDS, Tuberculosis, malaria, heart disease, stroke, hypertension, diabetes, cancer, emerging diseases, diseases with outbreak potential, overlooked tropical disease (lepra, filariasis, schistosomiasis), mental health, injury, vision problems, and mouth and dental problems. Dementia and ageing were not mentioned in this document; however, they might be seen as part of the wider mental health agenda (Kementrian PPN/BAPPENAS, 2019).

The Government of Indonesia prioritised funding of health insurance for low-income and vulnerable income groups as well as for the strengthening of primary care (Puskesmas) and the enhancing of specific programmes, such as maternal and child health and family planning (Agustina et al., 2019, p.90; Mahendradhata et al., 2017, p.241).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Kementrian PPN/BAPPENAS. (2019). Rancangan Teknokratik Rencana Pembangunan Jangka Menengah Nasional 2020 – 2024.

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

The sector working groups organized within the context of UN-classification of the functions of the government (COFOG) are responsible for formulation and prioritization of sector budget proposals. Within the health sector, the sector working group representatives are from the ministry of health and comprise of (Republic of Kenya, 2018a) page 15:

  • “A chairperson accounting officer mutually selected by other accounting officers”
  • “Sector governor appointed by the national treasury”
  • “Sector governor appointed by State department for planning”
  • “Technical working group appointed by the sector working group”
  • “Sector working group secretariat appointed by the accounting officers to coordinate the activities of the sector”
  • “Representatives from development partners”
  • “Representatives from the private sector”
References:

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

Each institution sets their priorities. Financing is negotiated with the Ministry of Finance.

The National Fund for Health (Fundo Nacional de Saúde) transfers the budget to the federal government (Ministry of Health), states and municipalities, according to the Pluriannual Plan, Law of Budgetary Guidelines and the Annual Budget Law. It is considered a decentralized system in which each level of government can decide how the money will be spent. The amount of money to be transferred to each level is set by law (Brazilian Ministry of Health, 2019m; International Budget Partnership, 2018). In theory, the budget should not be dispersed through geographical areas as there is transfer according to the three levels of governance in Brazil. However, as each level is responsible for managing and setting priorities for spending the budget, it is not rare to find geographical areas with different levels of investment depending on regional or local management.

References:

Brazilian Ministry of Health. (2019m). Sobre o FNS. http://portalfns.saude.gov.br/sobre-o-fns

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

As mentioned above, the health budgets are a total of central budget and state budgets. Most of the programmes visualised in the central budget for health get to be implemented by the states/Union Territories (UTs). A good example is the National Health Mission, which has several components: the national rural health mission, the national urban health mission, a communicable diseases programme, a non-communicable disease programme, and infrastructure maintenance are the major ones. States have the flexibility to plan and implement state specific action plans and need to draw up their respective Project Implementation Plans (PIP) (MoHFW, 2020), which spell out the key strategies, activities undertaken, budgetary requirements and key health outputs and outcomes. The funds flow from the Central Government to the states/UTs, as described above.

Previously, funds for various schemes initiated by the central government were directly transferred to the implementing agencies in states, bypassing treasuries of state governments. Since March 2014, funds are being released first to the treasuries of sub-national (State) governments, which are then responsible for transferring the funds to the implementing agencies (Choudhury, and Mohanty, 2018).

References:

Choudhury, M., & Mohanty, R. K. (2018). Utilisation, Fund Flows and Public Financial Management under the National Health Mission. New Delhi. Available from https://www.nipfp.org.in/media/medialibrary/2018/05/WP_2018_227.pdf

Ministry of Health and Family Welfare (MoHFW). (2020). Programme Implementation Plan. National Health Mission. Available from http://pip.nhm.gov.in/.

As outlined above, most health care spending is allocated to hospital care, with only 20 per cent of funds allocated at primary care level. This creates considerable inequity in access to health. Treatment for complex illnesses, such as diabetes, hypertension, or cancer are covered by the health budget; however, many adult vaccinations and screening tests needed to establish the prevalence of these illnesses at primary care level are not (Claramita et al., 2017, p.21). In addition, limited availability of data causes difficulties in detailed understanding of budget allocation in primary and secondary care settings (Claramita et al., 2017, p.21).

