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Health care finance and budget
1. Budgeting in Health Care System and
Health Care Financing
1
Presenter: Dr. Vaishnavi C
Guide: Dr. Chethana T
Dept of Community Medicine
MSRMC, Bangalore
6/20/2016
2. Contents
2
Introduction
Budgeting in Health care
Definition,
Need
Types
Approaches
Procedure
Challenges
Union budget 2016-17
12th five year plan
Health Care Financing
Definition
Principles
Sources
Models
Criteria
Trends of financing
Financing in India
NHA
Conclusion & References
6/20/2016
3. Introduction
Government – to provide affordable, equitable,
accessible and quality health care
Progress towards a healthier nation - close correlation of
health sector with economy
Health care expenditure requires a significant
contribution from the government
Countries that need the largest health advances are
precisely those spending the least on health
36/20/2016
4. Introduction
Public health expenditure - component for the
provisioning of health facilities
*Definition–
“recurrent and capital spending from government
budgets, external borrowings and grants and social
health insurance funds”
*Source: World Bank- Health Systems Financing
46/20/2016
5. Financial Control in Health Settings
Proper accounting system for funds, equipment
Laid down standards of performance against which actual
performance would be measured
Tools of control:
Budget
Hospital cost control
Financial statement analysis
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6. 6
Source: Health Systems Financing- Toolkit on monitoring health
systems strengthening, WHO
6/20/2016
7. Budgeting in health care system
‘Budget’ - French word “Bougette”
- leather ‘pouch’ or leather bag
Public sector invention
Anticipated receipts & available resources of an
organisation during the given year
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8. ‘Budget System’ was introduced
in India on 7th April, 1860. James
Wilson the first Indian Finance
Member delivered the budget
speech expounding the Indian
financial policy as an integral
whole for the first time
History of budget in India
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9. Post independence, the first
budget was presented on
November 26, 1947 by India's
first Finance Minister Sri
R.K. Shanmugham Chetty.
History of budget in India
6/20/2016 10
10. Budget:
Definition:
“A statement of future plans described in quantitative
and monetary terms, for a specific period of time, which
is usually one year in case of financial budgets”
11
Source: Union Budget 2016-17. Ministry of Finance, GOI.
http://www.unionbudget.nic.in/
6/20/2016
11. Need for Budget
Need for proper budgeting arises to allocate scarce
resources to various governmental activities
Planned expenditure and accurate foresight of
earnings are sine-qua-non
Has to be based on the long term strategy & focus on
future
All health care professionals should have a sound
knowledge of budgeting and health care financing
126/20/2016
12. Types of Budgets
• Long term
• Short term
• Current
• Rolling (Progressive)
Time-based Budgets
• Capital based (Planned)
• Operational (Non-Plan)
• Research budgets
Function-based
budgets
Flexibility-based
budgets
•Fixed budgets
•Flexible budgets
146/20/2016
13. Approaches to budgeting in health care
3 approaches to budgeting:
15
1. Incremental approach
2. Performance budgeting
3. Zero Based Budgeting (ZBB)
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14. 1. Incremental approach
› Previous year’s expenditure is applied to the next year
with additional components
› Only the increment over the previous year’s budget is
actually justified for the present duration
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15. Advantages:
Easy to prepare, less preparation time and lower
preparation costs
Easy to understand & prevents conflict
Disadvantages:
wasteful expenditures and priorities are not ascertained
Alternative better options are not considered
176/20/2016
16. 2. Performance budgeting
Presents the actual operations undertaken department-
wise & evaluation of actual performance of the
organisation
Periodic performance reports is prepared which
compares the budgeted actual performance with the aim
to detect any deviations at the earliest possible.
186/20/2016
17. 3. Zero Based Budgeting (ZBB)
Must review the existing & old programs, especially
which involve a high degree of discretionary costs
Justification that the activity proposed is essential, cost
effective is required
No activity or action is financed simply because it was
done in the past and the entire program must be justified
each time a budget is being drawn up.
