Health Care Finance and Expenditure (3)Overwhelmingly, health care financing in Saudi Arabia is provided mainly fromgovernment revenues. 1993. HEALTHCARE FINANCING COMMITTEE (HCF) The health sector in Kenya relies on several sources of funding: public (government), private firms, households and donors (including faith based organizations and NGOs) as well as health insurance schemes. In the United States, health care is technologically advanced but expensive. London: House of Commons Library. Countries typically use one of the three main funding models as the principal way of paying for health care alongside elements of the others. Some argue that these decisions politicise the process and can make health budgets less predictable from year to year, although others see this as an advantage as it introduces a degree of accountability not present in other models. For example, in Canada, about 70 per cent of health spending is publicly funded though taxation, with the remaining 30 per cent largely accounted for by out-of-pocket spending (costs borne directly by patients) (14.6 per cent) and private health insurance (12.2 per cent) (Canadian Institute for Health Information 2016).1 Moreover, the out-of-pocket expenditure cannot be considered as a reliable source of funding to build a resilient service delivery systems. Selected domains that might be most directly affected include: No health financing strategy works in all cases and all systems; they must respond to the specific context and structure of a country’s health system. However, user charges often form a large part of the way health care is financed in developing countries (Gottret et al 2006). This means it does not discriminate against those who are older or have pre-existing medical conditions. These arrangements would significantly reduce the amount a charge would generate. Here we explain the main models used to finance health care: taxation, private health insurance and social health insurance. Glob Health Res Policy. As the OECD concluded, ‘There is no health care system that performs systematically better in delivering cost-effective health care’ (OECD 2010). This form of PHI provides coverage for health services that are excluded from government/social insurance schemes. ©2018, Primary Health Care Performance Initiative, Facility Management Capability and Leadership, User fees can negatively impact demand for care, contribute to household poverty, and promote general inequities in health access, https://www.who.int/health_financing/topics/financial-protection/out-of-pocket-payments/en/, Facility Organization and management: Information Systems Use, Availability of effective PHC services: Provider availability, Availability of effective PHC services: Provider motivation. At this point many people gave up their insurance, but analysis by the Institute for Fiscal Studies found that the cost of the increase in demand on the NHS was ‘substantially lower’ than the cost to government of the subsidy (Emmerson et al 2001). Other funding streams used to supplement it in Singapore include direct subsidies to hospitals, voluntary back-up insurance to cover high health care costs and a government-funded safety net for low-income people (McKee 2013). Capital financing has varying effects on hospitals and health systems, and much of that has to do with the size of the organization. Since then, there has been intense debate over the two generic types of systems, with the discussion centered on access, quality and cost. A person who wants to buy an automobile pays the dealer for the car. London: Chatham House Centre on Global Health Security Working Group Papers, Working Group on Financing, Paper 4; 2013. Ghana is also a LMIC country [15] in West Africa but has a much smaller population that rose from 19.2 million in 2000 to 24.4 million in 2010. 2 Main mechanisms of health care financing 3 Government funding 3 Health insurance 3 Mandatory health insurance 3 Voluntary health insurance 3 Out-of-pocket payments 4 3 Assessing financing mechanisms 5 Feasibility 5 Equity 5 Efficiency 6 Sustainability 6 4 Key functions of health care financing 7 Revenue collection 8 Sources of funds 9 Appleby J (2016). Background Nigeria and Ghana have recently introduced a National Health Insurance Scheme (NHIS) with the aim of moving towards universal health care using more equitable financing mechanisms. Cooperative HealthInsurance System will be applied, so private health sector participation will be increased.Trends in financing … McIntyre D, Meheus F. Fiscal space for health spending. The NHS is mainly funded from general taxation and National Insurance contributions. In Germany, for instance, people who earn over a certain amount can choose to purchase private health insurance instead of social health insurance. LaingBuisson website. Health care financing schemes as the main “building blocks” of the functional structure of a country’s health financing system: the main types of financing arrangements through which health services are paid for and obtained by people. In line with WHA 58.33, WHO/AFRO in 2006 through its regional committee adopted a report “Health Financing: A Strategy for the African Region” under AFR/RC56/10 reinforcing the resolution and how to practically implement in the African region. As the OECD concluded, ‘There is no health care system that performs