The combination of central government and district level financing leads to a complex and fragmented system. By Law (law number 26/2009), local governments (province, district, and city) have to allocate at least 10 per cent of their regional budget to health. According to the Ministry of Health, regions slightly underspend, allocating on average 9.37 per cent (2012). However, according to 2012 data, some provinces have spent up to 16 per cent of their budget on health. At district/city levels almost half (42.2%) allocated more than 10 per cent of their budget for health (Ministry of Health Republic of Indonesia, 2015b, pp.29-30). This leads to considerable variation in health expenditure between districts causing considerable inequities (World Bank, 2016b, p.5). We are unable to identify how local governments allocate their spending on health.

Despite the considerable share of out-of-pocket expenditure, voluntary health insurance uptake has been relatively consistent between 2010 and 2017, at 3-4% of current health expenditure. Meanwhile, the proportion of household out-of-pocket expenditure has been declining, amounting to 34% of current health expenditure in 2017. This may be an indicator that government schemes including the National Health Insurance introduced in 2014 are starting to reduce out-of-pocket expenditure.

References:

Claramita, M., Syah, N. A., Ekawati, F. M., Hilman, O., & Kusnanto, H. (2017). Primary Health Care Systems (PRIMASYS): Comprehensive case study from Indonesia. World Health Organization. https://www.who.int/alliance-hpsr/projects/AHPSR-PRIMASYS-Indonesia-comprehensive.pdf

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

The National Government will periodically release funds to the county governments. The amount of funding per county depends on several factors: population, poverty index, land area, basic equal share, and fiscal responsibility. The release of funds from the national government will depend on whether a county has prepared an integrated development plan with the Commission on Revenue Allocation setting the payment formula (Government of Kenya, 2016).

Before the disbursement process, the Ministry of Finance sets 3-year budget ceilings for each sector rather than each sector submitting a budget request based on actual needs. This is done through the Budget Review and Outlook Paper or the County Budget Review and Outlook Paper which is released in September and must be approved by the Cabinet and legislative assembly at each level of government (Ministry of Health, 2016b). The Ministry of Health (MoH) then disburses the funds through the county health Management Boards in each County (Nyakundi et al., 2011) and this depends on the population, poverty levels, land share etc.

The process of budget allocation to the specific sectors in counties is the same as at the national level where the county communicates to the various sectors the budget ceilings. National and county health departments determine how their budget is distributed to programs, but they are not allowed by the law to transfer funds between approved projects and recurrent allocations. They can shape the allocations in an efficient way while prioritizing cost-effective and efficient programmes (Ministry of Health, 2016b). Although, it is important to note that each county department of health decides using their own criteria or formula on how health services should be distributed. There is little information on how finances for health services should be distributed within specific departments. Each county department of health decides using their own criteria or formula on how health services should be distributed (Otieno, 2016). However, ministries and departments are required to prioritize allocations towards the achievement of “Big Four Plan”. The sector working groups then conduct a thorough review of the proposed budgets to ensure that they are not only directed towards improving productivity but also in achieving the “Big Four Plan” agenda. This is done by establishing resources required for different programmes and projects and the level of provision are within the ceilings provided by the sector working groups (Republic of Kenya, 2018a).

References:

Government of Kenya, E. of the K. N. (2016). Kenyan Healthcare Sector. Kenyan Healthcare Sector, 86.

Ministry of Health. (2016b). National and county health budget analysis FY 2016/17. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/6138-6239_FINALNationalandCountyHealthBudgetAnalysis.pdf

Nyakundi, C. K., Teti, C., Akimala, H., Njoya, E., Brucker, M., Nderitu, R., & Changwony, J. (2011). Health Financing in Kenya: The case of RH/FP. Nairobi, Kenya. https://silo.tips/download/kenya-health-financing-in-t-h-e-c-a-s-e-o-f-r-h-f-p

Otieno, M. (2016). Resource allocation to health sector at the county level and implications for equity, a case study of Baringo county. University of Nairobi. http://erepository.uonbi.ac.ke/handle/11295/98703

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

In Mexico, health budgets are dispersed at the state level through state-level representations of each health or social security institution. The Ministry of Health has a State Health Minister in each state who oversees the priorities, negotiates part of the budget, plans, and implements the local development of priority health programmes and is also responsible for their correct implementation. As state level budgets are based on target populations, programmes and priority strategies, budgets are allocated and dispersed according to these definitions. For some Federal programmes, the budget comes directly form the Ministry of Finance through targeted budgets, specific Operation Regulations (Reglas de Operación) which include evaluation indicators.

