fiji living hit update - who · 2017-11-30 · fiji living hit update 1 3.1 section summary this...

FIJI LIVING HiT UPDATE

a


H E A L T H S Y S T E M S I N T R A N S I T I O N 0 3 / 2 0 1 4

Chapter 3: Health Financing3.1 Section summary 1

3.2 Health expenditure 3

3.3 Sourcesofrevenueandfinancialflows 9

3.4 Overviewofthestatutoryfinancingsystem 12

Coverage:breadth,scopeanddepth 12

Collection 13

Poolingoffunds 13

3.5 Out-of-pocket payments 14

3.6 Voluntary health insurance 15

3.7 Othersourcesoffinancing 16

3.8 Payment mechanisms 16

Payingforhealthservices 16

Payinghealthworkers 16

Acknowledgments 18

References 18


b


1

3.1 Section summaryThissectiondescribesfinancingofthehealthsectorinFijiincludinganoverviewofthesystem,levelsofspending,sourcesoffinancingandpaymentmechanisms.Governmentbudgetallocationsforhealthhaveremainedrelativelyconstantdespitetheincreasingdemandandcostforhealthcare.Since1995,theGovernmentofFijihasallocatedbetween7%and10%ofitstotalexpendituretohealth;thelatestfigurebeing7.2%in2012.Inthesameperiod,governmenthealthexpenditureasaproportionofgrossdomesticproduct(GDP)hasfluctuatedbetween2.7%and3.5%,whiletotalhealthexpenditure(THE)hashoveredaround4%ofGDP;itwas4.5%in2012.TheseproportionsofGDPspentonhealtharethelowestamongPacificislandcountries.Percapitahealthexpenditurehasincreasedsteadilysince1995upuntil2009,decreasingslightlyuntil2011.

Theshareofhealthexpenditurespentoninpatientservicesdecreasedfrom35.4%in2005to26.5%in2012.In2012,governmenthealthexpenditurerepresented60%ofTHE,lowerthanallotherPacificislandcountries,butrelativelyhighwhencomparedinternationally.Privatehealthexpenditurehasincreasedandwas34%oftotalhealthexpenditurein2012.Thisincreaseislargelybecauseofout-of-pocket(OOP)expenditure,whichhasmorethandoubledovertheperiod2005(12%)to2012(27%).Apartfromgovernmentandprivatesourcesoffunds,developmentpartnersrepresent6%ofTHE.

TheFijihealthsystemhasbeenfinancedmainlythroughgeneraltaxation.OOPexpenditure,althoughrelativelylowwhencomparedwithmanycountries,isthesecondhighestsourceoffinancingforhealth.Therearenocompulsorysocialinsuranceschemes.A2012socialhealthinsurancefeasibilitystudyconcludedthatitwouldbedifficulttoachieveanadequatebaseofcontributorsforanationalhealthinsurancesystem(Rannan-Eliyaetal.,2013),andvoluntaryhealthinsuranceisuncommon(duemostlytolackofaffordability).Nevertheless,spendingpremiumsforprivatehealthinsuranceincreasedfrom2005to2012.

Publicprovisionofhealthcareisfreeoratverylowcostforallpersonsinthecountry.Userfeesarechargedforsomebasicandselectedservices,butevenatrevised2012ratestheyaremodestcomparedwiththecostsofprovidingtheseservices.Certainpopulationgroupsareexemptedfrompayinguserfees.Privatehealthspendingisnotadequatelydocumented.Privateproviderschargeuserfeesthatareconsiderablyhigherthanthoseinpublicfacilities;privatefeesarenotregulatedbytheGovernmentbuttosomeextentbymarketforces.Privateprovidersaremainlysituatedinurbanareasandtheirservicesareusedmostlybythosewhoare formally employed.

Figure3-1depictsthehealthfinancingflowsoftheFijihealthsystem.Thediagramshowswhererevenueforhealthisgenerated,thehealthprovidersthatreceivethisrevenue,andthehealthservicestheyprovidethatarefundedfromthisrevenue.


2

Figure 3-1 Financial flows in the Fiji health system

Tax Office

Central Government

BudgetDonors

Ministry ofEducation

Ministry of Health

Divisional Health Offices

Population

Firms(Employers, Insurance

Companies)

Universities

Hospitals

Specialised institutions

Healthcentres

Nursing Stations

EducationR&D

Other (e.g.NGOs)

mostly to public health programs

Public health programs

Inpatient services

Private hospitals

Other private health provider clinics

Pharmacies

Outpatient services

Primary care services

Specialised services

Taxes Taxes

Revenue

Fee for service / co-payments

Bud

get A

lloca

tions

Pri

vate

sec

tor

Premiums

Source:AsiaPacificObservatoryonHealthSystemsandPolicies

ThesamegovernmenthealthservicesareavailabletoallresidentsofFiji;foreignersareentitledtotheservicesatacosttwicethatofresidentuserfees.GivenFiji’sgeography,urbanpopulationsinevitablyhavegreateraccesstohealthservicesthan rural populations. Access to specialized health services and cost of transport isamajorbarrierforthoselivinginremoteareas,andthegovernmentbudgetforemergencytransportislimited,asistheallocationforoverseasevacuationandtreatment.

