Provider payments, incentives and motivation What mechanisms do we currently rely on to motivate providers to provide high quality services What are the problems? Do we need to use the old system better or reform it? What can we measure that we can base payment on? How robust are our measures? Who is likely to oppose reform (or components of reform) and what actions are they likely to take?

How Finance and Payment Mechanisms Relate to the Flow of $$ Financing Fundholding Payment Where $$ for health comes from (e.g.,taxes) Who pools & manages the $$ (e.g. MOF/MOH, DHA, Social or Private Insurance Funds) How providers of care are paid for the services they render = provider payments

Sources of Funds: Public Taxation 1.Income Tax = direct taxes 2.Sales Taxes = indirect taxes User Fees paid Out-of-Pocket 3. Charged by government facilities 4.Charged by private sector Formal Insurance 5.Social Insurance 6.Private Insurance

Community Based Health Funds 7. Health Fund Card for basic health care 8Revolving Drug Fund External Sources 9. Donor Funds

Structure of Revenue for 2 Countries SourceCote d’Ivoire (%)Peru (%) Direct Tax Indirect Tax Import duties, etc Managed Soc Sec./Payroll Non-Tax (fees, donors) Total100.0

Shift in Public Health Revenue Sources in Russian Federation, (source: Igor Sheiman, 1997, in Innovations in Health Care Financing, p.67 Source General Revenue Budget --Federal budget --Regional & local budget Mandated payroll tax Total100.0

Mandated Payroll Tax Contribution Rates Source: World Bank and Chintz, Balancing Competition and Solidarity in Health Financing, in Saltman, Critical challenges for European Health Policy, forthcoming, Open Univ. Press CountryPublic Sector Revenue from Mandated Payroll Taxes (%) Total Contribution Rates (%) Employer Share (%) Employee Share (%) Bulgaria9.050 Czech Republic Estonia Latvia Romania8.550 Russian Federation Slovakia Slovenia12.850

Links between reforms and health system goals Goals (positive & negative effects) EfficiencyQualityEquityClient Respon- siveness Sustain- ability Financing Provider Payments Organiza- tional Change Regula- tions