Access to Health Care for All in Haiti: Challenges and Perspectives for Funding

Glossary

Access: The presence or absence of physical, economic, or cultural barriers that people might face in using health services. Physical barriers are usually interpreted to mean those related to the general supply and availability of health services and distance from health facilities. Economic barriers are usually interpreted to mean those related to the cost of seeking and obtaining health care, in relation to a patient’s or household’s income. 10 Cultural barriers relate to social or community perceptions about receiving or knowing about certain health services.

Adverse Selection: (1) Tendency of people more likely to incur health costs to seek health insurance. (The opposite is favorable selection.) (2) A situation in which patients with greater than average need for medical and hospital care enroll in a prepaid health care plan in greater numbers than they occur in a cross-section of the population. A plan enrolling only the Medicare population would suffer from adverse selection, as would one that somehow encouraged or allowed people to sign up when they were already ill.

Agency Relationship: a situation in which a person (the agent) makes decisions on behalf of another person (principal).

Capitation: ( 1) A payment made directly to a health care provider for individuals who have signed up with that provider to receive a particular package of services. The health care provider is both a fundholder and deliverer of services. Under full capitation of full fundholding, the provider assumes responsibility for paying all components of health care (inpatient and outpatient). Under partial capitation or partial fundholding, the provider assumes responsibility for paying for only selected services. (2) A method of payment in which a provider receives a fixed fee per person (per capita) for a period of time, and the provider agrees to furnish to persons for whom the capitation payments are received all the care that may be required (within contract limitations) without further fee. Capitation may, for example, pertain to virtually all medical and hospital services through a health care plan, or only to primary care services.

Catastrophic Health Expenditure: A situation where a household spends on health more than 40% of its income after paying for subsistence needs, e.g. food. It can be caused by catastrophic illness, either high cost but low frequency event or by low cost and high frequency events.

Case Mix: The mix of different types of patients (defined by severity of illness and complexity of diagnosis and/or treatment) treated in a health care organization.

Case-based Payment: A fixed payment covering all services for a specified case or illness.

Co-insurance: Portion of covered health care costs for which the covered person has a financial responsibility, usually a fixed percentage.

Co-payment: A cost-sharing arrangement in which an insured person pays a specified charge for a specified service. It is also an out-of-pocket charge paid by an insured individual.

Conditional Cash Transfers: Monetary transfers to households over a certain time period when complying with certain behaviors.

Contracting (or Contracting-Out): The process in which a legal agreement between a payer and a subscribing group or individual such as purchasers, insurers, takes place which specifies rates, performance covenants, and the relationship among the parties, schedule of benefits and other pertinent conditions.

Contributory Scheme: This terminology is often used for social security systems where members regularly contribute to a particular social security scheme in order to have clearly defined social benefits such as old age pension, health services, maternity allowance and other monetary allowance in the event of disability or death. Noncontributory social security scheme refers to social assistance programs as well as services funded directly by the state budget or other public sources.

Cost Recovery: Receipt, by a health provider, of income from individuals or the community in exchange for health services. These fees were introduced to cover a portion of the costs of service delivery.

Costs: What has to be given up to achieve an objective: either the value of the benefits that are foregone in order to achieve that objective (the economic definition), or the total money expenditure required to achieve it (the accounting definition).

Covered Services-Benefits Package: The types of medical care for which the insurer will pay all or part of the cost. An “exclusion” refers to care that is not a covered benefit.

Decentralization: A process of transferring responsibility, authority, control, and accountability for specific or broad management functions to lower levels within a organization, system, or program.

Deductible (Franchises): The amount of the loss or expenditure to be incurred by an insured person or otherwise covered before an insurer support all or part of the balance of the cost of covered services. The deductible can be either fixed amounts or monetary value depending on the value of specific services (such as two days of hospital treatment or a visit to the doctor).

Diagnosis Related Group (DRG): A group of cases arranged according to their diagnosis, determined using the International Classification of Diseases (represent a classification type that is part of the case mix system). Note: The purpose of grouping is to assist in the comparison of costs or in calculating the price to be charged for each case conforming to a particular pattern or grouping.

Effectiveness: The effect of the activity and the end results, outcomes or benefits for the population achieved in relation to the stated objectives. It is an expression of desired effect of program, service intervention in reducing a health problem or improving an unsatisfactory health situation.

Efficiencies (Allocational and Technical): a difference is made between technical efficiency which is concerned with using given resources to the maximum advantage; and allocative efficiency which relates to achieving the right mixture of health care programs to maximize the health of society. For technical efficiency one can think about the numerous empty beds in the numerous hospitals, indicating that respective human and financial resources are not used to full extent while for allocative efficiency one may consider low delivery of non-integrated preventive services.