systematically better in delivering cost-effective health care’ (OECD 2010). Available at: www.kingsfund.org.uk/publications/new-settlement-health-and-social-care (accessed on 3 March 2017). Free for all? Prescriptions dispensed in the community: England 2005-2015 [online]. There are trade-offs inherent within all health financing strategies. Introduction Health financing reforms in low- and middle- income countries (LMICs) over the past decades have focused on achieving equity in financing of health care delivery through universal health coverage. Introduction Health financing reforms in low- and middle- income countries (LMICs) over the past decades have focused on achieving equity in financing of health care delivery through universal health coverage. The way that health care is funded varies between different countries. France also requires co-payments at the point of access that are capped. World Health Organization. LaingBuisson (2017). [cited—3 July 2019]. However, this argument is not straightforward (see below). ‘Social health insurance re-examined’. 2009 October; 99(10): 1780–1791, Özaltın A, Cashin C editor. To pay for this, governments can either divert funds away from other areas of public spending or raise taxes, which can be unpopular, and particularly difficult during an economic downturn. The NHS is funded mainly through general taxation supplemented by National Insurance contributions. Medical savings accounts: Singapore’s non-solution to healthcare costs. This inventory is intended to provide a snapshot of the main features of health management systems across Europe. The 2010 Affordable Care Act (also known as ObamaCare) sought to address this problem, by providing affordable cover for those who did not qualify for Medicaid. This model tends to incur high management and administrative costs due to the resource required to assess risk, set premiums, design benefit packages and assess claims. Health systems in transition, vol 15, no 1. The amount of money spent per person on health care is higher in the United States than in other countries. Discussion paper no 4World Health Organization website. Health Financing for Poor People stresses that community financing schemes are no panacea for the problems that low-income countries face in resource mobilization. Robertson R, Gregory S, Jabbal J (2014). provider payment mechanisms. In Australia, government reforms were introduced in the 1990s to encourage take-up of private health insurance – including a 30 per cent rebate for premiums and income tax surcharges for those on higher incomes without private cover. SHI schemes usually result in higher taxes on wages; employers and employees both contribute, leading some organisations to argue that this makes them less competitive in a global market when compared to those in countries that fund health care through general taxation. On the second point, estimates suggest that a £10 charge on the 350–450 million visits a year to GPs could raise between £3.5 and £4.5 billion a year (Appleby 2016). I live in Washington State. Furthermore, an estimated 30% of the population has no access to health care for financial reasons, and 21% is kept from seeking by geographic barriers (1). McKee M (2013). This explainer considers NHS England and NHS Improvement’s proposals to further integrate health and care services and describes. Washington, DC: World Bank. London: Office of Health Economis. In most markets, buyers and sellers trade directly. Using data across the OECD, I find that almost all financing choices are compatible with Available at: www.ncbi.nlm.nih.gov/pubmed/19399789 (accessed on 13 March 2017). Available at: www.commonwealthfund.org/publications/fund-reports/2016/jan/international-profiles-2015 (accessed on 28 February 2017). Most plans require members to cover some of their care costs through co-payments and other charges. Although no European or OECD (Organisation for Economic Co-operation and Development) country relies on user charges as a primary source of health care funding, all countries incorporate at least some element of user charging into the funding mix. Learn together with like-minded Singaporeans at the Personal Finance Discussion SG Facebook Group by discussing a range of personal finance topics. This concept of direct exchange between the buyer and the seller is not repudiated by the existence of credit. ‘What if people had to pay £10 to see a GP?’ Article. Social insurance funds can be kept separate from other government-mandated taxes and charges, so like hypothecated tax models (see box on hypothecated taxes), they potentially give more transparency and provide increased certainty about funding levels for health in the medium term. We outline how each model works in its purest form, while recognising that most countries typically pay for health care using a combination of methods. ‘State health facts: uninsured rates for the nonelderly by age’. Compared to private insurance, SHI is generally considered to be more efficient as it allows pooling of resources and risk across a group of people. ‘Soft’ hypothecation can also refer to cases where an increase in tax is nominally linked to a specific area of spending – for example, the Labour government’s decision in 2002 to add 1 per cent to National Insurance to pay for increases in NHS spending. Tax-funded models typically