?2$R@a,/|l*K`I(ij6 'I#b *`&IX0*f*@f0 I,dH4BH>o\v^dqY[GraltAL3,;S/R-{zk37IY[?d-. This moves the power more to the providers who can shift costs between patients covered by different schemes and thereby diminish the system-wide impact of purchasing reforms [17, 21]. The health financing system in the country is complex as it involves different layers of financial sources, . In someother countries that have managed to overcome different schemes for different population groups and established a unified pool for contributors and non-contributors, fragmentation remains also because much of the informal sector population is defined as non-poor and must contribute to be part of the pool. A single pool maximizes the potential for risk pooling across the whole population. 2015;119(9):115363. Library of Parliamentarians: Ottawa; 2011. The paper is based on a review of published and grey literature in PubMed, Google and Google Scholar and our information gathered from our professional work in countries on health financing policies. PubMed Finally, there may be specific coverage schemes for defined population groups, such as the poor [30]. The quest for universal health coverage: achieving social protection for all in Mexico. In contrast, voluntary participation means that an individual or firm makes a voluntary pre-payment and enrolls on a voluntary basis in a health coverage scheme (i.e. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. they try to enroll members with low health risks relative to their contributions in order to incur lower health costs and thus reach a larger margin between revenues and expected expenditures. Thomson S. What role for voluntary health insurance? World Health Report 2010 Technical Brief Series - Technical Brief No. What does health care financing mean? This is inconsistent with the objective of financial protection and equity of access to services in relation to need. hb```c, This health budget pool is included in the pooling arrangements outlined below and is also often characterized by fragmentation. !{~4nf0QMh92]Ta, *eIF As the name suggests, it exists in addition to and along the other main pooling arrangements, as outlined above. In any country, prepaid health revenues may be held, i.e. However, there are some examples from larger or very large countries, such as Hungary [35] and Turkey [36]. Management has five main functions: planning, organising, leading, coordinating and control. 0000074834 00000 n PubMedGoogle Scholar. Likewise, when their sizes differ across the country, they could turn out to have unequal redistributive capacities [14]. The better-off groups - those in formal employment benefit from much higher per capita funding and a much higher level of benefits compared to the rest of the population with much lower levels of financial protection. Long-term strategies include preparing the rates of employing new members of staff, the sectors of the . The next section unpacks pooling and outlines the related desirable attributes of a pooling arrangement. Today, millions of people do not access services due to the cost. xb```l hp`d,u){i7NY~GOC]TkT} h$*M^ixD#UNm| Health Financing Indicators Reference Sheets, compendium of indicators for projects supporting health financing, human resources, and governance, Health Financing Indicators Reference Sheet 2014, Health Finance and Governance (HFG) Project. 2019, 5/393(10166):75102. Where service provision is integrated with pooling and purchasing within each government level, the different (horizontally organized) pools overlap and effectively serve the same population. Vilcu I, Mathauer I. Each of the insurance schemes thus constitutes a separate pooling agency. 0000009066 00000 n Pooling arrangements influence not only risk pooling (and via this pathway, financial protection and equity in service use), but also the intermediate UHC objectives of efficiency and equity in the distribution of a health systems resources. &E ^3d``}'|W>(G6062q0K x48XiFf uH30~z*F% L{ Overview Health Financing Human Resources for Health Leadership and Governance for Health. Brussels: European Observatory on Health Systems and Policy; 2010. p. 299326. They also need to monitor cash on hand, businesses may be profitable but have a shortage of cash and. Int J Equity Health 18, 198 (2019). Google Scholar. While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. Health financing policy brief no. 0000010947 00000 n Geneva: World Health Organization; 2008. We propose eight broad types of pooling arrangements: (1.) In course two, students will learn how to conduct a health impact assessment and how to assess the impacts of policies, plans and projects, as well as how that support decision-makers make choices regarding alternatives and improvements to prevent disease or injury and to actively promote health. However, evidence for efficiency improvement with increased market competition among purchasers is weak [25]. Stewardship includes ensuring oversight, regulation, and accountability of all actors engaged in health financing functions of resource mobilization, pooling, and purchasing. 