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18. Advantages of ZBB:
Based on cost benefit analysis
Strictly based on priority of programs/ actions
Identifies areas of wasteful expenditure
Limitations:
Planning requires greatest effort and time
Less applicable for those activities which do not have a
direct cost-benefit relationship
206/20/2016
19. Advantages of budgeting
Effective means of communicating future organizational
plans to all people, in monetary and financial terms
Pre-decided and approved budget serves as an effective
benchmark for monitoring ongoing operations
Reduces wastage and losses by identifying wasteful
expenditures well in advance and rectifying them.
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20. Advantages of budgeting
Budgets through participation, encourage & develop team
spirit and collective responsibility towards excellence.
Basis for assessing performance of senior managers in
any organisation
226/20/2016
21. Procedure of Budgeting in India
23
Ministry of Finance – Shri Arun Jaitley
Department of Economic Affairs
(Secretary - Shri Shaktikanta Das)
Budget Division (Joint secretary)
The finance secretary, revenue secretary, secretary of
Economic Affairs & Planning Commission -
determine the contour of the budget.
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22. Execution of the budget
24
Enactment of the budget
Execution of the budget
Parliamentary control over finance
•Compilation and co-ordination
of the estimates
•Scrutinized by the Planning
Commission
Presenting the budget to
Lok Sabha and Rajya Sabha
Ministries are authorized to
draw the necessary amounts
And spend them
Ensuring that the money has been
spent for the purpose stated by it
Procedure of Budgeting
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23. Key challenges to health care budgeting
in India
Public expenditure on healthcare to be increased from 1.3
(2014) per cent to 5 per cent of the GDP to match the
global average expenditure
A robust plan for effective utilisation of existing budgets
so that public expenditure is fully utilised
256/20/2016
24. Key challenges to health care budgeting
in India
High burden of out - of-pocket expenditure (OOP) in
India
Hospital bed density - 0.9 per 1,000 persons*
0.7 doctors per 1,000 patients*
Focus on geriatric care
Shortage of medical institutions and with majority
present in urban areas
Technology promotion
26
Source: Health Systems Financing- World Bank Report
6/20/2016
25. Twelfth Five Year Plan
Allocation three times greater than 11th five year plan
expenditure
Share of healthcare – 2.5% of GDP
Focuses on providing universal healthcare, strengthening
healthcare infrastructure, promoting research and
enacting strong regulations for the healthcare sector
276/20/2016
26. 28
Budget allocation to health care (USD billion)
Source: Planning commission-
http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_vol2.pdf
6/20/2016
27. Union Budget 2016-17: Vikas ka budget
Allotments: Total: 31,300 Cr ( 1.58% of total)*
Medical, Public Health and Family Welfare (Rs.
5188.63 cr)
Rs.2077.55 cr for major central and medical
institutions
Rs.384 cr for medical education, training and
research
Rs.252.70 cr towards Ayurveda, Yoga and
Naturopathy Siddha and Homoeopathy.
29
Source: Union Budget 2016-Ministry of finance, GoI6/20/2016
28. Budget 2016-17 contd...
New health protection scheme - health cover up to one
lakh per family.
Prime Minister’s Jan Aushadhi Yojana- 3000 stores
‘National Dialysis Services Programme’ under National
Health Mission through PPP mode
306/20/2016
29. Budget 2016-17 contd...
Social Security and Welfare (Rs. 1,329.60 cr):–
Rs. 760.16 cr for pension and other benefits to freedom
fighters,
Rs. 61.03 cr for child and women welfare and
Rs. 67 cr for the welfare and empowerment of persons
with disabilities.