The Ministry of Health works with large budgetary actions within a unique program. This strategy makes shifting resources between various programme areas easier to the Ministry of Health to manage (International Budget Partnership, 2018).

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

The Ministry of Health and Family Welfare (MoHFW) oversees two departments: the Department of Health and Family Welfare and the Department of Health Research. When the Union Budget has been presented to Parliament, the Standing Committees of the Parliament scrutinise each Ministry’s Demand for Grants in detail. This document lays out the various priorities of the government in the form of estimated expenditures under various line items or programme areas. The MoHFW also presents its Demand for Grants for scrutiny to the Standing Committee. For example, the observations and recommendations of the Committee when scrutinising the 2018-19 Demands for Grants was that the government health expenditure (at 1.35% of GDP) (NHSRC, 2021) may not meet the goals of the National Health Policy that envisages a health expenditure of 2.5% of GDP by central and state governments by 2025. The feedback also mentioned that attention is needed to be paid to the wide gap between demands of the Department and allocation made as well as delays in transfer of funds and scaling down on various health initiatives and programmes due to the reduced budgetary allocation (Kala, Mann, & Tiwari, 2019).

When the Demands for Grants are passed, they are then consolidated into an Appropriation Bill and then subsequently the Finance bill is also taken up for consolidation. A similar process takes place at the State/UT level, where state legislative assemblies and state departments of health are responsible for preparing the estimates for different budget heads under the departments’ Demand for Grants.

References:

Kala, M., Mann, G., & Tiwari, S. (2019). OVERSEEING PUBLIC FUNDS.

National Health System Resource Centre (NHSRC). (2021). National Health Accounts-Estimates for India: 2017-2018. Ministry of Health and Family Welfare, Government of India. Available from: https://nhsrcindia.org/sites/default/files/2021-11/National%20Health%20Accounts-%202017-18.pdf

In Indonesia, there are two pooling mechanisms that allocate and disperse health budgets across the country. First, central government funds are pooled and then transferred to provincial and district governments. Second, the BPJS pools social insurance funds (Mahendradhata et al., 2017, p.87).

Pooling of central government funds means that the State Revenue and Expenditure Budget (APBN) determines allocation of funds centrally. For health funds, this allocation is decided by the Ministry of National Development Planning of the Republic of Indonesia (BAPPENAS) in consultation with the Ministry of Heath and the Ministry of Finance. The final allocation of funds needs to be approved by the national parliament (DPR). The budget allocation is based on:

  1. ‘Historical budgets,
  2. Proposal by ministries,
  3. Calculation of local needs according to population size’ (Mahendradhata et al., 2017, p.87).

It is noteworthy that non-technical and political considerations by the House of Representatives (DPR) that influence the indicate budget levels, play a role as well. (Mahendradhata et al., 2017, p.87).

The Ministry of Health distributes the health budget to central-level departments and health agencies as well as to provincial and district governments. The fund allocation includes:

  1. Dana dekon (de-concentration fund) is allocated to provincial health offices to manage health functions in its districts and to ‘build capacity of [district health offices] in national priority programmes’.
  2. Tugas perbantuan (assisting task fund) is given to district health offices for spending related to carrying out assisting/operational tasks around the puskesmas.
  3. Dana alokasi khusus (special allocation fund) is ‘allocated […] to local governments and earmarked for specific health infrastructure construction such as […] puskesmas, sub-puskesmas, and district hospitals’. For health, this fund can used for financing primary health care, referrals to secondary and tertiary care, and pharmacy services (including generics procurement) (Mahendradhata et al., 2017, p.88).