Equity: The absence of systematic disparities in health between social groups who have different levels of underlying social advantage or disadvantage – that is, different positions in a social hierarchy. Inequities in health systematically put groups of people who are already socially disadvantaged such as by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group at further disadvantage
with respect to their health.

• Horizontal Equity: Equal payment for households in the same circumstances such as the same income.
• Vertical Equity: Persons with greater need should be treated more favorably than others. The extent to which unequal households pay unequal share.

Expenses: Costs that have been used or consumed in carrying on some activity.

Fee-for-Service: Reimbursement of providers on a service-by-service basis rather than on a salaried, per-case, or capitated basis. A method of paying physicians (and other health care providers) in which each “service,” for example, a doctor’s office visit or operation, carries a fee. The physician’s income under this system is made up from the fees he/she collects for services.

Fee Schedule: An organization’s list of prices for each of its services.

Formal Sector: Enterprises, which are registered and licensed to conduct business and whose employees earn regular salaries and wages.

Funds/Fundholder: The institution responsible for accumulating and spending the (prepaid) contributions for insurance. Funds are usually third party payers (public or private) but can also be providers. In the latter case, some functions of insurer and provider are integrated in a single institution.

Gross Domestic Product (GDP): The total value of goods and services produced within a country each year.

Health Equity Funds: Third party system that reimburses health care providers for services rendered to eligible population.

Health Financing: The system of fund generation, fund expenditures, and flow of funds used to support the health care delivery system.

Health Insurance: The purpose of health insurance is to provide an individual with financial coverage against the risk of illness. Those insured pay a premium or contribution to the insurance company, which offers a range of benefits depending on the type of health coverage being provided.

• Community-based Health Insurance (CBHI): A micro-insurance scheme managed independently by community members, a community-based organization whereby the term community may be defined as members of a professional group, residents of a particular location, a faith-based organization etc.
• Micro Insurance: Small-scale, local and independently managed scheme often set up because people are unwilling to trust in larger schemes. Most of the micro schemes are too weak to deal with unpredictable large expenses. Second definition: health protection/insurance linked to a micro lending scheme.
• Private Health Insurance: A health insurance scheme often characterized with the following features: voluntary, managed outside the social security system with risk rated or community rated premiums, managed by an independent legal entity (an incorporation, organization, association or foundation) not by a state/quasi state body, operating for profit or non-profit.
• Voluntary Health Insurance: Health insurance that offers benefit to its members entitled on a voluntary basis, which can be managed by a private, public or quasi-public body.

Health Maintenance Organization (HMO): (1) A prepaid, organized health care service delivery arrangement in which beneficiaries receive services through a system of affiliated hospitals, clinics, physicians, etc. Comprehensive benefits are financed by prepaid premiums and limited copayments. Services rendered are carefully managed to control what services a patient receives. (2) A health care providing organization that ordinarily has a closed group of physicians (and sometimes other health care professionals) along with either its own hospital or allocated beds in one or more hospitals. Patients “join” an HMO, which agrees to provide “all” the medical and hospital care they need, under a contract stipulating the limits of the service, for a fixed, predetermined fee.

Informal Sector: Enterprises, which are not registered and licensed to conduct business but do so in an entrepreneurial, independent manner, and whose earnings are not reported or declared as part of a payroll process. Compared with wage-earning workers in the formal sector, the informal sector has more labor-intensive mode of production. Informal production units typically operate at a low level of organization, with little or no division between labor and capital on small-scale labor operations. Their existence is based on casual employment, kinship or personal and social relations rather than contractual arrangements with formal agreement.

Inputs: Goods, services, personnel, and other resources provided for an activity with the purpose of producing output and achieving the activity’s objective.

Moral Hazard: (1) The situation in which persons who acquire insurance change their behavior because they no longer bear the full cost of that behavior. (2) Impact on an individual’s demand for care of an out-of-pocket payment that is less than the cost of providing services. Because insurance (including centrally tax-funded services) covers some or all of the costs of service use, individuals tend to use more services than if they faced the full cost of care.

National Health Accounts (NHAs): It provides a framework and methodology for measurement and presentation of information on total national health expenditure including public and private sources of funds. NHA tracks financial resources from sources, to providers and functions. It is important because, health systems are complex and policy makers need tools to analyze health financing – how much resources are used in a health system, what resource allocation patterns, use and options exist. Following an update in methodology to SHA 2011, NHA are now referred to as Health Accounts (HA).

Parastatal Organization: Organization linked to the State, which enjoys more autonomy than public or government agencies whose management systems are very close to those of the private sector.

Payer: (1) Any entity that pays for health care services. It is usually an insurer or government agency, but it can be one provider paying another or a self-insured employer paying providers. See also fundholder. (2) An organization or person who furnishes the money to pay for the provision of health care services. A payer may be the government (for example, Medicare), a nonprofit organization (such as Blue Cross and Blue Shield), commercial insurance, or some other entity. In common usage, payer most often means third party payer.

