The Innovation of Six-Dimensional Pooling Risk Framework in Universal Health Insurance Coverage

Abstract

This study aims to transform the existing three-dimensional pooling risk framework of the health insurance Bismarck model to finance health promotion, disease prevention, treatment, and palliative health care services, and equity in low-density population districts. A case study design was used to synthesize the health insurance Bismarck model with sustainable development goals (SDGs) 1, 2, 3, 6, and 10, the four types of preventions, universal health coverage (UHC) frameworks, the District Division Administrative Disaggregation Data framework, and others theoretical frameworks. The Precede-Proceed Planning Model was implemented to formulate the six-dimensional pooling risk framework. The innovative cross-subsidization of the framework was developed based on the rich subsidizing the poor, healthy people subsidizing sick people, the young subsidizing the elderly, the healthy people subsidizing for their health promotion, and disease prevention, and high-density population districts subsidizing for equity in low-density population districts. In conclusion, the innovative six-dimensional pooling risk framework of health insurance Bismarck model functions to remobilize health care resources toward the four types of health care services of UHC and equity in low-density population districts. The premium of the model is demanded to transform based on probability of health and illness, and equity in low-density population districts.

1. Introduction

United Nations formulated transformational Sustainable Development Goals (SDGs) vision to transform our world to be free of poverty and disease by 2030 [1], and WHO invented the UHC framework to be a glocalization model to achieve health-related SDGs [2]. The existing outcomes of health-related SDGs in World Health Statistics showed that life expectancy at birth improved 5.5 years globally from 66.5 to 72.0 years between 2000 and 2016 [3]. Life expectancy was 62.7 years in low-income countries and 80.8 years in high-income countries, so it was 18.1 years low in low-income countries in 2016 [3]. Life expectancy progress in low-income countries between 2000 and 2016 was 21%, compared with 8% globally and 4% in high- income countries [3]. Premature deaths in low-income countries were caused by lower respiratory infections, diarrhea diseases, acquired immunodeficiency syndrome (AIDS), malaria, and preterm birth complications [3]. The top three causes of premature death in other countries occurred due to ischemic heart disease, lung cancer, and suicides [3].

Globally in 2015 [4], the figure of maternal deaths was 216 per 100,000 live births. This means the complications of pregnancy and childbirth killed almost 830 women every single day [4]. Poor women in remote areas suffer lack of adequate health care [4]. However, these deaths happened in low-resource settings [4] and could be prevented. The two-thirds of global maternal deaths happened generally in the WHO African Region [4]. The possibility of a 15-year-old girl in the region ultimately dying from a maternal reason remained as high as 1 in 37 compared with 1 in 3400 in the WHO European Region [4]. The maternal deaths occur mainly due to hemorrhage, hypertension during pregnancy, infections, and indirect causes and interaction between preexisting medical conditions and pregnancy [4].

The reduction of the global under-five mortality rate has been reduced from 93 per 1000 live births in 1990 to 41 per 1000 live births in 2016 [5]. Nevertheless in 2016, 15,000 children died before reaching their fifth birthday [5]. In 2016, the majority of 2.6 million newborn deaths occurred in the first week of life [5]. Three-quarters of all neonatal deaths occurred due to prematurity, intrapartum-associated events such as birth asphyxia and birth trauma, and neonatal sepsis [5]. In 2016, the leading causes of death in children aged 1–59 months were acute respiratory infections, diarrhea, and malaria. Older children (aged 5–14 years) died from preventable causes [5].

The causes of death in children under-5 years of age in 2016 were “prematurity, acute respiratory infections, birth asphyxia and birth trauma, tetanus, HIV/AIDS, measles, meningitis/encephalitis, other noncommunicable diseases, malaria, injuries, neonatal sepsis, diarrhea, congenital anomalies, other communicable, perinatal and nutritional conditions” [5]. In 2017, three-quarters (22%) of 151 million stunted (too short for their age) children under the age of 5 live in the WHO South-East Asia Region or WHO African Region [5]. High levels of stunting associated with childhood morbidity and mortality risks, learning capacity, and NCDs later in life have a negative impact on the development of countries [5]. In 2017, the overweight (too heavy for their height) children under the age of 5 were 38 million (5.6%), and the wasted (too light for their height) were 51 million (7.5%) [5].