In addition to central resources mechanism, provincial and district government also prepare plans and budget proposals (bottom-up approach). Local government’s revenue and expenditure budget (APBD) is divided into indirect expenditure (salaries of civil servants in health facilities) and direct expenditure (operations of health services and programmes and allowances of health services staff). However, indirect expenditure can take up more than 80% of the total budget allocation, which may limit funding for operational expenditure (Mahendradhata et al., 2017, pp.88-89).

The second mechanism represents the distribution of social insurance funds through the BPJS. All social insurance contributions of the population, including government funds, are pooled into a single trust fund (Dana Amanat). ‘The allocation of revenue from central government to the BPJS is based on the number of members entitled to have their contribution paid by the government (PBI members), and the agreed premium to be paid by the government’. ‘The PBI contribution is then allocated to districts based on the number of PBI members in each district’ (Mahendradhata et al., 2017, p.88).

References:

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Please refer to 02.02.05.01.

Data from the National Regulatory Agency for Private Health Insurances and Plans showed that around 23% of the population of Brazil purchased private health care insurance by the end of 2018 (National Regulatory Agency for Private Health Insurances and Plans, 2019a).

References:

National Regulatory Agency for Private Health Insurances and Plans. (2019a). Agência Nacional de Saúde Suplementar. https://www.gov.br/ans/pt-br

According to the National Health Profile (CBHI, 2019), about 37.2% of the population was covered by any health insurance in 2017-18, while 62.8% of the population remain uninsured. Of those insured, 78% were covered by public insurance and the rest by private insurance  (CBHI, 2019).

References:

Central Bureau of Health Intelligence (CBHI). (2019). National Health Profile. Ministry of Health & Family Welfare, Government of India. Available from http://www.cbhidghs.nic.in/showfile.php?lid=1147

In 2017, life/health insurance made up 6.66% of all financial products owned by Indonesians aged 18 and older. However, this figure dropped to 4.47% in 2018 (Mahendradhata et al., 2017, p.44). (Please note the percentages are out of all respondents and there were 23.59% and 24.86% of people who did not have any forms of financial products in 2017 and 2018, respectively).

In 2013, BPJS established a coordination of benefits with some of the leading private health insurance providers to provide a top-up option for middle- and high-income members of the JKN, which may increase the uptake of private insurance in Indonesia (Mahendradhata et al., 2017, p.44). In 2019, BPJS and 11 insurance providers (members of Forum Asuransi Kesehatan Indonesia) signed a Coordination of Benefit agreement to simplify the process of adding on private insurance policies to their existing BPJS schemes (Kartika & Walfajri, 2019).

References:

Kartika, H., & Walfajri, M. (2019). Gandeng perusahaan asuransi, peserta BPJS Kesehatan bisa naik kelas gratis.

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Private health insurance growth has stagnated over the years and slight decrease was even seen from 2009 to 2014, where the 32 private health insurers collectively covered 1.15%  from 1.17% of the Kenyan population (Kazungu & Barasa, 2017).

References:

Kazungu, J. S., & Barasa, E. W. (2017). Examining levels, distribution and correlates of health insurance coverage in Kenya. Tropical Medicine & International Health, 22(9), 1175–1185.  https://doi.org/10.1111/tmi.12912

While the market for private health insurance has increased in the past decade and more multinational insurance companies have entered the market, the last available estimate from the OECD is 4% of total population purchasing private health care insurance (OECD, n.d.).

References:

OECD. (n.d.). Health data. Retrieved March 16, 2020, from https://data.oecd.org/healthres/health-spending.htm

Yes. There is the National Regulatory Agency for Private Health Insurances and Plans (Agência Nacional de Saúde Suplementar – ANS), that is linked to the Ministry of Health and is in charge to regulate the private health insurances and plans sector in Brazil  (National Regulatory Agency for Private Health Insurances and Plans, 2019a).