TheGovernmentoperatesaconsolidatedfundinwhichtaxationrevenuesanduserfeesarepooled.MinistryofHealth(MoH)officialssubmitbudgetproposalstotheGovernmentbasedonnational-,regional-andlocal-levelsubmissions,andtheycompetewithotherministriesfortheirfinancing.Allocationsareusuallybasedonhistoricalbudgetsandtherulinggovernment’sannualpriorities.Externalsourcesoffundingincludecontributionsfrommultilateralandbilateraldevelopmentagencies,andnongovernmentorganizations–anestimated6%ofTHEin2012.


3

Paymentmechanismsforhealth-careprovidersarerelativelystraightforward,astheGovernmentbothfinancesandprovidesthemajorityofservices.TheMoHreceivesitsbudget(finances)accordingtoresourceinputssuchashumanresources,services,capitalinvestments,andpurchaseofpharmaceuticalsandmedicalequipment,andusesasimilarprocessindistributingthesefundsacrossvariousgovernment-ownedhealthfacilities.ThemajorityofhealthworkersinthecountryaresalariedstaffoftheMoHorgovernmentwage-earners.Someservicesareoutsourcedsuchascleaningandsecurity,andthereareplanstooutsourceotherssuchaslaundryandfoodcatering.Privategeneralpractitionersreceiveafee-for-servicepayment,andsomearecontractedtoprivateorganizationstoprovide employee health care. Private insurers can either cover all health service costsupfrontorreimbursepatientsonprovisionofreceipts.Pharmaceuticalsandothermedicalgoodsareimportedbythegovernment-fundedFijiPharmaceutical&BiomedicalServicesCentre,whichsuppliesallgovernmenthealthfacilities.PrivatepharmaciescanchoosetopurchasefromtheCentrewithallowablewholesaleandretailmark-upssetbytheFijiPricesandIncomesBoardandtheFijiCommerce Commission.

3.2 Health expenditureThehealth-caresysteminFijiisfinancedmainlythroughgeneraltaxation.TheothermajorsourceoffinancingisOOPpayments,whicharemostlygeneratedintheprivatehealthsector.Privatehealthinsuranceanddonororganizationscontributesmalleramountsoffinancing.

Governmentbudgetallocationsforhealthhaveremainedrelativelyconstantdespitetheincreasingdemandforandcostofhealthcare.Overthedecade1995–2004,theGovernmentallocatedbetween9%and11%ofitstotalannualpublicexpenditurestohealth,exceptin1999,whentheallocatedpercentagewasitslowestat7.6%.

Figure 3-2 Total government budget and health budget (in constant 1995 FJ$)

1200

1000

800

600

400

200

0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Govt budget 1995 constant MoH budget 1995 constant

Mill

ions

Source:Azzam(2007)


4

Thetotalgovernmentbudgetshowedaslightincreaseovertheperiod2005to2012.TotalgovernmentexpenditureamountedtoFJ$1424.5millionin2005(33%ofGDP).By2012,ithadrisentoFJ$2077.9million(34%ofGDP).Howeverhealthexpenditureasapercentageoftotalgovernmentexpenditurehasdecreasedasapercentagesharefrom9.6%in2005to7.4%in2012.Overtheperiod2005to2012,healthexpenditurehasaveraged8.8%ofgovernmentexpenditure.

Figure 3-3 Total government budget and health budget (constant 2005 FJ$)

1800

1600

1400

1200

1000

800

600

400

200

02005 2006 2007 2008 2009 2010 2011 2012

Govt budget 2005 constant MoH budget 2005 constant

FJ$

Mill

ions

Sources:MinistryofHealth(2005,2006,2007,2008,2009,2010,2011and2012a).

Table3-1summarizesinformationobtainedfromFijiHealthAccountsreportsfor2005to2012andWHOdata.1Since1995,governmenthealthexpenditureasaproportionofgrossdomesticproduct(GDP)hashoveredbetween2.7%and3.5%.ThisisoneofthelowestratesamongPacificislandcountries(seeFig.3-3),despitethefactthatFijiismoreeconomicallydeveloped.

1 CautionisadvisedincomparingthesefiguressinceitisprobablethattheestimationmethodologiesusedinNationalHealthAccounts(NHA)reportsdifferfromthoseusedintheWorldHealthOrganization(WHO)report.Thefiguresfor1995to2005arefromWHO,whilethefiguresfor2007to2012arefromFijiNHAreports.


5

Table 3-1 Trends in health expenditure in FijiExpenditure 1995a 2000a 2005b 2007c 2008c 2009d 2010d 2011d 2012d

Total health expenditure (THE)inUS$percapita

125.4 166.7 170.1 170.7 168.5 198.7 193.8 182.9 -

THEas%ofGDP 3.9 4.7 4.1 4.3 4.2 4.9 4.8 4.4 4.5

Publicexpenditureonhealthas%ofTHE

58.2 69.0 72.0 71.2 69.6 62.9 60.8 61.7 60.3

Private expenditure on healthas%ofTHE

- - 24.0 25.4 24.5 31.0 30.4 33.4 33.8

MeanannualrealgrowthrateinGDP

- –1.7 3.6 –6.6 0.2 –1.3 –0.2 2.1 2.5

Totalgovernmentspendingas%ofGDP

34.9 35.1 31.4 33.2 35.2 33.9 32.0 33.7 37.4

Government health spendingas%oftotalgovernmentspending

8.6 9.8 9.6 10.0 8.2 9.3 9.2 8.1 7.2

Government health spendingas%ofGDP

3.0 3.5 3.2 3.3 2.9 3.1 2.9 2.7 2.7

Out-of-pocket payments as%ofTHE

- - 11.9 15.4 15.5 22.5 20.0 27.2 26.8

Sources:(a)WorldHealthOrganization(2013)foryears1995and2000;(b)Azzam(2007)foryear2005;and(c)FijiHealthAccounts(2007,2008,2009,2010,2011and2012)

Figure3-4showsthatwhilethegovernmentbudgetasapercentageofGDPhasfluctuated,ithasremainedrelativelyconstantbetween30and35.However,thegovernmenthealthbudgetasapercentageofGDPshowsagradualdecreasefromapproximately11%in2005toapproximately8%in2012.