Premium: ( 1) Amount of money paid to insurers on a regular basis in return for coverage (membership in an insurance plan). Premium rates for health insurance may be based on average costs of claims of the covered population or vary by socio-demographic characteristics such as age, sex, and occupational activity. (2) An amount paid for an insurance policy for a given period of time.

Prepayment: Payment made in advance giving a guarantee of eligibility to receive a service when needed at reduced or zero additional cost at time of use (e.g., insurance premiums).

Pre-Payment Mechanism: a method of paying for the cost of health care services in advance of their use. A method providing in advance for the cost of predetermined benefits for a population group, through regular periodic payments in the form of premiums, dues, or contributions, including those contributions that are made to a health fund by employers on behalf of their employees.

Provider Payment Methods (or Mechanisms): Ways or means of paying health care providers such as on a capitation, case-based, fee-for-service or other basis (see also individual definitions).

• Prospective Payment: Payment based on a formula that allows service providers to agree the total amount of funding in advance and then payments against that amount are made on a monthly basis.
• Retrospective Payment: Payment based on services actually delivered in accordance with a fee schedule that is determined in advance.

Purchaser: This entity not only pays the premium, but also controls the premium amount before paying it to the provider. Included in the category of purchasers or payers are patients, businesses and managed care organizations. While patients and businesses function as ultimate purchasers, managed care organizations and insurance companies serve a processing or payer function.

Regressive Financing: Financing whereby the better-off pay a smaller share of their income compared with the poor for accessing health care.

Reimbursement: Payment to a provider (health facility or physician from the government, insurance company, or other fundholder) after services were rendered amount of which equals the institutions or individuals expenses.

Resource Allocation: The process by which available resources are distributed between competing uses as a means of achieving a particular goal.

Risk: (1) The unexpected but estimated loss an insurer considers in issuing a contract to cover the loss in the event that it occurs. (2) The possibility of financial loss because of an injury to a patient (or visitor or employee), either through custodial liability (such as slips and falls) or professional liability (harm from the medical or hospital care). (3) Health care plan risk is a term which, when used in connection with organizations for providing patient care, refers to finances. For example, a health maintenance organization (HMO) that offers prepaid care for a given fee or premium is “at risk;” it must provide the care within the premium funds available or find the money elsewhere (the individual assets of the partners, for example).

Risk Pool: A fund set up as a reserve for unexpected expenses. Organizations providing prepaid health care for a fixed fee typically set up such pools to cover, for example, unusually large demands for hospital care or specialist services.

Risk Pooling: The World Health Organization defines risk pooling as “the practice of grouping together several levels of risk for insurance purposes in order to balance the consequences of the completion of each risk individually.” [World Health Organization (2000), The World Health Report 2000. Health systems: Improving performance, Geneva. World Health Organization] In other words, it is the function that combines the uncertainty of individuals (in terms of service needs) in a calculable risk for large groups. While the pooling of risks is necessary for the insurance principle works, all risks can not be effectively grouped / pooled / shared. In particular, it is difficult to Common dissimilar risks in voluntary insurance, unless there is a grant available to encourage participation. The theory behind the pooling of risks is the aggregation of risk between all users based on the principle that the strong demand for healthcare for a user will be offset by weak demand on the other.

Social Health Protection Schemes: Includes all kinds of health financing protection mechanisms, from tax-based financing, statutory social health insurance to private health insurance, health equity funds, community-based health insurance, and various fee exemptions for health services.

Subsidy: A payment made by the government with the object of reducing the market price of a particular product or of maintaining the income of the producer. The aim of a subsidy may be to sustain demand for a particular product; to protect a particular industry; or to ensure that those consumers, especially the poor, who would otherwise not purchase a product or whose demand for it would decline, maintain their previous level of consumption.

Third Party Payer: (1) Intermediary institution responsible for paying providers for services rendered to covered patients. Such funds or purchasers are called third party payers because they are neither patients nor health care providers. (2) An intermediate institution (e.g., insurance company) that modifies the transactions between consumers and providers of health care. Third party payers can be the government or private sector companies. (3) A payer who neither receives nor gives the care (the patient and the provider are the first two parties). The third party payer is usually an insurance company, a prepayment plan, or a government agency; organizations that are self-insured are also considered third parties.

Universal Health Coverage (UHC): Universal health coverage (UHC), is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship

User Charges (or Fees): Payment for goods and services according to price list or fee schedule.

User Fees (or Fee-Charging): Payment for goods and services according to a price list or tariff schedule.

User Fees: Payment of out-of-pocket charges at the time of use of health care.

Vouchers: A voucher entitles its holder the use of specific health services without paying the respective user fee at selected health providers as the voucher can be exchanged for a specified amount of money by the provider upon receipt.