References:

National Regulatory Agency for Private Health Insurances and Plans. (2019a). Agência Nacional de Saúde Suplementar. https://www.gov.br/ans/pt-br

 

The Insurance Regulatory and Development Authority of India (IRDA) has the duty to protect the interests of the policyholders to regulate, promote, and ensure orderly growth of the insurance business and re-insurance business in India (Insurance Regulatory and Development Authority of India (IRDA), 2016). For the health insurance sector, IRDA has attempted to improve service standards and has issued guidelines standardising 42 most used definitions/terms/conditions in health insurance policies. The guidelines also include definitions of twenty-two common critical illnesses covered under various health insurance policies in India (IRDA, 2016).

References:

Insurance Regulatory and Development Authority of India (IRDA). (2016). Guidelines on Standardization in Health Insurance.

Private insurance companies operate under the supervision of the Ministry of Finance (House of Representatives, 1992) (Mahendradhata et al., 2017, p.44). Otoritas Jasa Keuangan Republik Indonesia is the regulatory body for private insurance and re-insurance companies. Peraturan OJK no. 71/POJK.05/2016 regulates on the financial health of the companies, determining areas of investments allowed with its assets, governing its liabilities, etc. (Otoritas Jasa Keuangan Republik Indonesia, 2016). Note that there are also some non-profit insurance companies with sharia type products (Mahendradhata et al., 2017, p.96).

References:

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

Otoritas Jasa Keuangan Republik Indonesia. (2016). Peraturan Otoritas Jasa Keuangan (POJK) No 71 Tentang Kesehatan Keuangan Perusahaan Asuransi dan Perusahaan Reasuransi. 50. https://www.ojk.go.id/id/kanal/iknb/regulasi/asuransi/peraturan-ojk/Documents/Pages/POJK-tentang-Kesehatan-Keuangan-Perusahaan-Asuransi-dan-Perusahaan-Reasuransi/SAL-POJKKesehatan Keu PA PR -.pdf

The Insurance Regulatory Authority is the body in-charge of managing all insurance firms including the medical insurance firms under the Insurance Act (Amendment) 2006, CAP 487 (Government of Kenya, 2010).This body is in charge of setting the rules and regulations that govern all insurance companies in Kenya. However, it is not clearly stated whether private insurance health firms have specific market regulations set. Insurance companies use their own resources and strategies to reach a wider market, with particular interest in those employed.

References:

Government of Kenya. (2010). The Kenya Constitution, 2010. Kenya Law Reports. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010

Yes, the National Insurance and Bonds Commission, a decentralised entity of the Ministry of Health, regulates the companies regarding the operation and administration of these services. The Federal Commission for the Protection against Health Risks (Comision Federal para la Protección contra Riesgos Sanitarios, COFEPRIS), regulates all health-related issues in all private institutions from board certification of medical doctors to malpractice in hospitals, health clinics, etc. COFEPRIS also regulates these matters within public (Ministry of Health) and Social Security institutions.

It seems not to have official estimates about the proportion of the population incurring out-of-pocket payments for health services. However, a study conducted by the Credit Protection Service Brazil (SPC Brasil) and by the National Confederation of Stores Owners (CNDL) with 1,500 people from large capitals showed that, from the 70% of people who did not have private health insurance, 25% made out of pocket payments for private services (CNDL, 2018).

References:

CNDL. (2018). Gastos dos Brasileiros com Saúde.

A study indicates that overall the proportion of households with catastrophic health expenditure “increased 1.47-fold between the NSS 1993–1994 and 2011–2012 expenditure surveys, and 2.24-fold between the NSS 1995–1996 and 2014 utilization surveys” (Pandey et al., 2018).

References:

Pandey, A., Ploubidis, G. B., Clarke, L., & Dandona, L. (2018). Trends in catastrophic health expenditure in India: 1993 to 2014. Bulletin of the World Health Organization96(1), 18–28.

Out-of-pocket expenditure in Indonesia is significant and despite the introduction of social health insurance in 2014 remains one of the main funding sources for health care. In 2013, it was estimated to be 49 per cent out of total health expenditure; however, the figure has been reported to have declined to 34 per cent in 2017.

Despite this high proportion, the share of families facing catastrophic out-of-pocket expenditure (more than 25% of household expenditure) remains at only about 1 per cent. On the other hand, approximately 7 million households (8% of households) were reported to have been impoverished due to health-related out-of-pocket payments (World Bank, 2016b, p.4). The WHO, therefore, groups Indonesia among countries with high out-of-pocket expenditures (Agustina et al., 2019, p.85; WHO, 2017, pp.126,133; World Bank, 2016b, p.4).