Figure 3-4 Government and Ministry of Health (MoH) budget as a share (%) of GDP, 2005–2012

40.0%

35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

2005 2006 2007 2008 2009 2010 2011 2012

Government budget as a percentage of GDP constant (2005 prices)

MoH budget as a percentage of GDP constant (2005 prices)

Sources: MinistryofHealth(2005,2006,2007,2008,2009,2010,2011and2012).


6

EstimatesfromFijiHealthAccountsreportsshowaslightincreaseinTHEasapercentageofGDP,from4.1%in2005to4.5%in2012.Thisindicatoriswithinthe4–5%rangerecommendedbytheWorldHealthOrganization(WHO)regionalstrategyonhealthfinancing(WHO,2009).TheincreaseislargelydrivenbyinvestmentsintheprivatesectorsincegovernmenthealthspendingasapercentageofGDPhasdecreasedfrom3.2%in2005to2.7%in2012.

Figure 3-5 Total health expenditure as a share (%) of GDP, WHO Western Pacific Region, 2011

Brunei DarussalamLao People’s Democratic Republic

MalaysiaFiji

PhilippinesVanuatu

Papua New GuineaSingapore

ChinaMongolia

TongaCook Islands

CambodiaViet Nam

SamoaRepublic of KoreaSolomon Islands

AustraliaJapanNauru

KiribatiNew Zealand

PalauFederated States of Micronesia

NiueMarshall Islands

Tuvalu

2.5%2.8%

3.6%3.8%

4.1%4.1%4.3%

4.6%5.2%5.3%5.3%

5.5%5.7%

6.8%7.0%7.2%

8.8%9.0%9.3%

9.8%10.1%10.1%

10.6%13.4%

14.6%16.5%

17.3%

Note:No2011valuesareavailableforAmericanSamoa,FrenchPolynesia,Guam,HongKong(China),Macao(China),NewCaledonia,NorthernMarianaIslands,Tokelau,WallisandFutuna.

Source:WHO(2013)

Table3-1showsthatprivatehealthexpenditureasapercentageofTHEincreasedfrom24%in2005to34%in2012.ThisincreasewaslargelyaresultofOOPexpenditurewhichmorethandoubledoverthesameperiod.OOPexpenditureasapercentageofTHEincreasedfrom11.9%in2005to26.8%in2012.

TherewasasteadyupwardtrendingovernmentpercapitahealthexpenditurefromUS$62.72in1995toUS$124.23in2007(seeFig.3-6).Howeverin2008,therewasadecreasetoUS$101.63duetoareductioningovernmenthealthexpenditure.Thereafterfrom2008to2011,governmenthealthexpenditurehasremained fairly constant.


7

Figure 3-6 Government health expenditure per capita

140

120

100

80

60

40

20

0

Am

ount

in U

S$

Years

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

62.72

124.23

101.63

106.54

Sources:MinistryofFinance(1995,1996,1997,1998,1999,2000,2001,2002,2003,2004,2005,2006,2007,2008,2009,2010,2011,2012)

InFigure3-7thepercapitahealthexpenditureofFijiiscomparedwiththatofothercountriesintheregionfortheyear2011.WiththeexceptionofPapuaNewGuinea,FijispendsmuchlesspercapitaonhealththanotherPacificislandcountries.

Figure 3-7 Total expenditure on health per capita at PPP international dollars, WHO Western Pacific Region, 2011

Lao People’s Democratic RepublicPapua New Guinea

CambodiaPhilippines

FijiVanuatu

Viet NamNauruTonga

MongoliaKiribati

Solomon IslandsSamoa

Marshall IslandsChina

Federated States of MicronesiaTuvalu

Cook IslandsMalaysia

Brunei DarussalamPalau

Republic of KoreaSingapore

New ZealandNiue

JapanAustralia

78115135169183191231240245251255260321

383432461469495

5591295

16002181

27873033

31633174

3692

Note:No2011valuesareavailableforAmericanSamoa,FrenchPolynesia,Guam,HongKong(China),Macao(China),NewCaledonia,NorthernMarianaIslands,Tokelau,WallisandFutuna. Source:WHO(2013)


8

Inpatientandoutpatientservicestogetheraccountformorethan50%ofTHEintheyears2005to2010.Howeverin2011and2012,withtheadoptionofthenewSystemofHealthAccounts(SHA)methodology2(OECD,2011),combinedinpatientandoutpatientexpenditureaccountforlessthan40%ofTHE.Table3-2showstheproportionofTHEforoutpatientservicesasrelativelyunchangingovertheperiod2005–2010.Inpatientservices,ontheotherhand,experiencedsomefluctuationwithanincreaseto49.2%ofTHEin2008followedbyadecreaseto36.4%in2010.Dentaloutpatientexpenditureincreasedfrom0.3%ofTHEin2005to4.3%in2010,asaresultoftheexpansionofpublicsectordentalservices.Publichealthandpreventionremainedrelativelyconstantovertheperiod2005–2010.From2007to2010thecategory‘Allotherhealthservices’(whichreferstohealtheducationandtraining,healthresearchanddevelopment,andnon-profitinstitutionsservinghouseholds)hasshownasteadyincrease.