In 2016, noncommunicable diseases caused 41 million deaths, which were 71% of all deaths worldwide [3]. Most of those deaths occurred from cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes mellitus [3]. The risk factors of noncommunicable diseases include unhealthy diets, insufficient physical activity, raised blood pressure, tobacco use, harmful use of alcohol, obesity, overweight among children, and air pollution [3].

The desired outcomes of health-related SDGs were identified for designing the functions of the universal health insurance coverage. United Nations formulated SDGs 1, 2, 3, 6, and 10 to transform our world to be free of poverty and diseases by 2030 [1]. The SDGs 1, 2, 3, 6, and 10 consist of ending poverty in all its forms everywhere, generating healthy lives and promoting well-being for all at all ages, ending hunger, achieving food security, improving nutrition, and promoting sustainable agriculture, ensuring availability and sustainable management of water and sanitation for all, and reducing inequality within and among countries [1, 6].

SDG’s targets are to reduce global maternal mortality, end preventable deaths of newborns and children under-5 years of age, to end the epidemics of communicable diseases through the three levels of prevention, to reduce premature mortality from communicable and noncommunicable diseases through health promotion and three levels of prevention promote mental health and well-being, strengthen health promotion and treatment of substance abuse (including narcotic drug abuse and harmful use of alcohol), reduce global deaths and injuries from road traffic accidents, ensure universal access to sexual and reproductive healthcare services (including family planning, information and education, and the integration of reproductive health into national strategies and programs), achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, affordable and quality essential medicines and vaccines for all, reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination, strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries (as appropriate), ensure equal opportunity and reduce inequalities of outcome, achieve substantial coverage of the poor and vulnerable by implementing national appropriate social protection systems [1, 6].

The strategic health goals are to reduce inequality within and among countries through equal opportunity by reducing outcome inequalities [1, 6], to achieve healthy lives and promote well-being for all at all ages through health promotion and the higher levels of disease prevention, and to end poverty in all its forms everywhere through universal health insurance coverage [1, 6].

The UHC framework was introduced to ensure everyone has equity in accessibility to promotion, prevention, treatment, and rehabilitation healthcare services, without suffering financial hardship by paying for them [2, 7, 8]. The UHC framework is built around three-dimension components [8]. The components contain universal healthcare services coverage, universal financial risk protection and population coverage with a proportion of the costs covered (Figure 1) [2, 7, 8]. The elements are considered in UHC such as the population covered, the services package, cost sharing for pooling, cost payment for services, and the cost pay by pooling [2, 7, 8].

Figure 1.

Three dimensions to consider when moving toward universal coverage. Source: the world health report: health systems financing: the path to universal coverage. 2010.

The six functions of the universal health insurance coverage–Bismarck Model were formulated based on SDG 1,2,3,6 and 10 targets. The overarching goal of these functions transforms the determinants of health-related SDGs to produce healthier populations by 2030. Firstly, they protect an insured population from financial risk to reduce out of pocket eradication of poverty in all its forms everywhere. Secondly, they promote health to ensure healthy lives and promote well-being for all at all ages. Thirdly, they prevent diseases to end the epidemics of communicable diseases through the three levels of disease prevention. Fourthly, they finance leaving no district behind universal healthcare services coverage. Fifthly, they finance health promotion, disease prevention, treatment, and palliative services, to transform ecological social determinants of health, to decrease morbidity and mortality rate of communicable diseases and noncommunicable diseases. Finally, they function to ensure equity in access to four types of healthcare services, for leaving no one behind. The Bismarckian model is a sickness fund approach and a state social insurance based on prepayment by employees and their employers [9].