Even though access to services is increasing, there appears to be a lack in uptake with about 50 per cent of those entitled to outpatient care and 20 per cent of those entitled to inpatient care not taking up services. This may be due to issues with access, waiting times, quality of care, and providers falsely charging for treatments and medication (Agustina et al., 2019, p.90).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

World Bank. (2017). Indonesia Can Improve Opportunities for and Protection of Its Migrants Working Abroad. Press Release. https://www.worldbank.org/en/news/press-release/2017/11/28/indonesia-can-improve-opportunities-for-and-protection-of-its-migrants-working-abroad

The number of patients who for pay health services out of pocket is very high. It amounted to 26.11% out of the total health expenditure in 2014 (Index Mundi, 2019a). The high costs incurred from out-of-pocket health expenditure pose a barrier for Kenyans accessing healthcare services because it drives the poorer households into poverty. The costs of treatment continue to limit the access of care especially by the poor. The Ministry of Health estimates that 16% of the sick do not seek treatment due to financial constraints, while 38% of them must sell some of their assets or borrow in order to finance their medical bills (Luoma et al., 2010). In Kenya, one has to directly pay for health services at the point of consumption. This led to 7.1% of households in Kenya to face catastrophic expenditures and increased the poverty head count by 2.2% due to OOP payments in 2018 (Salari et al., 2019).

References:

IndexMundi. (2019a). Kenya – Out-of-pocket health expenditure (% of total expenditure on health). https://www.indexmundi.com/kenya/health_expenditures.html

Luoma, M., Doherty, J., Muchiri, S., Barasa, T., Hofler, K., Maniscalco, L., … Maundu, J. (2010). Kenya Health System Assessment 2010. Health Systems 20/20 Project, 20(August), 1–133. https://www.hfgproject.org/wp-content/uploads/2015/02/Kenya-Health-Systems-Assessment-2010.pdf

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6). https://doi.org/10.1136/bmjgh-2019-001809

A consequence of low levels of government health spending, is the relevant participation of the private market. Most of this privately purchased health care is paid through out-of-pocket transactions, as private insurance makes up a very small segment of the market (approximately 4% of total health expenditures). Mexico has the highest out-of-pocket share of total health care spending among OECD countries: out-of-pocket health spending (paid directly by patients) in 2017 reached 40.4% of total spending (OECD, n.d.; OECD, 2016b).

Despite slightly decreasing from 55% in 2005, out-of-pocket health spending (paid directly by patients) in Mexico in 2017 still amounted to 40.4% of total spending. As a result, the high burden of out-of-pocket spending continues to create financial barriers to health care access, particularly for the low-income population. In this same year, government/compulsory health spending represented 51.6% of total health expenditures, while the remaining 8% corresponded to health expenditures by the voluntary sector (NGOs and private corporations) (OECD, n.d.)

References:

OECD. (n.d.). Health data. Retrieved March 16, 2020, from https://data.oecd.org/healthres/health-spending.htm

OECD. (2016b). OECD Reviews of Health Systems: Mexico. In OECD Publishing (Ed.), OECD Reviews of Health Systems (OECD Reviews of Health Systems). OECD Publishing. https://doi.org/10.1787/f7b8c403-ja

According to the World Bank, remittances play an important role in Indonesia. The World Bank states that almost seven per cent of Indonesia’s labour force (9 million people) worked overseas in 2016. They sent more than IDR 118 trillion ($8.9 billion), which amounts to about one per cent of GDP, in remittances. It remains unclear what proportion is spent on health care (World Bank, 2017).

Research has found that remittances positively contribute to the health status of adult recipients in rural areas. It was reported that adults in household with family members who were labour migrants were ‘40% less likely to be underweight than those in non-migrant households’. This suggests that remittances may improve the overall health of families (Lu, 2013; UNESCO, 2017, p.6).