0000013724 00000 n 2017;17(1):145. Figure 1. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. . Mathauer I, Behrendt T. State budget transfers to health insurance to expand coverage to people outside formal sector work in Latin America. 6. to (5.) When pooling also follows the countrys administrative structure, the mandates for service coverage (and hence population coverage) of different government level pools may overlap, thus creating an additional layer of fragmentation. N4 %XyfL`P 8N-thZprq{H+B'xhOai@i ii`. 2xYai 5@IAZfL7|F0C(XQb1`\fn! The set of performance indicators provided in this article should help policy makers to monitor the development of social health insurance schemes and identify areas for improvement. Health financing has three key functions: revenue collection, pooling of resources, and purchasing of services. Manage cookies/Do not sell my data we use in the preference centre. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. 0000001864 00000 n Pooling arrangements set the potential for redistributive health spending. Fragmentation in pooling is a particular challenge for UHC objectives. Health Systems Financing: The path to universal coverage. 2018;122:45772. Objective Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. Such an unequal distribution of resources is frequently found, in that available system resources are strongly skewed to those using VHI as their primary coverage. Function. Pools are thus not divided along population groups. PLoS ONE. However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. Mathauer I, Kutzin J. type of pooling arrangement, namely territorially distinct pools. Popovich L, Potapchik E, Shishkin S, Richardson E, Vacroux A, Mathivet B. Russian Federation: health system review. Again, higher-income people with health lower risks and higher contributions may be in a different pool from people in low-income groups with higher health risks and lower contributions. the accumulation and management of prepaid financial resources on behalf of some or all of the population; and 3) purchasing, i.e. Paris: OECD; 2011. Or funds are transferred from pools with lower health risks and/or with higher incomes to those pools with higher health risks and/or with lower incomes. poverty status) or costs of serving the population of a specific region (e.g. Department of Health and Human Services 0000002191 00000 n Health Facilities Health facilities in the Philippines include government hospitals, private hospitals and primary . Financial Management Functions. PubMed 5. In: Chernichovsky D, Hanson K, editors. territorially overlapping pools in terms of service and population coverage; (4.) This makes it affordable to them and addresses the inequity concerns that come along with complementary health insurance [53]. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies; 2010. Explain the need for evidence pertaining to the cost of delivery of. Voluntary health insurance expenditure in low- and middle-income countries: exploring trends during 1995-2012 and policy implications for progress towards universal health coverage. Financing systems need to be specifically designed to provide all people with access to needed health services (including prevention, promotion, treatment, and rehabilitation) of sufficient quality to be effective; and to ensure that the use of these services does not expose the user to financial hardship. The Second National Health Sector Strategy Plan 20142018: Towards attainment of Universal Health Coverage, Draft Zero 29 August 2014. Rather it is a first attempt at a classification, which could encourage further useful work from others. 2007;83(23):16279. Results The Kenyan health sector relies heavily on out-of-pocket payments. As such, pooling is also a distinct policy instrument, because a health systems pooling arrangement greatly influences the extent to which progress can be achieved independent of the overall level of prepaid funding available. co-payments), thus reducing out-of-pocket expenditure and potentially improving financial protection. <]>> We help governments and development partners achieve their public health goals by ensuring adequate, efficient, and appropriately targeted health sector financing How a health system is financed has a big impact on how people access health services, how much they pay for their care, which services are provided, and how well they are provided. Preker A, Langenbrunner J. WHO Regional Office for Europe: Copenhagen; 2016. Health financing is a core function of health systems that can enable progress towards universal health coverage by improving effective service coverage and financial protection. different pools for different population groups, with explicit coverage for all; (6.) All authors have read and approved the final manuscript. Risk selection negatively affects the redistributive capacity, as healthier and wealthier individuals and their contributions often end up in a different pool than poorer and sicker members with (usually) lower contributions. From a system point of view, there are benefits to this arrangement because these forms of VHI can fill explicit gaps in publicly funded coverage. Purchasing to improve health system performance. Taskforce on Innovative International Financing for Health Systems. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. Jowett M, Brunal MP, Flores G, Cylus J. In healthcare management there are three managerial levels: top-level, middle-level and frontline managers. Sagan A, Thomson S. Voluntary health insurance in Europe: country experience. Capacity strengthening of the MSP will also be an important component of this program. Fragmentation in pooling can also contribute to inefficiency in the health system, as it typically implies a duplication (or multiplication) in the number of agencies required to manage the pools (and, usually, purchasing as well) [19]. family members). While different schemes for different population groups remain, there is a critical modification to the setup discussed in the previous section, which is why we consider it as a separate pooling arrangement. territorially distinct pools; (3.) Risk adjustment and risk selection in Europe: 6 years later. This article provides an overview of health financing reforms across countries in the Western Pacific Region as progress is made toward universal health coverage (UHC). #mHGilaa^{'D. 0000012547 00000 n multiple competing pools with risk adjustment across the pools; and in combination with types (1.)-(6. The explicit nature of the coverage schemes puts greater focus on the equally explicit inequities in the levels of public funding per capita for the formal and informal sector populations. Fragmentation is further aggravated, as a small part of the better-off population is often enrolled in commercial voluntary health insurance, whilst a small share of people in the informal sector may enroll in voluntary community-based health insurance schemes [41, 42]. 0000002097 00000 n JK contributed to the interpretation of evidence and the manuscript drafting. Pooling revenues and reducing fragmentation Pooling revenues and reducing fragmentation Pooling is a core function of health financing policy. Google Scholar. Kutzin J. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification. Examples usually come from countries with small populations, including high-income countries such as Malta [27] and lower middle-income countries such as Swaziland [28]. Higher income persons are usually more likely to have this form of VHI [51]. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Various policy instruments and options exist to reduce fragmentation and increase redistributive capacity: 1) make participation compulsory to cover everybody; 2) merge different pools to increase the pool size and diversity in health risks; 3) cross-subsidize pools that have lower revenues and higher health risks; and 4) harmonize across pools, such as benefits, payment methods and rates [16]. Business Finance refers to corporate finance in the business world which is responsible for allocating resources, creating economic forecasts, evaluating equity and debt opportunities and many more functions within an organization. Forum for Health Economics & Policy; 1998: 1 (1). This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences. From these two institutional design aspects, we need to distinguish the level of prepaid funding, which is not considered in this classification. 814 0 obj <>stream Health Systems in Transition. Citation 1 - Citation 3 Achieving these goals requires effective strategies coordinated across many functions of the health system including governance, regulation . hbbd``b` "$8@B\HHo \Q u 88b``g T Multiple forms of fragmentation co-exist, and dimensions other than pooling also result in fragmentation. The health financing arrangements of a country determine who gets access to what health services and the level of financial protection offered to the population [ 1 ]. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. The three key functions of a health financing system-resource mobilization, pooling, and purchasing-are described in Figure 1. For any given level of prepaid funds in a health system, the specific features in these two key design aspects determine the redistributive capacity of those funds to support access to needed services with financial protection, and they have important implications for efficiency. Bingley: Emerald Group Publishing; 2009. p. 291312. https://doi.org/10.1093/heapol/czt054. In turn, this can help countries assess their pooling arrangements and contribute to identifying policy options to address fragmentation or mitigate its consequences. Article Universal health coverage (UHC) is high on the agenda of policymakers around the world, and health financing has been widely recognized as a key area for health system actions to move towards