Census, Surveys and Statistics- Rs808.81 cr
316/20/2016
31. Shortfalls
Increasing the public expenditure as proposed by 12th
five year plan to over 2.5 per cent - not been met
Long way in achieving universal health coverage from
burgeoning healthcare costs
Efforts to reduce the manpower and skill gap were also
missing from the budget
Reforms in health care sector is necessary
336/20/2016
32. Guidance for strengthening public
expenditure management
Strengthened budget formulation process
Enhanced government capacity for efficient public
expenditure management and monitoring
To generate expenditure priorities and arbitrate between
competing needs for scarce resources and reflect
government policy objectives
346/20/2016
33. Health care financing
Financing is the most critical of all determinants of a health
system
WHO – “function of a health system concerned with the
mobilization, accumulation and allocation of money to
cover the health needs of the people, individually and
collectively, in the health system”
to ensure that all individuals have access to effective public
health and personal health care
356/20/2016
34. Principles of a health financing system
36
• Have to be collected equitably
and efficiently
Revenue
collection
• costs of health care are shared by
all and not borne by individuals
Pooling
• Used to buy or provide health
interventions that are allocatively
and technically efficient
Purchasing
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35. 37
Action 1:
Establishing
the vision
Action 2:
Situational
analysis
Action 3:
Financial
assessment
Action 4:
Constraint
assessment
Action 5:
Strategy
for change
Action 6:
Implement
ation
Action 7:
Monitoring
and
Evaluation
Decision Process of
Health Financing
Source: Health systems financing-The path to universal coverage - WHO
36. Models of healthcare financing
38
Beveridge
model
Bismarck
Model
National
Health
Insurance
Model
The Out of
Pocket
Model
Source: Health Systems financing. Report - World Bank.
6/20/2016
37. Sources of health care financing
The tax-based public sector
Out of Pocket Expenditure
Insurance- social, community- based, private
External financing
396/20/2016
39. Out of Pocket Expenditure
Simplest form
Main financer of health services in India is individual
household
Consequences:
Lower the access to health care
Impoverish the households
41
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40. Insurance
Most complex mechanism of financing health care
Objective - manage the revenues equitably and
efficiently allowing for subsidies from healthy to
unhealthy, rich to poor and productive workers to
dependents
426/20/2016
41. 43
• Employees State Insurance
Scheme (ESIS) and the Central
Government Health Services
(CGHS)
Social Health
Insurance (SHI)
• Generally preferable to out of
pocket expenditure
• Increase financial protection
and access
Private Health
Insurance
• Not-for-profit prepayment plans
Community
Health Insurance
6/20/2016
42. Criteria for choosing the financing system
44
Risk pooling
Equity
Economic
Effects
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44. Health care financing in India
Health sector - high maternal and child mortality, dual
burden of communicable & non-communicable diseases
Hospitalization for major illness is a cause of
indebtedness for all income groups
Inability of the poor to access good health care
466/20/2016
45. 47
Private Public Others
Debt financing Annual govt budget for
rural health
Foreign
donations
Foreign direct
investment
Annual govt budget for
urban health
PPP project
funding
External
commercial
borrowing
Govt. funding for
community programmes
Individual investors Govt. sponsored
schemes
Avenues of Health care financing- India
46. Factors influencing health care financing
in India
Demography data
Economic Recession
Expectations from health care
Drive for Equity
Changing disease pattern
486/20/2016
47. Health financing issues in India
Low level of public health expenditure
18% - no access to OPD services*
40% have to sell their assets or borrow to pay the bill*
A mismatch between policy and practice – eg. NACO,
RNTCP
Weak absorption capacity in the government
Budgeting - not functional
Source: NSSO- 2011
496/20/2016
48. 50
Indicators (2014) Value (US$)
Total Health Expenditure (THE) - % (GDP) 5
General Government Health Expenditure
(GGHE) as % of Total Health Expenditure
30
Private Health Expenditure (PvtHE) as % of
Total Health Expenditure (THE)
70
Health expenditure series. Global health expenditure database. WHO
Financial indicators in health care-India
6/20/2016
49. 51
Indicators (2014) Value (US$)
Out of Pocket Expenditure (OOP) as % of
Total Health Expenditure (THE)
62
General Government Health Expenditure
(GGHE) as % of GDP
1.2
Total expenditure on health 97,140
million
General government expenditure on health 29,177
million
Source: Health expenditure series. Global health expenditure
database. WHO
Financial indicators in health care-India
6/20/2016
50. 52
Fig: Trends in centre-state share % in TPHE on health
Source: National Health Profile - 2015
6/20/2016
51. 53
Source: National Health Profile - 2015
Fig: Composition of public expenditure on medical and public
health
6/20/2016
52. National Health Accounts (NHA)
Consistent, comprehensive information of all the
resources that flow through the country’s health system
over time
Standard management tool for situation analysis,
planning, monitoring and evaluation purposes
546/20/2016
53. NHA address four basic sets
of questions:
where do resources come
from
where do they go
what kinds of services and
goods do they purchase
whom do they benefit
556/20/2016
54. Six dimensions are considered:
Financing sources
Financing agents
Providers
Functions
Cost of Factors of Production
Beneficiaries
566/20/2016
55. Conclusion
Countries have to move forward faster to develop
equitable and efficient institutional structures, revenue-
raising mechanisms and spending prioritizations
To become more efficient and equitable in the use of
resources
Need for constant re-evaluation and adjustment
576/20/2016
56. References
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Practice. 8th ed.USA: Times Mirror; 1979.p.