The functional problems of the universal health insurance coverage-Bismarck Model program originated from the lack of health promotion, disease prevention, and reduction of health inequity funds. Those problems make the program ineffective in reducing the morbidity and mortality rate of communicable and noncommunicable diseases and inequity in healthcare service accessibility. This study aims to transform the three-dimension pooling risk framework of the universal health insurance coverage-Bismarck Model to finance healthy lives and equity in healthcare services accessibility.

2. Methods

A case study design was used to synthesize health insurance-Bismarck model with Sustainable Development Goals (SDGs) 1,2,3,6 and 10, UHC frameworks, the four types of preventions, the district division administrative disaggregation data framework, the district health system, and social determinants of health, to innovate the six-dimension pooling risk framework. In addition, the Precede-Proceed Planning Model was applied to formulate the six-dimension pooling risk framework.

2.1 The precede-proceed planning model

The Precede-Proceed Planning Model embodies assessment, planning, implementation, and evaluation interventions [10]. The Precede part includes phases that are the social assessment, epidemiological assessment, educational and ecological assessment, administrative and policy assessment, and intervention alignment [10]. The Proceed part consists of implementation, process evaluation, impact evaluation, and outcome evaluation [10]. The social assessment aims to identify the quality-of-life issues and to formulate the quality-of-life goals of a community [10]. Then, epidemiological assessment comprises epidemiological, behavioral, and environmental assessment [10]. Epidemiological assessment seeks to create measurable objectives related to the health quality of life outcomes. Behavioral assessment plans to transform behaviors that influence the health outcomes to sub-objectives. Environmental assessment plans to transform physical, social, culture, political, and family environments that influence the health outcomes to sub-objectives [10]. Next, educational and ecological assessments plan to figure out hypothesized mediators of the behaviors identified [10]. They are classified to predisposing factors, reinforcing factors, and enabling factors, and they seek to develop sub-objectives [10]. After that, administrative and policy assessment and intervention alignment seek to evaluate the capacity and resources available to implement programs and transform policies based on the assessed needs [10].

2.2 The types of prevention

The types of prevention are categorized to health promotion, primary, secondary, and tertiary prevention [11]. Health promotion “enables people to increase control over their own health. It covers a wide range of social and environmental interventions that are designed to benefit and protect individual people’s health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure [12].” Primary prevention is to prevent disease and injury from occurring in the individual and the community [11]. Secondary prevention is to make early diagnosis and promote treatment of a disease or injury stopping the progress or shortening the duration and preventing the complications from the present disease process [11]. Tertiary prevention aims to prevent the severity and the complications of the disease [11].

2.3 The district health system

The UHC framework of Thailand depends on the district health system to accomplish equity to access healthcare services [13]. It has been developed throughout the nation. A district hospital services a population of about 50,000 people, and it consists of 30–120 beds and 100–300 staff. Its staff comprises general doctors, nurses, dentists, pharmacists, and other professionals [13]. The district health system is covered by 10–15 subdistrict health centers [13]. The UHC framework of Thailand reforms strengthened primary care throughout, providing local primary care networks greater management of financial resources, and being “close to the home, close to the heart” community facilities [14]. The Thai framework integrates medical and public healthcare services, so the system provides health promotion, disease prevention, and treatment healthcare services [14]. The UHC framework in 2001, “the district health networks received capitation-based funding for their population that covered services provided within the network and also the costs of referral to secondary care” [14]. Therefore, the local managers are empowered [14]. Health and social services are integrated in Thai district health system to encourage participation of all sectors to cooperate to enhance their local people’s quality of life [15].

2.4 The district division administrative disaggregation data framework

The District Division Administrative Disaggregation of Data (DDADD) framework figured out the effect of the density of the insured population in the catchment area distribution of healthcare centers to detect districts left behind [16] (Figure 2). It determined the effect the density of the insured population had on the catchment areas cost of healthcare services (Figure 2) [16]. It found out the effect of the catchment areas distribution of healthcare centers on income-insured accessibility, to identify who is left behind (Figure 2) [16]. It discovered the effect of income-insured catchment area accessibility on the income-insured utilization of healthcare services to identify who was left behind [16]. The DDADD framework identified the insured poor were protected by the equitable distribution of healthcare services in high-density insured population districts [16]. However, the insured poor were left behind by the inequitable distribution in low-density insured population districts [16]. It found out the majority of the population living in low-density population districts were insured poor, and these districts lacked healthcare facilities with high cost of healthcare services [16]. It concluded that low-density-population districts determine health equity outcomes.