Table 3-2 Health expenditure by function (service programme)

Expenditure % of total expenditure on health

% of current expenditure on

health2005 2007 2008 2009 2010 2011 2012

Health services

Inpatientcare 35.4 48.7 49.2 38.5 36.4 19.5 18.5

Outpatient/ambulatoryphysician services

22.0 20.8 21.1 21.8 22.4 16.9 17.4

Outpatient/ambulatorydental services

0.3 4.9 3.3 4.8 4.3 3.8 3.8

Ancillary services 1.2 1.5 1.0 2.2 2.6 10.5 9.5

Traditional healers 1.2 0.8 0.8 0.3 0.4 - -

Pharmaceuticals and medicalnondurables

13.0 5.2 5.7 12.2 10.9 18.3 17.7

Publichealthandprevention

4.6 5.4 5.3 4.7 4.2 11.4 13.9

Health administration 8.3 9.6 7.8 7.6 9.9 17.1 17.2

All other health services 14.0 3.1 5.8 7.9 8.9 2.5 2.0

Note:Theyears2005–2010useSHA1methodologywhile2011–2012usesSHA2011 Sources:Azzam(2007);FijiHealthAccounts(2007,2008,2009,2010,2012)

Intermsofexpenditurebyserviceinputs,governmenthealthfundingspentthemajorityofitsfundsonhumanresourcesforhealth(Fig.3-7).From2000

2 Cautioniswarrantedincomparisonofthefiguresbetweentheyears2005and2010againstthefiguresfortheyears2011to2012.Thisisbecausedatafor2005to2010usetheSHA1methodologywhiledatafor2011and2012usetheSHA2011methodology.


9

to2012,governmenthealthhumanresourceshaveaveraged53%oftotalgovernmenthealthexpenditure.Operationsaveraged32%overthesameperiodandincludeexpenditureformedicinesanddurablemedicalgoods.Theremaining15%issharedbetweencapitalinvestments(mostlyinfrastructureandmedicalequipment)andvalueaddedtaxes(taxespaidonhealthservicesandproducts).

Figure 3-8 Government health expenditure by service input (% of TGHE expenditure)

Human Resources Operations Capital Tax-VAT70%

60%

50%

40%

30%

20%

10%

0%2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Sources:MinistryofFinance(1995,1996,1997,1998,1999,2000,2001,2002,2003,2004,2005,2006,2007,2008,2009,2010,2011,2012and2013)

3.3 Sources of revenue and financial flowsFiji’shealthserviceshavebeenhistoricallyandpredominantlyfinancedbytheGovernment.Financingofhealthcareisstilllargelyreliantonpublicfundingfromgeneraltaxation.Successivegovernmentshaveassessedthatthelowsocioeconomic status of much of the population precluded the introduction of costrecoverythroughuserfeesand/orthatsuchamovewouldbeunpopular.Therefore,publicprovisionofhealthcareismostlyfreeoravailableatverylowcostforallpersonsinthecountry.Modestuserfeesarechargedforsomeselectedservicesprovidedbythepublicsystem.Therevenuegeneratedfromuserfeesamountedtoanaverageof1.6%ofhealthexpenditureovertheperiod2003–2012(Table3-3).Revenueincreasedslightlyinrecentyears(2010–2012)andthiswasaresultofarevisionofuserfeesin2010andagainin2012.

In2012,theGovernmentinitiatedastudytolookintothefeasibilityofimplementingaSocialHealthInsurance(SHI)scheme(Rannan-Eliyaetal.,2013),withtheobjectiveofincreasingfinancingforhealth.Recommendationsarisingfromthatreportsuggesteditwouldbedifficulttoachieveasignificantcontributionbasegiventhelargesizeoftheinformalsector.Therewasalsoaneedtofirstdevelopstrongmanagerial,administrativeandtechnicalcapacity,aswellasregulatoryoversightbeforeimplementingsuchascheme.

Voluntaryhealthinsuranceschemesarenotwidelyusedbythepopulation.OOPexpenditure,althougharelativelysmallproportionofexpenditurecomparedwith


10

manycountries,isthesecondlargestcontributoraftergovernmentfunding.Whilepublicsectorexpenditureiswell-documentedinannualgovernmentreports,thecontributionmadebyprivatefinancingortheamountspentthroughtheprivatehealth sector is only estimated in national health accounts reports.

Table 3-3 Government financial expenditure on health and user-fee collection (FJ$)

YearActual health

expenditure (‘000)

Government revenue from health services

(‘000)

Revenue as percentage of expenditure (%)

2003 124 423 270 0.2

2004 130149 1410 1.1

2005 130756 1336 1.0

2006 149312 971 0.7

2007 137779 1650 1.2

2008 127 656 1111 0.9

2009 155 838 1719 1.1

2010 153830 2732 1.8

2011 149784 6172 4.1

2012 158 348 6071 3.8

Sources:FijiHealthAccounts(2007,2008);MinistryofHealth(2009,2010,2011and2012a)

UserfeeswerefirstlegislatedforinthePublicHospitalsandDispensariesAct1955toprovideaddedrevenuetotheGovernment,butwerenotintroduceduntiltheearly1960s.Despitethefactthatthefeeswerebasedoncostsinthe1940s,theyremainedlargelyunchangeduntilsomeminormodificationsweremadeintheearly1980sandlaterinthelate1990s.In2000outpatientfeesatpublichealthfacilitiesweresuspendedbytheGovernmentbutwerelaterreintroduced.Table3-4summarizesthechargesrevisedin1983,in2010and2012.Theuserfeesmandatedinthe2012revisionandwhichiscurrentlyinusearemodestincomparisonwiththecostsofserviceprovision.The2012feerevisionwasreducedfromthe2010revisionwhenadeclineinuseofhealthserviceswasnoted.Somefeesweredroppedalltogether,suchasthosechargedatoutpatientclinics.