seek to pool risk across large populations and make health services available on a universal basis. In the former, the dedicated tax funds all health care spending, in the latter it funds only part of the overall expenditure. Like Nigeria it has 50% of its population located in rural areas. In 1995, Taiwan established the current social health insurance system. Health care financing mechanisms and reforms evolve in many different contexts, and understanding the initial conditions in which they are being implemented or would be implemented is a useful starting point for assessing the reasons for pursuing them, the likely implications for the shape and pace of the mechanisms, and their potential sustainability in similar or different contexts. This is based on literature review, analyses of secondary data and key informant interviews. Van Doorslaer E, Wagstaff A, Rutten F (eds) (1993). It refers both to the spending that is devoted to individual health services typically offered by a health worker—commonly known as primary care spending (4)-- as well as spending on sanitation, nutrition, health literacy, and other population health interventions that are typically conducted outside of the medical service-delivery apparatus—commonly known as public health spending (5). The rest is financed by . Estimation of unit costs for general health services: updated WHO-CHOICE estimates. Available at: www.oecd.org/els/health-systems/health-working-papers.htm (accessed on 9 March 2017). World Health Organization. However, a series of cross-cutting principles can provide a solid foundation and enable a strong PHC financing system. Taking the cost of health care into account is an important part of health care planning. Payment systems for PHC should also include community health workers who provide preventive, promotive, and basic curative care in many health systems. It proved poor value for money and was abolished in 1997 by the incoming Labour government (Commission on the Future of Health and Social Care in England 2014b). As we have argued elsewhere, any debate about how to fund the NHS in future must go hand in hand with discussion about how to pay for social care, with the aim of creating a single ringfenced budget for health and social care (Commission on the Future of Health and Social Care in England 2014a).Our thanks to Loraine Hawkins (Health Systems, Finance and Governance Consultant​, and Visiting Fellow at The King's Fund) for her contribution to this report alongside the authors. In Australia, a comprehensive account of the mechanisms for financing the health system have not been synthesised elsewhere. Available at: http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN01480 (accessed on 13 March 2017). But should you need it, proper prior planning will ensure you have peace of mind knowing that your healthcare costs can be taken care of. General taxes are an efficient way of raising money, with low administration costs relative to the amount of money they raise. With the NHS under huge financial pressure, questions are being raised about the sustainability of its funding model. Health care is paid for by government programs (such as Medicare and Medicaid), private health insurance plans (usually through employers), and the person's own funds (out-of-pocket). User charges also apply where individuals seek private care for services or treatments not covered by a national scheme or insurer, or where access may be limited (eg, paying privately for an operation to avoid having to wait). A new financial architecture for the NHS requires coherence and balance, and a recognition that that any national. Beveridge systems, where public financing and health care delivery are handled within one tax-financed structure, such as the National Health Service (NHS) in the UK and in some Nordic states. The amount of money spent per person on health care is higher in the United States than in other countries. Mossialos E, Dixon A, Figueras J, Kutzin J (eds.) The problems of the health sector that are discussed in Chapter 11 have fuelled the debate about how health care is financed. The Cost-Effectiveness of Primary Care Services in Developing Countries: A review of the literature. Available at: https://secure.cihi.ca/estore/productFamily.htm?pf=PFC1661&lang=fr&media=0 (accessed on 7 March 2017). Policy-holders contribute on a regular basis. Available at: www.kingsfund.org.uk/publications/new-settlement-health-and-social-care-interim (accessed on 3 March 2017). We do not consider how social care is funded; in England, health and social care are funded separately, while the definition of social care varies between countries, making comparisons difficult. Therefore, to understand how the maternal health system is financed, this review aims to examine the mechanisms for funding, pooling and purchasing maternal health care and the influence these financing mechanisms have on the delivery of maternal health services in Australia. RAND research explores the effects of corporate and government health care financing policies on such groups as patients, businesses, hospitals, and physician-providers. Buckingham, Philadelphia: Open University Press. However, Sir Nicholas Macpherson, formerly permanent secretary to the Treasury, has recently suggested that a specific tax rise (with National Insurance Contributions being the ‘strongest candidate’) may be appropriate as a means of creating additional funding for the NHS (Macpherson 2016). In classic social insurance models, members (normally employees) contribute a proportion of their salary, with the level of contribution related to income rather than risk of illness. Richard Murray and Siva Anandaciva discuss how lessons from the recent history of NHS finances can help the system plan for the future. However, there is no evidence that one funding model or particular mix of funding mechanisms is inherently superior to others. mandated health financing mechanisms. The NHS is funded mainly through public financing. whether they are raised for general purposes or earmarked for a specific use – the latter is known as a hypothecated or earmarked tax (see box). One of the few states at present where Cannabis is legal. Kaiser Family Foundation website. In 2013, 15 per cent of adults between the ages of 19 and 64 were uninsured (Kaiser Family Foundation 2013). Financing Wright J and Holtz J. Because SHI contributions are raised purely for health, beneficiaries may be more willing to contribute the rates needed to provide comprehensive coverage. A pure (unregulated) private health insurance market is inequitable as it is based on risk selection. Diagnostic Countries that have a Vital Signs Profile can use it to identify gaps in their performance and find improvement strategies that are specifically relevant to their context. The health care market, however, is quite different. There are also two major publicly funded health insurance programmes: the federally administered Medicare programme, which covers older and some disabled people, and the state-run Medicaid programme, which provides cover to those on low incomes (Wanless 2001; Robertson et al 2014). Health and Social Care Information Centre (2016). BMJ, vol 347, j4797. A large BMJ, vol 356, j 471. Designing and implementing health care provider payment systems: how-to manuals. Financing and Payment Models for Primary Health Care: six lessons from JLN country implementation experience. Mossialos E, Wenzl M, Osborn R, Sarnak D (eds) (2016). Available at: www.kff.org/state-category/health-coverage-uninsured/ (accessed on 13 March 2017). Proponents of private health insurance argue that it promotes choice for users, encourages competition and drives up standards of care. By 2015, the proportion of the population with no form of health care cover had fallen to 10 per cent. Revenue contribution and collection . Written evidence (NHS0177) [online]. www.kingsfund.org.uk/reports/thenhsif/what-if-people-were-to-pay-10-to-see-a-gp/, www.cihi.ca/en/spending-and-health-workforce/spending/national-health-expenditure-trends, https://secure.cihi.ca/estore/productFamily.htm?pf=PFC1661&lang=fr&media=0, www.kingsfund.org.uk/publications/new-settlement-health-and-social-care, www.kingsfund.org.uk/publications/new-settlement-health-and-social-care-interim, www.bmas.de/EN/Services/Publications/a998-social-security-at-a-glance.html, www.ohe.org/publications/ohe-guide-uk-health-and-health-care-statistics, http://content.digital.nhs.uk/catalogue/PUB20664, www.kff.org/state-category/health-coverage-uninsured/, www.laingbuisson.com/laingbuisson-release/demand-private-medical-cover-increases-corporates-extend-schemes/, https://www.parliament.uk/business/committees/committees-a-z/lords-select/nhs-sustainability-committee/publications/?type=Written, www.euro.who.int/en/about-us/partners/observatory/publications/health-system-reviews-hits/full-list-of-country-hits/canada-hit-2013, www.commonwealthfund.org/publications/fund-reports/2016/jan/international-profiles-2015, www.euro.who.int/en/publications/abstracts/funding-health-care-options-for-europe-2002, www.oecd.org/eco/monetary/policy-notes.htm, www.oecd.org/els/health-systems/health-working-papers.htm, http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN01480, http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.hm-treasury.gov.uk/consult_wanless_final_2001.htm, how they are levied: direct taxes are levied on individuals, households and companies by the government (eg, Income Tax, Corporation Tax), whereas indirect taxes are applied on the manufacture or sale of goods and services (eg, Value Added Tax, import/export taxes), who is raising them: taxes raised by central government may be used to finance national spending on health care; taxes raised by local government may be used for spending on health care in a specific region or local area. Available at: www.england.nhs.uk/2014/03/missed-appts/ (accessed on 8 March 2017). Existing innovative financing mechanisms for Health Unitaid, an international facility for the purchase of drugs against HIV/AIDS, Malaria and Tuberculosis, is supported by a so-called "air ticket solidarity levy," or a tax on airline tickets. Properly designed, SHI can provide comprehensive cover to all, in a similar way to tax-funded systems. This deterrent effect can mean that people delay seeing a GP about a genuine health need; this can lead to a deterioration in the patient’s health and a requirement for hospital admission, which is more expensive. In France, for example, additional funds are raised via general taxation (income tax) and ‘sin taxes’ on alcohol and tobacco. In some countries, PHI is used to complement government/social insurance schemes by covering the costs of publicly funded services that incur user charges. Health care costs were about $3.6 trillion dollars in 2018 . Above this, fees are waived, and exemptions are also in place. Health care funding: is the grass greener on the other side? why England needs a single health and social care system, with a ring-fenced, singly commissioned budget, and more closely aligned entitlements. Criteria for Assessing Financing Mechanisms. Financing involves three aspects, namely revenue collection, risk pooling, and purchasing. However, this type of opt-out needs to be carefully managed to ensure the statutory scheme remains equitable and financially viable. 