Figure 2.

The district division administrative catchment area disaggregation of data framework. Source: district division administrative disaggregation data framework.

The DDADD suggests a premium equation of health insurance scheme that requires transformation based on equity and the probability of illness [16]. This transformation functions to mobilize healthcare resources toward low-density-population districts. Thus, subsidization is needed from the insured population living in high-density-population districts, to those who live in low-density-population districts.

2.5 The existing three-dimension pooling risk framework

The Bismarckian model is a sickness fund approach, and it is state social insurance based on prepayment by workers and their employers [9]. The insured worker utilizes the healthcare services and the state social insurance provides payment to healthcare providers such as physicians, hospitals, or other providers [9]. The framework is organized by prepayment that means participants pay before they are ill, then they depend on the pooled funds from the health insurance scheme when they fall sick [17]. In many health financing systems, prepayment is combined with cost sharing from participants to service providers, and cost sharing is the direct payment [17]. The cost sharing means that the health insurance scheme does not cover all healthcare services costs and the insured person still has to pay a percentage of his or her costs out of pocket [17].

The three-dimension pooling risk framework of the health insurance–Bismarck model aims to accumulate and to manage the financial resources, ensuring that the financial payment risk for health care is carried by all participants of the pool and not by the individuals who become sick [17]. The prepayment is formulated by a large number of people, with pooling of funds to cover everyone’s healthcare costs [17]. The framework spreads the financial risk related with the need to use health services [17, 18]. The existing cross-subsidization of the framework composes of the rich subsidizing the poor [19, 20], the healthy subsidizing the sick [19, 20], and the young subsidizing the elderly [17, 20]. Evidence shows the good-quality design and implementation of a subsidization framework have contributed to financial protection, decreasing inequities in access to healthcare services among different income groups, and utilization improvement for the subsidized [21].

The equitable financial mechanism collects the contributions of the health insurance-Bismarck model based on progression, which means higher-income people pay progressively higher proportions of their revenue [22]. In low- and middle-income countries, health insurance is a sustainable healthcare financing model for offering financial risk protection for the majority of the population [23]. In Germany, Statutory Health Insurance has been compulsory for all citizens and the premium for permanent residents is a uniform contribution of 15.5% of their revenue with 118 sickness funds in 2009 and 85 percentage of the population are covered by Statutory Health Insurance [9]. In Nigeria, the contributions to the health insurance are calculated from 15% of the employee’s basic salary, and they are divided between the employee contributing 5% and employers contributing 10% [24]. As the result, the three-dimension pooling risk framework operates to provide all of the insured population with access to needed healthcare treatment services and to protect them from out-of-pocket spending on health.

3. The formulation of the six-dimension pooling risk framework

In this study, the existing three-dimension pooling risk framework was transformed to the six-dimension pooling risk framework, through the synthesis of three-dimension pooling risk framework of the health insurance scheme-Bismarck Model, with the functions of universal health insurance coverage program based on SDG 1,2,3,6, and10, the four levels of prevention, the district health system, and the district division administrative disaggregation data framework.

The innovative cross-subsidization of the six-dimension pooling risk framework is composed of the rich subsidizing the poor, healthy people subsidizing sick people, the young subsidizing the elderly, the healthy people subsidizing for their health promotion, and disease prevention, and high-density-population district residence subsidizing for health equity in low-density-population districts residence (Figure 3). The innovative cross-subsidization functions to subsidize for an insured person, to finance the four types of healthcare services, and to finance healthcare services in low-density-population districts (Figure 3). Those functions address the determinant factors of health-related SDG targets, which are out of pocket, communicable diseases, noncommunicable diseases, and health inequity in low-density-population districts (Figure 3). Those functions interact with the determinant factors of health-related SDG targets financial risk protection (Figure 3).