AllcollectedrevenuesreceivedatpublichealthfacilitiesarepaidintotheGovernment’sconsolidatedfundaccountandarenotdirectlyavailable(nordotheyhaveauthority)forusebytheMoH.PersonsexemptfromuserfeesincludemembersoftheRepublicofFijiMilitaryForces,PoliceForceandRoyalNavy,officersoftheprisonsservice,personsdetainedinhospitalsunderanystatutoryauthority,andchildrenundertheageof15.Servicesprovidedinthegeneralinterestofpublichealtharealsoexcluded.

Privateprovidersofhealth-careservices(e.g.generalpractitioners,eyecarespecialists,dentists,privatehospitalsandpharmacies)chargefeesfortheirservicesthatareoftenconsiderablyhigherthantheamountschargedinpublic


11

healthfacilities.Thesemaybefourtofivetimesthepublicchargeor,insomecases,substantiallyhigher.Forexample,atoothextractionthatcostsFJ$5(2012revisedfees)ingovernmentfacilitiesmaycostanywherebetweenFJ$25andFJ$50ataprivatedentalpractitioner.Currentlythereisnoregulationgoverningfee-settingformostprivatehealthfacilities;userfeesvarywidelyacrossprivatepractitioners.In2012theFijiCommerceCommissionsetthepricesfor75essentialdrugitemsinthepharmaceuticalmarket.Suchregulationisenvisionedtoincreaseacrossotherprivatehealthsectorservices,withtheFijiCommerceCommissionandtheFijiConsumerCouncilbeingstrongadvocatesandtheregulatorsforsuchinterventions.Theobjectiveoftheseinterventionsisfairtradeandpricing,aswellasincreasedaffordabilitytoconsumers.

Table 3-4 User fees for selected services at public health facilities

Services at public health facilities Cost / day residents (1983 amendment)

Cost / day residents

(2010)

Cost / day residents

(2012)Privatesuite(perday) 25 115 115Privatewardsinglebed(perday) 10 46 46Semi-privatewards2beds(perday) 6 34.5 34.5Generalpayingward(perday) 4 23 23Outpatientclinic(divisionalhospitals) 0.5 0.6 0Outpatientclinic(otherfacilities) 0.2 0.2 0Special clinics 2 2.3 0Consultant clinics <8.0 0.6 0Minor operation <30.0 <230.0 <230.0Intermediateoperation <60.0 <690.0 <690.0Majoroperation <150.0 <2875.0 <2875.0Useofdeliveryroomsbyprivatedoctor 50 230 150.0Dentalexamination 1 5.8 3.0Dentaltoothextraction 2 5.8 5.0DentalX-ray 2 5.8–9.2 5.0–8.0Conservativedentistry(e.g.amalgam) 3.0–8.0 3.5–230.0 3.0–120.0Oralsurgery 5.0–30.0 23.0–103.5 10.0–90.0Prosthetics-F/Fdentures 1.0–60.0 3.0–200.0 3.0–150.0Periodontics 1.0–24.0 3.5–230.0 3.0–50.0Orthodontics 20.0–100.0 115.0–460.0 100.0–390.0X-rays(immigration,employment,etc.) 10 23 23X-rays(variousotherprocedures) 8.0–40.0 23.0–460.0 23.0–460.0Laboratorytests 1.0–10.0 8.1–115.0 8.0–115.0CathlabchargesInsuredpatients 3450 3450Uninsuredpatientsearning>15k 1725 1725Patientsearning<15k 575 575

Note:Feesfornon-residentsareusuallydoublethosechargedtoresidents;“<”means“lessthan”Sources:PublicHospitalsandDispensariesAct(1983and2010amendment);MinistryofHealth(2012b)


12

Privatehealthserviceprovidersaremainlylocatedinurbanlocationsandareusedlargelybythoseinformalemployment.RevenuesofprivateproviderswereestimatedatFJ$80millionin2011andFJ$87millionin2012(FijiHealthAccounts,2013).Inboth2011and2012,Fiji’sprivatepharmaceuticalindustry(mostlyretailoutlets)accountedforapproximately50%ofthatrevenue.

There are no compulsory social insurance schemes. The supply of voluntary privatehealthinsuranceislimitedandaffordableonlyforthoseearningrelativelyhighincomes(seesection3.6).Theproportionofthepopulationcoveredbyvoluntaryhealthinsuranceisunknown,butisthoughttobeconcentratedintownsandurbanareas,andamongtheformalworkingsector.TheproportionofTHEfundedthroughprivatehealthinsurancecontinuestoincreasefrom4.9%in2005to7%in2008and9%in2012(FijiHealthAccounts,2013).Thisincreaseisassumedtobedrivenbyboththeincreasedcostsofhealthinsurancepackagesandincreasingmemberships.

