HS229f: International Health Financing and National Health Accounts

DRAFT SYLLABUS (Revised March 4, 2015) Modular course, Spring 2015 (block II, Second half of semester)

Dr. Wu Zeng and Dr. Yara Halasa Classroom: Heller School G055 Office: Heller Room 273 E-mail: [email protected], [email protected] Office Hour: By appointment

Overall Objective: This module examines the mobilization of resources for the health system as a whole, and the funding of individual providers for health services in developing countries. Adequate levels of financing, equitable means of raising this funding, and appropriate ways of using this financing to pay health providers, are all key to an effective and efficient health care system. Many countries are undergoing processes of health reform, in which fundamental changes in the funding and organization of the health system are being examined. This module will provide the tools for examining both broad reforms, as well are refinements of individual components of the health care system.

Approach: The module uses interactive discussions and computer exercises where students will learn to develop and assess the performance of alternative health financing instruments. Real world, relevant examples of health financing systems, drawn from a number of developing countries and supplemented by examples from industrialized countries, will be used to reinforce the lectures. To reinforce the techniques, students will be asked to solve a written, pass-fail computer exercise using Excel approximately every other class. The course begins with an overview; successive sessions discuss alternative approaches to health financing. The module concludes with a synthesis and policy analyses.

Evaluation: Students will be evaluated based on (1) a mid-term exam based on National Health Accounts case study, and (2) a brief (8-page) written final paper. The written paper will require students to apply principles of health financing to a problem or question of the student’s choice, such as analyzing the impact of an existing or proposed program or reform in health financing in a country of the student’s choice. The analysis should be based on real data when available, but may use assumptions, based insofar as possible, on experience or plausible judgments, where actual data are not available. Students may either work individually or in pairs.

Time and Place: Thursdays between 2:00 pm and 4:50 pm at Heller School G055, beginning on March 12, 2015, except no class on April 9th, and the last class is April 30.

Disability: If you are a student with a documented disability on record at Brandeis University and wish to have a reasonable accommodation made for you in this class, please see the instructor immediately 1 Sessions 1 through 3: National Health Accounts

National Health Accounts (NHA) is a globally accepted framework and approach for measuring total – public, private, and donor – national health expenditures. Conducting NHA provides crucial financial information to health care decision makers, because it answers important questions such as: Who in the country finances health services? How much do they spend and on what type of services? Who benefits from these health expenditures? To date, more than 100 countries worldwide have conducted NHAs.

The NHA methodology is particularly suited to developing countries unique health sector environments and the challenges exhibited in these countries, where financial information systems may not be readily developed, data from the private sector may not be forthcoming, and the general size of the health system may not have been previously estimated.

In these three sessions I will cover the concept of NHA, how NHA data are currently used at the national and international level, and through cases studies we will work on classifying sources of health financing, agents, providers and functions, defining NHA boundaries, and generating NHA tables. Additionally, we will discuss the methodological changes suggested by the System of Health Accounts 2011.

Attendance is mandatory.

Evaluation: For the mid-term exam, students will have the options of (1) critique an existing NHA, or (2) develop NHA tables based on a case study and answer some policy questions based on the data from the cases study. Students need to decide the exam option by the second session.

Readings: Main Book: World Health Organization, World Bank, and United State Agency for International Development. 2003. A Guide to producing national health accounts with special application for low-income and middle-income countries. Geneva: World Health Organization. You can download an electronic version from the website below: http://www.who.int/nha/docs/English_PG.pdf

Web based resources: http://www.phrplus.org/nha.html -- Partners for Health Reform Plus Project http://www.hsph.harvard.edu/ihsg/publications.html#9 -- International Health Systems Group at Harvard http://www.iadb.org/en/inter-american-development-bank,2837.html -- Inter American Development Bank http://www.unescap.org/aphen/asia-pacific-nha.htm -- Asia Pacific Health Economics Network

http://www.lachealthaccounts.org – Latin America Health Accounts

http://webnet1.oecd.org/oecd/pages/home -- Organization for Economic Cooperation and Development 2 http://paho.org -- Pan American Health Organization

http://worldbank.org/healthreform -- World Bank, Health Reform Site

http://who.org – World Health Organization website

Session 1: Thursday, 3/12 – Introduction to National Health Accounts

Topic: Conceptual overview of National Health Accounts tool and its policy implications, NHA boundaries and International classification of health accounts.

Assigned reading: Chapters 1, 2, 3 and 4 from World Health Organization, World Bank, and United State Agency for International Development. 2003. A Guide to producing national health accounts with special application for low-income and middle-income countries. Geneva: World Health Organization.

Farag, M., Nandakumar, A.K., Wallack, S.S., Gaumer, G., and Hodgkin, D. 2009. Does Funding from Donors Displace Government Spending for Health in Developing Countries? Health Affairs. 28(4):1045-1055

Garg, C.C., Evans, D.B., Dmytraczenko, T., Izazola-Licea, J., Tangcharoensathien, V. and Ejeder, T.T. 2012. Study Raises Questions about Measurement of “Additionality” or Maintaining Domestic Health Spending Amid Foreign Donations. Health Affairs. 31(2):417-425

Session 2: Thursday, 3/19 – Building NHA tables

Topic: Defining Expenditures and Boundaries and International Classification of Health Accounts and preparing data and building the Financing Sources (FS) x Financing Agent (FA) and Financing Agent (FA) x Provider (P) tables

Assigned reading: Chapters 5, 9, 10, 11, 12, 13 from World Health Organization, World Bank, and United State Agency for International Development. 2003. A Guide to producing national health accounts with special application for low-income and middle-income countries. Geneva: World Health Organization.