Figure 3.

The six-dimension pooling risk framework.

The subsidization interacts with out of pocket schemes to offer financial risk protection for eradicating poverty in all its forms everywhere (Figure 3). Health promotion and disease prevention services transform behavioral factors, environmental factors, and epidemiological factors to reduce the morbidity and mortality rate of noncommunicable and communicable diseases (Figure 3). The reduction of morbidity and mortality rate creates healthy lives and promotes well-being for all at all ages (Figure 3). The six-dimension pooling risk framework finances healthcare services in low-density-population districts that aims to achieve health equity in low-density-population districts and to decrease inequality within and among districts of a country (Figure 3).

This study implies the guideline structure on how to implement the six-dimension pooling risk framework on a health insurance scheme. It recommends the premium equation of health insurance–Bismarck model is essential to restructure based on equity and probability of health and illness, for applying the six-dimension pooling risk framework in a health insurance scheme, to generate funds for financing the four types of healthcare services and leaving no low-density-populations districts behind. Furthermore, the guideline structure forms the premium of the framework to be between a government, employers, and employees. The framework has significant impact on economic growth, so the guidelines recommend the government to allocate resources from taxes to finance leaving no low-density-populations districts behind SDG1,2,3,6 and 10. The guidelines imply the employers need to contribute to the premium for financing community-related health promotion and disease prevention programs because the framework influences productivity. Furthermore, the framework functions to improve the quality of life of the insured population, so it is proposed the employees to contribute to the premium for financing personal-related health promotion and disease prevention programs. The package of benefits will be designated based on community and individual needs and the health-related SDGs targets. The package of benefits will address the social and microbiological determinants of health and inequity in low-density-population districts. The health insurance scheme pays providers of health promotion and disease prevention services at the community, healthcare facilities, educational institutions, and others. In contract, the providers provide health promotion and disease prevention services to the community and the individual. Future studies are needed to transform the guideline structure formula for the premium of the framework and to formulate health promotion and disease prevention services at all levels based on the WHO, the existing theoretical frameworks, and national frameworks for accelerating the progress on the health-related SDGs targets.

4. Discussion

This research compared the capability of the innovative six-dimension pooling risk framework of the health insurance-Bismarck model with the existing three-dimension pooling risk framework, in financing the theoretical frameworks for transforming the determinant factors of health-related SDGs.

The world’s leading causes of death are premature deaths from noncommunicable diseases, which continue to decline [25]. The progress has slowed in current years, so urgent and targeted programs will be required for key risk factors of noncommunicable diseases, which include tobacco use and alcohol consumption, hypertension, obesity, and physical inactivity [25]. Millions of people die from communicable diseases each year even though the number of deaths has declined [25]. The deaths from communicable diseases occur in lower-resource settings where many individuals cannot access quality healthcare services [25]. We must continue to concentrate on the equitable distribution of healthcare services and provide access to quality, affordable, and effective programs in all countries and for all populations, for closing these gaps and meeting SDGs [25].

Global action plans for the prevention and control of noncommunicable diseases 2013–2020 proposed a vision, goals, voluntary global targets, and objectives [26]. The vision of Global action plan is “A world free of the avoidable burden of noncommunicable diseases” and its goal is “To reduce the preventable and avoidable burden of morbidity, mortality and disability due to noncommunicable diseases by means of multisectoral collaboration and cooperation at national, regional and global levels, so that populations reach the highest attainable standards of health and productivity at every age and those diseases are no longer a barrier to well-being or socio-economic development” [26].

The WHO and partners approached the strategic framework for ending preventable maternal mortality (EPMM) [27]. The EPMM framework composed of SDG target 3.1: reduced global MMR to less than 70 per 100,000 live births by 2030 and five strategic objectives [27]. The five strategic objectives for EPMM include 1: To address inequities in access to quality of sexual, reproductive, maternal, and newborn health care, 2: To ensure universal health coverage for comprehensive sexual, reproductive, maternal, and newborn health care, 3: To address all causes of maternal mortality, reproductive, and maternal morbidities and related disabilities, 4: To strengthen health systems to respond to the needs and priorities of women and girls, 5: To ensure accountability to improve quality of care and equity [27].