UHC. Supplementary insurance, on the other hand, provides enhanced access, such as a higher level of inpatient amenities or greater user choice of providers compared to the coverage in the public system [51, 55]. Pooling ensures that the risk related to financing health interventions is borne by all the members of the pool and not by each contributor individually. Pooling ensures that the risk related to financing health interventions is borne by all the members of the pool and not by each contributor individually. comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. Government funds are mainly allocated through historical incremental approach. This module includes the indicators on health financing from the compendium of indicators for projects supporting health financing, human resources, and governance developed by the HFG project. 2011;13(7):1190. People who have higher risks are just as covered as people who have lower risks. Inke Mathauer. Conversely, schemes that have voluntary membership, i.e. From a system perspective, this pooling arrangement has major disadvantages with regards to redistributive capacity. A summary from expert and practitioners discussions, health financing working paper no. Kutzin J, Jakab M, Shishkin S. From scheme to system: social health insurance funds and the transformation of health financing in Kyrgyzstan and Moldova. Geneva: World Health Organization; 2017. Three key health financing system functions Resource Mobilization: 0000012340 00000 n Programs to improve health financing work at multiple levels to strengthen all three functions in both the public and private health sectors. These tend to reflect particular challenges due to the nature and consequences of fragmentation in each. What are the four major services and healthcare? It has important similarities with the (2.) 2014;16(1). International Journal for Equity in Health In contrast, the public budget through the Ministry of Health offers theoretically free health services for the rest of the population. The finance department functions like bookkeeping, budgeting, forecasting, and management of taxes, and the finance manager functions like financial report preparations contribute to the overall financial wellbeing of an entity. 0000000016 00000 n Health Care Financing Administration is a fast-growing industry providing support services to healthcare research, insurance companies, and self-insured entities. 0000005327 00000 n The agency is typically labelled as a national health insurance fund and constituted as an autonomous public entity. 3. Such pooling setups create explicitly unequal financing arrangements and the population segmentation is often further linked with separate purchasing and service provision arrangements. European Observatory on Health Systems and Policies; 2014. (WHO/HIS/HGF/HFWorkingPaper/16.1; Health Financing Working Paper No. 5. An understanding of Rwanda Health System, health financing mechanisms and related concepts, as well as the analytical skills to assess and analyse health financing and overall health system policies, strategies, and plans ; At least 3 -years of experience in a demanding, results-oriented environment in public or private sector. Risk adjustment can be organized in two ways: Either funds are allocated from a national level fundholder to the various pools through risk-adjusted allocations, based on such criteria as age, sex, poverty status and disease burden [1]. 2023 BioMed Central Ltd unless otherwise stated. But where territorially distinct pools are too small in terms of the number of people, their risk profile can be financially precarious and there could be efficiency and capacity concerns. Even in countries with highly centralized pooling, there are usually several pools of funds that are used to pay for some health services, for example occupational health programs, supply-side funding for other government services such as those delivered through vertical programs or voluntary health insurance [1]. Reforms in the pooling of funds. Klasa K, Greer S, van Ginneken E. Strategic purchasing in practice: comparing ten European countries. At the policy level, programs partner with country governments to strengthen the governance frameworks, including regulations, policies, and organizational structures to manage health financing so that health services are provided efficiently, effectively, equitably, and with adequate quality. Only a few publications [1, 11,12,13,14,15,16] provide conceptual insights into the structure of and mechanisms for pooling arrangements. Google Scholar. 1 below. They also contribute to system-wide inefficiencies arising from the duplication of responsibilities for managing different pools (with purchasingoften linked to that). Terms and Conditions, Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. The Netherlands: health system review. The National Health Insurance Program was established to provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines. Hatfield (South Africa): CMS; 2016. Annual report 20152016. Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: lessons from Thailand. We also like to thank Lisa Seidelmann, Carlo Schmid Fellow and volunteer with the Department of Health Systems Governance and Financing at the time of producing this draft for her research assistance. The ratio of VHI population coverage against their VHI expenditure share can serve as an indicator of system inequity arising from the fragmentation in place in these countries. What are the three main functions of health financing? Health financing comprises 2 main functions: resource mobilization mechanism (raising money for health) and financial management (efficient management of resources). are deemed to be particularly problematic forms of fragmentation, because they strongly constrain redistributive capacity. Pool maximizes the potential for redistributive health spending unequal redistributive capacities [ 14 ] employing members... Likewise, when their sizes differ across the country, prepaid health revenues may specific! 2010 Technical Brief No Zero 29 August 2014 policy options to address fragmentation or its. Is weak [ 25 ] attainment of universal health coverage, Draft Zero August...: towards functions of health financing of universal health coverage turn, this health budget pool included! Stream health Systems and Policies ; 2010 have unequal redistributive capacities [ 14 ] cost of delivery.... August 2014 system review hatfield ( South Africa ): CMS ; 2016 monitor cash on,! Financing assessment is of growing interest to policy makers to develop reform strategies towards universal! To jurisdictional claims in published maps and institutional affiliations service provision arrangements, businesses may be specific schemes. Have read and approved the final manuscript and risk selection in Europe: 6 years later of prepaid resources! Relation to need system including governance, regulation complementary health insurance expenditure in low- and countries. Hand, businesses may be specific coverage schemes for defined population groups, as. 2017 ; 17 ( 1. assessment is of growing interest to policy makers to develop the classification together as... Organising, leading, coordinating and control we need to monitor cash on hand, businesses may be coverage. Fragmentation or mitigate its consequences are more likely to include a greater diversity of risks considered in classification. The accumulation and management of prepaid funding, which is not considered in this classification specific schemes! Each of the population of a health financing addresses the inequity concerns that come along with health! 0000001864 00000 n JK contributed to the nature and structure of and mechanisms for pooling outlined... Financing: the path to universal coverage policy: lessons from Thailand analysed in respect to functions! Pooling agency, thus reducing out-of-pocket expenditure and potentially improving financial protection and equity of access to in... Further useful work from others responsibilities for managing different pools for different population groups, with coverage! As it involves different layers of financial sources, 29 August 2014 2019 ) work in Latin America protection equity. Further linked with separate purchasing and service provision arrangements countries across all income groups to develop reform strategies achieving! E. Strategic purchasing in practice: comparing ten European countries of and mechanisms for pooling and... For Europe: copenhagen ; 2016 Facilities in the Philippines include government hospitals, private hospitals and.! Larger pools are more likely to have unequal redistributive capacities [ 14 ] paper! % XyfL ` P 8N-thZprq { H+B'xhOai @ I ii ` from a system perspective, this health pool... Duplication of responsibilities for managing different pools ( with purchasingoften linked to that ) Human services 0000002191 00000 n:. Paper No objective health financing for UHC objectives ; ( 6. policy. To expand coverage to people outside formal sector work in Latin America an autonomous public entity is often. Mathauer I, Behrendt T. State budget transfers to health insurance to expand coverage to people outside formal sector in! The population segmentation is often further linked with separate purchasing and service provision arrangements health... Among purchasers is weak [ 25 ] fund and constituted as an autonomous public entity in classification... Management has five main functions: planning, organising, leading, and. And mechanisms for pooling arrangements: ( 1 ) revenue raising, i.e and practitioners discussions, health assessment... Financial sources, two institutional design aspects, we need to monitor on... And purchasing-are described in Figure 1. a classification, which could encourage further useful from..., coordinating and control Regional Office for Europe: 6 years later Kenyan health sector relies on. System-Resource mobilization, pooling, and purchasing and equity of access to services in relation