References:

Lu, Y. (2013). Household Migration, Remittances and Their Impact on Health in Indonesia 1. International Migration, 51, e202–e215. https://doi.org/10.1111/j.1468-2435.2012.00761.x

UNESCO. (2017). Overview of Internal Migration in Indonesia. Unesco.

World Bank. (2017). Indonesia Can Improve Opportunities for and Protection of Its Migrants Working Abroad. Press Release. https://www.worldbank.org/en/news/press-release/2017/11/28/indonesia-can-improve-opportunities-for-and-protection-of-its-migrants-working-abroad

A large part of payments for healthcare come from remittances, where richer family members living in the cities or diaspora send money to less affluent family members often living in the slums or rural areas. Research based on household surveys, suggested that about one third of hospital bills in Kenya are paid through remittances (Stuart & Ph, 2011).

References:

Stuart, G. U. Y., & Ph, D. (2011). Cash In , Cash Out. (January).

While remittances played an important role in supporting families in many localities throughout the country given the large migration to the U.S. through decades, their use has been primarily spent in basic subsistence items such as food and clothing.

Mexico is the fourth largest remittance recipient in the world, and the rise in technology based financial services that make sending money much easier, using banks, mobile devices, stores, etc., have facilitated this. In 2015 it received nearly $25 billion in remittances, just behind India ($72 billion), China ($62 billion), and the Philippines ($30 billion). Most of these resources come from Mexican migrants living in the U.S. which represent 95.6% of Mexico’s remittances (Consejo Nacional de Población et al, 2018).

According to the study, based on different data sources, the main uses of remittances sent by Mexicans are buying clothes and groceries, followed in much less percentages by education, settling debts, health services, and buying, renovating, or building homes (CONAPO & Fundación BBVA Bancomer, 2018).

References:

CONAPO, & Fundación BBVA Bancomer. (2018). Anuario de Migración y Remesas México 2018. https://www.bbvaresearch.com/wp-content/uploads/2018/09/1809_AnuarioMigracionRemesas_2018.pdf

Consejo Nacional de Población, Fundación BBVA Bancomer y BBVA Research (2018). Anuario de Migración y Remesas. México 2018. CONAPO-Fundación BBVA Bancomer-BBVA Research. 1ra edición, México, pp.184.

No (Brazilian Ministry of Health, 2019i).

References:

Brazilian Ministry of Health. (2019i). Repasses financeiros.

External sources of financing, including donations, are considered to be the fourth largest source of health care funding in Indonesia. However, they are estimated to amount to only about between one to four per cent of the health budget (Mahendradhata et al., 2017, p.98; World Bank, 2016b, p.5).

The Asian Development Bank, followed by the World Bank, have been considered as the biggest donors for Indonesia in 2012. Donations from Japan were ranked on third place. Japan is considered to be the largest single donor country supporting Indonesia, accounting for 45% of the cumulative total of official development assistance (ODA) since 1960 (Japan International Cooperation Agency, 2018). Other significant donors include the Australian Agency for International Development, the Global Fund to fight Aids, Tuberculosis and Malaria, the Agence Française de Développement, the United States Agency for International Development, the United Nations, the Millenium Challenge Corporation, and the Federal Ministry for Economic Cooperation and Development. However, it is unclear what these donations were allocated for.

External health financing and technical assistance in Indonesia appears to be targeted at specific interventions, such as immunization, HIV, TB, and malaria. According to the Ministry of Health, external funding accounted for 60 per cent of spending on TB and 10-15 per cent on vaccination in 2015. Changes in funding over time may reflect the government’s ability to sustain programmes independently as well as donor interests (Mahendradhata et al., 2017, p.98; World Bank, 2016b, p.5).

References:

Japan International Cooperation Agency. (2018). Indonesia’ s Development and Japan’ s Cooperation : Building the Future Based on Trust (Issue April). https://www.jica.go.jp/publication/pamph/region/ku57pq00002izqzn-att/indonesia_development_en.pdf

Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., MArthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia Health System Review (Vol. 7, Issue 1). https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better. http://documents.worldbank.org/curated/en/453091479269158106/pdf/110298-REVISED-PUBLIC-HFSA-Nov17-LowRes.pdf

No, at the moment there are no significant donations from outside the country to support the healthcare system.