3.4 Overview of the statutory financing system

Coverage: breadth, scope and depthThestatutorypublic(government)healthsystemoffersthesameservicestoalllegalresidentsofFiji.Nonresidentsareentitledtoaccesstheseservices,butattwicethecostofuser-fees,whenfeesarecharged.Healthfacilities,whichareorganizedinathreetierarrangement(i.e.hospitals,healthcentresandnursingstations),providearangeofhealthservicesaccordingtotheirroleandfunctioninthesystem.Pharmaceuticalsontheessentialdrugslistareprovidedfreeofchargeatgovernmenthealthfacilities.Somehealthservicesarenotavailablewithinthecountryduetoinadequateresources,whetherhuman,physicalorfinancial.ThepopulationofFijiisdispersedacrossmanysmallislands,andthisposesasignificantchallengetothedeliveryofhealthservices.Urbanpopulationshavegreateraccesstohealthservices(particularlyspecializedhealth-caretreatment)thanthoseinruralandremoteareas.Privatehealth-carefacilities,whichareconcentratedinurbanareas,provideservicesatacosttoanyonewhoisabletopay. These services are mainly outpatient services.

Accesstospecializedhealthservicesandtransportcostsaremajorbarrierstoaccess,especiallyforthoselivinginremoteareas.TheMoHallocatesabudgetforemergencytransport,includingairflights,butthisserviceisrationedasthebudgetallocatedtoitislimited.Restrictionsalsoapplyregardingaccesstooverseasevacuationofpersonsrequiringhealthtreatmentthatcannotbeprovidedwithinthecountry.Expenditureonemergencydomestictravelandoverseastreatmentvariesconsiderablyfromoneyeartoanother.ItwasaroundFJ$3.5millionin2007,felltoaroundFJ$1millionin2008(FijiHealthAccounts,2010)androseagaintoapproximatelyFJ$2.5millionin2012(FijiHealthAccounts,2013).In2012thisexpenditurewasdistributedequallybetweendomesticandinternationaltreatment(andtravel)referrals.


13

CollectionGovernmentrevenuecollectedbytheFijiInlandRevenue&CustomsAuthoritythroughtaxationisusedtofinancethepublichealthsystem.Taxesrepresentedapproximately85%oftotalgovernmentrevenuein2012(MinistryofFinance,1995–2013).Taxrevenuesaccruemainlyfromindirecttaxessuchasvalueaddedtax(29%)andcustomstaxes(16%),andthroughdirecttaxviaincometaxes(19%).Incometaxesaccrueprimarilyfromtheformalemploymentsector.

Pooling of fundsAsmosthealthcareisfundedfromgovernmentrevenuesthroughtheallocationofabudgettotheMoH,thereisahighlevelofpoolingoffinancesforhealth.TheGovernmentoperatesaconsolidatedfund,whichincludestaxationrevenuesanduserfees.MoHofficialssubmitbudgetproposalstotheGovernmentbasedonnational-,regional-andlocal-levelsubmissions,andtheymustcompetewithothergovernmentministriesfortheirfinancing.Thesizeandcontentoftheallocatedbudgetisusuallybasedonhistoricaltrendsofpreviousresourceinputs,whetherthepastyearhasreportedanoveruseorunderuseoffundallocationandgovernmentpriorities.InthepasttheMoHhasgenerallymanagedtooperatewithinitsassignedbudget;however,therehavebeenoccasionswheretheMoHhasneededmorefundsfollowingnationaldisasters,suchascyclonesandfloods.Inthesesituations,supplementarybudgetallocationsaremadeavailableuponrequestfromtheMoH.

Figure 3-9 Government budget allocation for health

180

160

140

120

100

80

60

40

20

0

Mill

ions

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Mill

ions

Years

Sources: MinistryofFinance,1995–2013


14

TheFijiGovernment’sbudgetallocationforhealthhasincreasedfairlysteadilyfrom1995to2009inrealterms(SeeFig.3-8).Governmentexpenditurewas68%oftotalhealthexpenditurein2008andthisdecreasedslightlyto60%in2012.Althoughgovernmentfinancingconstitutesarelativelyhighproportionoffunding,itisstilllowerwhencomparedwithallotherPacificislandcountries(Fig.3-9).

Figure 3-10 TGHE as a share (%) of total health expenditure, WHO Western Pacific Region, 2011

CambodiaSingapore

PhilippinesViet NamMalaysia

Lao People’s Democratic RepublicChina

MongoliaRepublic of Korea

FijiAustralia

PalauPapua New Guinea

JapanKiribati

New ZealandMarshall Islands

TongaBrunei Darussalam

NauruVanuatu

SamoaFederated States of Micronesia

Cook IslandsSolomon Islands

NiueTuvalu

22.4%31.0%

33.3%40.4%

45.7%49.3%

55.9%57.3%57.3%

68.1%68.5%

74.7%79.0%80.0%80.0%

83.2%83.3%83.6%85.0%86.7%87.9%

89.0%90.8%

92.5%94.8%

99.2%99.9%


3.5 Out-of-pocket paymentsOut-of-pocketpaymentsconstitutethesecondlargestsourceoffinanceforhealthservices,aftergovernmentexpenditure.FijiisinthemiddlerangeofrelianceonOOPexpenditureinWHOWesternPacificRegioncountries(Fig.3-10).Asapercentageoftotalhealthexpenditure,OOPpaymentsincreasedfrom12%in2005to21%in2011.In2005,OOPpaymentstotalledFJ$21.7million;by2011,OOPhadrisentoFJ$67.8million.Inthesametimeperiodbothpublicfinancingandemployerfundingforhealthdecreased.MostOOPpaymentswereforprivatehealthservices,mainlyprescriptions,over-the-countermedicationsandoutpatientservices.TheriseinOOPexpendituremayreflectanincreaseintheuseoftheprivatesectorhealthservices.AhealthequityanalysisofOOPreportedinFiji’sHouseholdIncomeandExpenditureSurveyshowthatmostOOPisgeneratedfromwealthierhouseholdsinurbanareas.