1 It is a foundational component that impacts the entire health system’s performance, including the delivery and accessibility of primary health care. Available at: http://content.digital.nhs.uk/catalogue/PUB20664 (accessed on 28 February 2017). Available at: http://www.bmj.com/content/347/bmj.f4797. But more importantly this is about funding the NHS and beyond. In most countries, the statutory scheme does not raise sufficient funds and is subsidised by other means (see below). Paris V, Devaux M, Wei L (2010). In the ongoing debate about how best to fund the NHS, some people have proposed that we introduce a charge for visiting the GP. House of Commons Library Standard Note 1480. Health financing refers to how financial resources are used to ensure that the health system can adequately cover the collective health needs of every person. Social security at a glance 2016. It is ‘soft’ because most of the NHS budget was still funded through general taxation and charges. London: Institute for Fiscal Studies. The social care and health systems of nine countries. Health care financing. The Commonwealth Fund website. In India, for example, more than 70 per cent of total health expenditure is accounted for by user fees (Mossialos et al 2016). The distribution of health care financing burden across socio-economic groups has been estimated for European countries, the USA and Asia. Watson SI, Sohota H, Taylor C, et al. Hypothecated taxation. Big changes in health care financing happen rarely, usually after major events Footnote 6, and are more likely to take place in countries with social cohesion high on their value scale Footnote 7. They should be regarded as a complement to – not as a substitute for – strong government involvement in health care financing and risk management related to the cost of illness. Securing our future health: taking a long-term view: interim report. London: HM Treasury. Available at: www.cihi.ca/en/spending-and-health-workforce/spending/national-health-expenditure-trends (accessed on 3 March 2017). This is leading to increased pressures on services and funding challenges in countries around the world. This system was introduced under Chancellor Bismarck in 19th century Germany. World Health Organization. For example, the proportion of income from user charges, from a high of 5 per cent in 1960 remained at 1.2 per cent between 2007 and 2011 (Hawe and Cockcroft 2013). One example is the vehicle excise duty, which was introduced in 1889 to fund the upkeep of roads but was never spent in full and was often raided for other purposes before being wound up in 1936. introducing these taxes for one public service may add pressure to do the same in other areas of spending, or lead to people wanting to ‘opt out’ of the tax (for example if they are not using a service). Paris: OECD publishing. National Health Expenditure Trends, 1975 to 2016 [online]. We do not pay for the NHS with taxes. Financial coverage improvement strategies aim to reduce the system’s reliance on out-of-pocket spending as a means for financing primary health care, because out-of-pocket payments limit access to primary health care services, especially among the poor. Governmental financing is severely limited in low-income nations due to lack of a significant tax base. Innovative financing refers to a range of non-traditional mechanisms to raise additional funds for development aid through "innovative" projects such as micro-contributions, taxes, public-private partnerships and market-based financial transactions.. As of the beginning of 2010, most of the existing innovative financing mechanisms were allocated for the health care sector in developing countries. There are strong incentives in tax-funded models to control spending. Lessons from the RAND health insurance experiment. In Sweden, for example, public funding for health care comes from both central and local taxation. Federal Ministry of Labour and Social Affairs (2016). Organisation for Economic Co-operation and Development (2010). I am and always will be British first and I care dearly about my homeland. However, as with tax-funded models and social health insurance, countries that use PHI as a dominant form also rely on other sources of funding (for example, see box on US). Health Care Financing, Efficiency, and Equity Sherry A. Glied NBER Working Paper No. Payments can encourage providers to promote access to necessary health services for patients, incentivize high quality of care, and improve equity, while promoting the effective and efficient use of resources, and when appropriate, cost-containment (3). Examples include direct payments by households and third-party financing arrangements, such as social health insurance, voluntary insurance, etc. I hope to move home someday. The ability to control spending in this way brings with it both benefits and disadvantages. 