Sathe VP, Doke PP. Epidemiology and management of
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Detels R, Beaglehole R, Lansang MA, Gulliford M. Oxford
Textbook of Public Health. 2nd ed. United Kingdom: Oxford
University press;2001.p.
Health Systems Financing- World Bank [Online] 2016 [Cited on
2016 Jun 10];Available from:URL: http://web.worldbank.org/
586/20/2016
57. References
Balwar R, Vaidya R, Tilak R, Guptha RK, Kunte R. Textbook of
Public Health and Community Medicine. 1st ed. Department of
community medicine, AFMC, Pune in collaboration with WHO
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Systems in the 21st Century [online] 2006 [Cited on 2016 Jun 2]
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Health Systems Financing - Toolkit on monitoring health systems
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2016 Jun 4];Available
from:URL:http://www.who.int/healthinfo/statistics/toolkit_hss/EN
_PDF_Toolkit_HSS_Financing.pdf 596/20/2016
58. References
Budget in parliament- procedure. Ministry of Finance, GoI
[online] [Cited on 2016 Jun 2];Available from:URL:
http://www.parliamentofindia.nic.in/ls/intro/p4.htm
BUDGET MANUAL- 2016-17. Ministry Of Finance.
Department Of Economic Affairs, Budget Division, New Delhi
[online] 2016 [cited on 2016 Jun 10];Available from:
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_Manual.pdf
Srinivasan R. Health Care in India – Vision 2020, Issues and
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606/20/2016
59. References
Financing and Delivery of Health Care Services in India.
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Ministry Of Health And Family Welfare Government Of India
& WHO [Online] 2005 [ Cited on 2016 Jun 4];Available from:
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ocuments/Healthcare.pdf
616/20/2016
60. References
Choudhury M, Nath HKA. An Estimate of Public
Expenditure on Health in India. National Institute of Public
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stimates_report.pdf
Healthcare Infrastructure and Services Financing in India-
Challenges. Indian Chamber of Commerce [Online] 2012 Sep
[Cited on 2016 Jun 10];Available
fom:URL:https://www.pwc.in/assets/pdfs/publications2012/h
ealthcare_financing_report_print.pdf
Kurian OC. Financing Healthcare for all in India: Towards a
Common Goal. OXFAM India [Online] 2015 [Cited on 2016 Jun
4];Available from: URL:
https://www.oxfamindia.org/sites/default/files/WP-Financing-
Healthcare-for-All-In-India-29-05-2015-EN_0.pdf 626/20/2016
61. References
Adedigba MA. Health Care Costs and Comparison of Different
Methods Of Financing Health Care. Organisation of African
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636/20/2016
62. References
Health financing for universal coverage- Health financing
country diagnostic. A foundation for national strategy
development. WHO [Online] 2010 [Cited on 2016 Jun 10];
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http://www.who.int/health_financing/tools/diagnostic/en/
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df
646/20/2016
63. It is well enough that people do not understand the
monetary system, for if they did, there would be a
revolution before tomorrow morning
- HENRY FORD
THANK YOU
656/20/2016