15

Figure 3-11 OOP expenditure as a share (%) of total health expenditure, WHO Western Pacific Region, 2011

TuvaluNiue

KiribatiSolomon Islands

VanuatuSamoa

Cook IslandsNauru

Federated States of MicronesiaNew Zealand

TongaPalau

Papua New GuineaMarshall Islands

Brunei DarussalamJapan

AustraliaFiji

Republic of KoreaChina

Lao People’s Democratic RepublicMongoliaMalaysiaViet Nam

PhilippinesCambodiaSingapore

0.0%0.8%1.3%

3.0%6.9%7.1%7.5%7.8%

9.0%10.5%

11.1%11.6%11.7%

12.6%14.8%

16.4%19.8%

21.0%32.9%

34.8%39.7%39.7%

41.7%55.7%55.9%56.9%

60.4%


OOPpaymentsmaybeintheformofcashbutcanalsobein-kind,especiallyinruralareasandfortheservicesoftraditionalhealers.ItisestimatedthatexpendituresontraditionalhealersamountedtoFJ$2.1millionin2005,FJ$1.6millionin2007andFJ$1.7millionin2008.In2008,thisamountedto0.8%ofTHE.Thesefiguresarelikelytobeunderestimationssincemosttraditionalhealersarepaidin-kindanditisdifficulttoputadollarvalueonsuchpayments.

3.6 Voluntary health insuranceInFijithecoverageofvoluntaryhealthinsuranceisuncommonandaffordableonlybytheformallyemployed.Mostcoverageisthroughemployer-basedschemesthatprovideaccidentandinjurycoverage,aswellasco-paymentforgeneralmedicalinsurance.Atotalof10companiesoperateacrosstheinsurancesectorinFijibutonly4operatevoluntaryhealthinsuranceschemes.Healthinsuranceaccountedforonly0.3%oftheinsurancemarketpremiumpaymentsin2009(ReserveBankofFiji,2009)andthisremainedconstantin2012.

Companiescontractmostlywithinsurancefirmsandbrokers(ratherthanhospitalsandindividualpractitioners)toprovidetreatmenttotheirclients(mostlytheiremployees)andtocoverrelatedcostsatbothpublicandprivatehealth facilities. Some schemes also cover overseas medical evacuation and treatment.


16

AccordingtoFijiHealthAccountsreports,healthinsuranceexpenditurebybothindividualsandorganizationswasFJ$8.9millionin2005,FJ$14millionin2008andFJ$24.8millionin2012(FijiHealthAccounts,2012).Thisincreaseismainlyduetohigherenrolment,aswellasagrowingnumberofmembershipsfromorganizationsandindividualsthathasresultedinincreasedpremiums.The2012ReserveBankofFijiInsuranceAnnualReport(2012)statesthatgrouppoliciesformedicalschemeshaveincreasedfrom429in2011to491in2012.

3.7 Other sources of financingTheremainingsourceoffinanceforhealthcareisfromexternalsources,includingmultilateralandbilateraldevelopmentagenciesandnongovernmentalorganizations.InFiji,theseincludeUnitedNationsagencies(WHO,UNICEF,UNDP,UNFPA,UNAIDS),theGovernmentsofAustralia(throughAusAID),NewZealand(throughNZAID),China,Japan(throughJICA)andtheGlobalFundtoFightAIDS,TBandMalaria(GlobalFund).In2005,donoragencies’contributionstohealthamountedtoFJ$9.5millionor5.3%oftotalhealthexpenditure.In2007,itdecreasedtoFJ$6.9million(3.4%ofTHE)followingthecoupd’étatofDecember2006,andthenroseagainby2012toFJ$15.3million(6%ofTHE).GlobalFundsupporttoFijilargelycontributedtotheincreaseindonorfundsfrom2010onwards;however,itmayceasein2014becausetheWorldBankhaselevatedFiji’sstatusfromalower-middle-incomecountrytoanupper-middle-incomecountry.ExternalsupporttotheMoHisnotyetwellharmonizedtoachieveamoreeffectiveuseofthedonorfundsavailable.

3.8 Payment mechanismsPayment mechanisms for providers of health services are relatively straightforwardsincetheGovernmentbothfinancesandprovidesthemajorityofservices.

Paying for health servicesThesizeoftheannualgovernmenthealthbudgetisreliantontheavailablegovernmentrevenueandnegotiationsonbudgetsubmissionsbetweentheMoHandtheMoF.TheMoHreceivesallocationstoresourceinputlineitems,suchashumanresources,services,capitalinvestments,andpurchaseofmedicalandnonmedicalequipment.TheMoHusesthissameapproachwhenallocatingfinancestovariousgovernment-ownedhealthfacilities(includinghospitals,healthcentresandnursingstations).