Susmania case study

Session 3: Thursday, 3/26– Utopia Case Study and System of Health Accounts

Topic: Hand on training on conducting NHA using a case study from a fiction country named Utopia, and the latest development in Health Accounts and the move toward System of Health Accounts.

Assigned reading:

OECD, Eurostat, WHO (2011), A System of Health Accounts, OECD Publishing. You can download an electronic version from the website below: 3 http://www.who.int/health-accounts/methodology/sha2011.pdf

Utopia Case Study.

Session 4: Thursday, 4/2– Financing Health: Overview of health financing and universal health coverage

Topic: The first session will start with an overview of health financing (particularly the mix between the public and private sectors), with descriptive data drawn from national health accounts.

Readings:

Hsiao, William. Why Is A Systemic View of Health Financing Necessary? Health Affairs, 2007, 26(4) 950-960.

Wagstaff, Adam (2009). Social Health Insurance Reexamined. Health Economics.

WHO. Health systems financing: the path to universal coverage, Chapter1: where are we now? 2010. Geneva: WHO

Session 5: Thursday, 4/16 – Revenue collection and risk pooling

Objectives: The second session will discuss the functions of health financing on revenue collection and risk pooling, with the focus on social health insurance

Readings: WHO. Health systems financing: the path to universal coverage, Chapter2: More month for health? 2010. Geneva: WHO

Stenberg, K, R Elovainio, D Chisholm, D Fuhr, A-M Perucic, D Rekve, A Yurekli (2010). Responding to the challenge of resource mobilization – mechanisms for raising additional domestic resources for health. Background Paper 13, World Health Report 2010. Geneva: World Health Organization. (http://www.who.int/healthsystems/topics/financing/healthreport/13Innovativedomfinancin g.pdf?ua=1)

WHO. Health systems financing: the path to universal coverage, Chapter3: Strength in numbers? 2010. Geneva: WHO World Health Organization (2010). Fragmentation in pooling arrangements. Technical Brief Series – Brief No 5. Geneva: World Health Organization. (http://www.who.int/healthsystems/topics/financing/healthreport/FragmentationTBNo5.pdf?ua=1)

Lagomarsino, Gina, et al. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. 2012. Lancet. 4 Lu, Jui-Fen Rachel and Hsiao, William C (2003). Does Universal Health Insurance Make Health Care Unaffordable? Lessons From Taiwan. Health Affairs, vol. 22, no.3, pp. 77-88

Session 6: Thursday, 4/23 – Purchase of services and payment mechanisms

Topic: This lecture examines the operational level of health financing, the payment of health providers (hospitals, physicians, pharmacists, etc.). After a health financing system has mobilized resources, it must compensate health providers, such as hospitals and physicians. The method of contacting them affects the efficiency and equity in the health system. The session will examine several systems: fee for service, capitation, and the effects of supply side restrictions through managed care, such as prior authorization, or continuing stay reviews.

Readings:

WHO. Health systems financing: the path to universal coverage, Chapter4: More health for money? 2010. Geneva: WHO

Waters H, Hussey P. 2004. Pricing Health Services for Purchasers: A Review of Methods and Experiences. World Bank Health, Nutrition and Population (HNP) Discussion Paper. http://www- wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2005/03/02/000090341_2005030 2144436/Rendered/PDF/315900HNP0Chap1gHealthServicesFinal.pdf

Jegers, M., Kesteloot, K., De Graeve, D, Gilles, W. 2002. A typology for provider payment systems in health care. Health Policy 60(3):255-273.

Cashin, C, O Gubonova, N Kadyrova, N Khe, E Kutanov, M McEuen, S O’Dougherty, S Routh, O Zues (2009). “Overview: What, How, and Who: An introduction to provider payment system.” Chapter 1 (p.1-25) in Langenbrunner, JL, C Cashin, S O’Dougherty, eds. Designing and Implementing Health Care Provider Payment Systems: How-To Manuals. Washington, DC: The World Bank.

Phuong, NK, TTM Oanh, HT Phuong, TV Tien, CE Cashin (2014). Assessment of systems for paying health care providers in Vietnam: implications for equity, efficiency and expanding effective health coverage.

Session 7: Thursday, 4/30 -- Donor support and conclusions

Topic: In the lowest income countries, donors can play a key role in the health sector. While economic theory suggests that the public sector should support public goods, such as many preventive services, political forces often direct public funds to tertiary hospital services sought by vocal constituents and patients in major cities. Donors sometimes fill this gap, funding the most critical services.

Readings

5 Kates J, Lief E. 2007. Donor funding for health in Low- and Middle-income countries, 2001-2006. Kaiser Family Foundation.

Shiffman J. 2008. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan 23(2):95-100.

Shepard DS, Zeng W, Amico P, Kanyange AK, Avila C. 2012. A controlled study of funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as resource capacity building in the health system in Rwanda. American Journal of Tropical Medicine and Hygiene 86(5): 902- 907. Lu C, Michaud CM, Khan K, Murray CJ. 2006. Absorptive capacity and disbursements by the Global Fund to Fight AIDS, Tuberculosis and Malaria: analysis of grant implementation. Lancet 368(9534):483-8.

Cavagnero E, Lane C, Evans DB, Carrin G. 2008. Development assistance for health: should policy- makers worry about its macroeconomic impact? Bulletin of the World Health Organization 86(11):864-70. Farag M, Nandakumar AK, Wallack SS, Gaumer G, Hodgkin D. 2009. Does Funding from donors displace government spending for health in developing counties? Health Affairs 28(4): 1045- 1055

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