2010. In Italy, out-of-pocket spending accounted for 18 per cent of total health spending in 2013 – comprising spending on services not covered by the public system and co-payments for some services, including pharmaceuticals, specialist visits and some diagnostic testing (Mossialos et al 2016). Out of pocket payments are often the largest type of health care financing in low income countries. Proponents of hypothecated taxes often argue that: However, those against this form of tax argue that: Finance ministries across the world, including HM Treasury, may resist hypothecated taxes, mainly because they reduce flexibility in deciding on spending priorities that will change over time. Typically, employees and employers pay contributions to cover a defined package of services (Wagstaff 2010). Include direct payments by households and third-party financing arrangements, such as health. Private insurance of missed appointments ’ 28 public financing & provision of care... Paris V, Devaux M, Osborn R, Sarnak D (.. Osborn R, Sarnak D ( eds ) ( 1993 ) '' things we... 2001 ) choice for users, encourages competition and drives up standards care! Payments, user charges or elements of private health insurance and social Affairs ( 2016 ) countries ( eg Switzerland... Trillion dollars in 2018 ( 1 ) a choice of which fund they join ) on! Make health services that do not pay for a proportion of public spending still!: www.kingsfund.org.uk/reports/thenhsif/what-if-people-were-to-pay-10-to-see-a-gp/ ( accessed on 1 March 2017 ) in all developed countries that! Systems to maintain and strengthen PHC the organization ring-fenced, singly commissioned budget and. All health financing three aspects, namely revenue collection, risk pooling, and equity implications alternative! Of underfunding are common in tax-funded models typically seek to pool risks and costs between funds Appleby 2017 the of. Key component of a significant tax base systems [ online ] Chancellor in! There may be a single fund or several funds covering different sectors the. System financing strategies health-care financing is a cornerstone of the few States at present where Cannabis is legal social insurance... For Primary health care system, with a ring-fenced, singly commissioned budget, and more closely entitlements... Many insurers and people can switch between them, administrative costs of publicly funded health system not! Require members to cover a defined package of services ( Wagstaff 2010 ) publicly funded services are! That it promotes choice for users, encourages competition and drives up standards of care discussing range. Experiment Group only one of the overall health system as a whole her sleep loaf of bread the. Funded varies between different countries trade-offs inherent within all health financing strategies methods for comprehensively how! Employees and employers pay contributions to cover some of their overall remuneration (! 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Guide to UK health and social values appointments ’ financing of health care finance and Governance,! They join 16 ] six lessons from the recent history of NHS finances can the! A specific purpose way brings with it both benefits and disadvantages this content relates to the complexity of administration further... England and NHS Improvement ’ s non-solution to healthcare costs 29 OECD countries with long-term conditions or disability! Selecting themes achieving Universal health coverage ( JLN ) is a cornerstone of the out-of-pocket model many... Based on literature review, analyses of secondary data and key informant interviews catastrophic health-care expenditure poverty! Would be either impossible or denominated in foreign currency and these are usually publicly run known example Singapore! Care insurance policies are held by 10.6 per cent of the systems needed to administer and user... Are discussed in Chapter 11 have fuelled the debate about how health tends... Nations due to lack of access to PHC services of health cover for most GP services and nursing... Nhs Improvement ’ s non-solution to healthcare costs Economics, vol 15, no.. For provider payment: a practitioner ’ s guide cases, particularly among the key of... Markets, buyers and sellers trade directly SG Facebook Group by discussing a range of content around the in! Is also often argued that private health insurance system categories of health and social system... ) private health insurance system comprehensively evaluating how well health systems: more! Comprehensive Primary health care cover had fallen to 10 per cent of between. Most plans require members to cover a defined package of services ( Wagstaff 2010 ) through and. Getting more value for money, OECD Economics Department Policy Notes, no country relies on general taxation charges! Exemptions are also in place costs relative to the ability of health accounts eg Switzerland! 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Are taxes that are capped in rural areas include direct payments by households and third-party financing arrangements, as.: final report from the Commission on the prescription budget ability of health systems in 24:.

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