Paying health workersThemajorityofhealthworkersinthecountryaresalariedstaffoftheMoH,dividedintotwocategories:establishedstaffandunestablishedstaff.EstablishedstaffaregovernedbythePublicServiceActwhiletheconditionsandrulesforunestablishedstaffarestatedintheJointIndustrialCouncilagreement.Project,


17

cleaningandcasualpositionsarecommonlyunestablished.Privatehealth-careprovidersmaybecontractedbytheGovernmentandpaidonanoutputbasisaccordingtothetermsofindividualcontracts.

SalariesofgovernmentstaffaresetindetailednationalpayscalesdrawnupbythePublicServiceCommission.Thepercentageofhealthexpenditurespentonthecompensationofhumanresourceswas61%in2011and60%in2012(FijiHealthAccounts,2013).Therearenoincentivepaymentsforthenumberofpatientsseenorproceduresperformed,orpaymentaccordingtoresults.SalariedstaffmoveupthesalaryscaleaccordingtotheiryearsofexperiencewithintheMoH(thispracticeisslowlychanging),levelofeducationandrolewithintheorganization.Itisgenerallyconsideredthatunder-the-tablepaymentstohealthworkersareinfrequent;thishasnotbeenhighlightedasaproblembythoseinthepublicwhohave used the complaints procedures.

Employeeassociationsandtradeunionsrepresentworkers’interestsandoftennegotiatesalaryandworkingconditionsontheirbehalf.In2007,theFijiNursingAssociationwasvocalonissuespertainingtosalariesandemploymentconditionsfornurses,butwasunabletomakegains.Severalindustrialstrikeshavebeenunsuccessfulandhaveleftstafffeelingundervalued,whichhascontributedtoemigration.

General practitioners in private practice receive payment from individuals for healthservicesrendered.Thereisnolegislatedceilingforfeeschargedbyprivatepractitioners,sotheycanchargeattheirdiscretionwithinmarketconstraints.CurrentconsultationfeesrangefromaboutFJ$30toFJ$50,excludingthecostofmedications,whichareobtainedthroughprivatesectorpharmacies.Averysmallnumberofgeneralpractitionersenterintocontractswithprivateorganizationstoprovidecareforemployees,andprivateinsurersrefundsomeofpatients’healthexpenditure.

Healthworkersintheprivatesectormayworkinhospitals,clinicsandprivatesurgeriesthatarelegallyestablishedasprivatecorporations.Theyaregovernedbytherulesofthesecorporationsandusuallyreceiveafortnightlysalary.TheFijiEmploymentRelationsBill2006(MoLIRE,2006)setscertainworkterms,minimum salaries and conditions.

Pharmaceuticalsareimportedbythegovernment-fundedFijiPharmaceutical&BiomedicalServicesCentre,whichsuppliesallgovernmenthealthfacilities.In2011pharmaceuticalsaccountedfor9.2%oftotalgovernmentspendingonhealth,andin2012thisdecreasedto7.1%.PrivatepharmaciescanalsopurchasemedicineanddrugsfromtheCentre.Thereareapproximately55privateretailpharmacieslocatedinFiji.Privategeneralpractitionersarelegallyentitledtodispenseandsupplymedicinesaslongastheyarenotlocatedwithinfivekilometresofaprivatepharmacy,inwhichcasechargesformedicinesareaddedtopatients’consultationandtreatmentfees.Whendrugsareoutofstockatgovernmentpharmacies,patientshavetopurchasemedicinesattheirown


18

expensefromprivatepharmacies.TheFijiPricesandIncomeBoard,togetherwiththeFijiCommerceCommission,controlthepricesinthemarketbysettingpercentagemark-upsforbothwholesalersandretailers.

AcknowledgmentsThisLivingHiTUpdatewaswrittenbyWayneIravaandRoneshPrasad.

ReferencesAzzamO(2007).FijiNationalHealthAccounts2005.Suva:MinistryofHealthFiji.

MinistryofFinance(1995).Governmentbudgetestimate1995.Suva:GovernmentofFiji.














19







MinistryofHealth(MoH)(2005).AnnualReport2005.Suva:MinistryofHealthFiji.







MinistryofHealth(MoH)(2012a).AnnualReport2012.Suva:MinistryofHealthFiji.

MinistryofHealth(MoH)(2012b).PublicHospitalsandDispensariesRegulation(2012amendments).Suva:MinistryofHealthFiji.

FijiHealthAccounts(2010).FijiHealthAccounts2007–2008.Suva:MinistryofHealthFiji.



20


OECD(2011).SystemofHealthAccounts2011Edition.Paris:OrganisationforEconomicCooperationandDevelopment.524p.

Rannan-EliyaRP,IravaWandSaleemS(2013).AssessmentofSocialHealthInsuranceFeasibilityandDesirabilityinFiji.Suva:MinistryofHealthandWorldHealthOrganization.

ReserveBankofFiji(2009).ReserveBankofFijiInsuranceAnnualReport.Suva:ReserveBankofFiji.

ReserveBankofFiji(2012).ReserveBankofFijiInsuranceAnnualReport.Suva:ReserveBankofFiji.

WorldHealthOrganization(WHO)(2009).HealthfinancingstrategyfortheAsiaPacificregion2010–2015.Geneva:WorldHealthOrganization.

WorldHealthOrganization(WHO)(2013).[website]GlobalHealthExpenditureDatabase.Geneva:WorldHealthOrganization.[http://www.who.int/nha/expenditure_database/en/accessed30January2014].


c


d

fiji living hit update - who · 2017-11-30 · fiji living hit update 1 3.1 section summary this...

Documents