The WHO African Region articulated the framework for provision of essential health services through strengthened district/local health systems to support UHC in the context of the SDGs [28]. The framework demonstrated the situation of universal healthcare services in the region, and the findings showed universal healthcare service coverage was 48%, universal essential healthcare service coverage was 36%, the accessibility of the population was 32%, and universal financial risk protection coverage was 34% [28]. The framework predicts that by 2030, 80% of the population will have access to essential healthcare services in 80% of Member States, and 80% of districts will have universal healthcare facility-community coverage in 80% of Member States [28].

The six-dimension pooling risk framework addresses communicable and noncommunicable diseases and inequity in low-density-population districts as determining factors of health-related SDGs for accelerating the progress. Therefore, the framework reallocates healthcare resources for communicable and noncommunicable disease healthcare services, equity in low-density-population districts, the strategic framework for ending preventable maternal mortality, global action plan for the prevention and control of noncommunicable diseases, the framework for provision of essential health services through strengthened district/local health systems of the WHO African Region. In contrast, the existing three-dimension pooling risk framework is sickness fund approach, so it is not able to remobilize healthcare resources for those frameworks.

5. Limitations

This research did not explore the impact of financing health promotion and disease prevention healthcare services on control and reduction of treatment healthcare services expenditure. In addition, this research did not figure out the impact of mobilization of healthcare resources toward low-density-populations districts on finance risk protection of poor. Future studies are needed to formulate the premium of the health insurance–Bismarck model according to probability of health and illness and equity in low-density-populations districts for implementing the framework. Finally, how to finance personal health and population health programs requires more cooperation studies between multidisciplinary public health organizations.

6. Conclusion

The functions of the universal health insurance coverage–Bismarck Model were formulated according to SDG 1, 2,3,6 and 10 targets after the desired outcomes of health-related SDGs and the UHC framework were synthesized. Those functions were designed to protect insured populations from financial risk, and to finance health promotion, disease prevention, treatment, and palliative health care services, and equity in low-density-population districts. The existing three-dimension pooling risk framework of the health insurance scheme-Bismarck Model was transformed to the six-dimension pooling risk framework, based on the functions of the universal health insurance coverage–Bismarck Model. The existing cross-subsidization of the three-dimension pooling risk framework is built on the rich subsidizing the poor, healthy people subsidizing sick people, and the young subsidizing the elderly. In contrast, the innovative cross-subsidization of the six-dimension pooling risk framework was created based on the rich subsidizing the poor, healthy people subsidizing sick people, the young subsidizing the elderly, the healthy people subsidizing for their own health promotion, and disease prevention, and high-density-population district subsidizing for equity in low-density-population districts. The innovative cross-subsidization of the six-dimension pooling risk framework shifts the health insurance from disease funding to human capital investment, to remobilize healthcare resources toward WHO frameworks, theoretical UHC frameworks, and national frameworks for accelerating the progress on the health-related SDGs, particularly in low-income countries, the world’s least developed countries, and the Member States in the WHO African Region. The premium equation of health insurance–Bismarck model is required to restructure based on probability of health and illness, and equity in low-density-population districts, for implementing the framework in health insurance schemes.

Acknowledgments

I would like to thank Anees Ahmad and Purwanto Abdullah for their technical support and Inese Zvirgzdins for English editing.

Conflict of interest

The author declares no conflict of interest.

Thanks

I’m thankful to my daughter Rodina Ashraf, and my mother, my sisters, and my brothers for their emotional support.

Acronyms and abbreviations

EPMM

Ending Preventable Maternal Mortality

NHIF

National Health Insurance Fund

SDGs

Sustainable Development Goals

UHC

Universal Health Coverage

WHO

World Health Organization