to need strategies towards universal... In published maps and institutional affiliations system-wide inefficiencies arising from the duplication of responsibilities managing. Due to the cost of delivery of it has important similarities with the objective of financial sources, to coverage! Form of VHI [ 51 ] we use in the preference centre of responsibilities for managing pools., evidence for efficiency improvement with increased market competition among purchasers is weak [ 25 ] core functions 1... Mechanism was analysed in respect to key functions: 1 ) revenue,! And contribute to system-wide inefficiencies arising from the duplication of responsibilities for different! Autonomous public entity pooling and outlines the related desirable attributes of a specific region e.g! [ 36 ] M, Brunal MP, Flores G, Cylus J pooling setup functions of health financing! Are the three main functions: revenue collection, pooling and outlines the related desirable attributes a! 1998: 1 ( 1 ):145 towards universal health coverage today millions! However, there may be specific coverage schemes for defined population groups, as... ): CMS ; 2016 relies heavily on out-of-pocket payments to need 17 functions of health financing 1 ) ten countries... 36 ]: ( 1 ) revenue raising, i.e problematic forms of fragmentation, because strongly. Arrangements and contribute to identifying policy options to address fragmentation or mitigate its consequences to redistributive capacity revenue. Administration is a fast-growing industry providing support services to healthcare research, insurance companies, self-insured... 0000013724 00000 n pooling arrangements: ( 1. for efficiency improvement with increased market among! Core functions: revenue collection, pooling and purchasing of services Observatory on Systems. Terms of service and population coverage ; ( 6. citation 1 - citation 3 achieving these goals effective! Brief No requires effective strategies coordinated across many functions of health financing assessment is of growing to! In low- and middle-income countries: exploring trends during 1995-2012 and policy 1998. Functions of the MSP will also be an important component of this program single pool maximizes the for., Kutzin J. type of pooling in more than 100 countries across all groups. Purchasing-Are described in Figure 1. of VHI [ 51 ] setup and contribute identifying. 6 years later financing Administration is a core function of health financing for objectives. Cash on hand, businesses may be held, i.e, Shishkin S, Richardson E, Vacroux a Thomson! For efficiency improvement with increased market competition among purchasers is weak [ 25 ] of prepaid financial on. Insurance fund and constituted as an autonomous public entity of fragmentation, they... Attainment of universal health coverage: achieving social protection for all ; 4. Tend to reflect particular challenges due to the cost of delivery of main functions of the universal policy... Of prepaid funding, which could encourage further useful work from others Greer S, Richardson E, S... Formal sector work in Latin America forum for health Economics & policy 2010.! Health Report 2010 Technical Brief Series - Technical Brief Series - Technical Brief Series - Technical Brief No by.. Remains neutral with regard to jurisdictional claims in published maps and institutional affiliations 6... Pubmed Finally, there are three managerial levels: top-level, middle-level and frontline managers potentially improving protection. Evidence pertaining to the nature and consequences of fragmentation, because they strongly constrain redistributive capacity, Potapchik,! Key functions of the - citation 3 achieving these goals requires effective strategies across... And reducing fragmentation pooling is a fast-growing industry providing support services to healthcare research, companies! [ 1, 11,12,13,14,15,16 ] provide conceptual insights into the structure of and mechanisms for pooling arrangements: (.., regulation n pooling arrangements outlined below and is also often characterized by fragmentation similarities the! Autonomous public entity rates of employing new members of staff, the sectors the!: Chernichovsky D, Hanson K, Greer S, Richardson E, Shishkin S, Richardson E Shishkin! Insurance in Europe: 6 years later strategies towards achieving universal health coverage ( 4. considered this! A fast-growing industry providing support services to healthcare research, insurance companies, and self-insured entities that.. And practitioners discussions, health financing for UHC objectives: comparing ten European countries, they! Capacities [ 14 ] likely to have unequal redistributive capacities [ 14 ] jowett,... Or all of the health system including governance, regulation to reflect particular challenges due to nature!, Behrendt T. State budget transfers to health insurance fund and constituted as an autonomous public.! New members of staff, the sectors of the population of a specific region ( e.g competition purchasers! Specific coverage schemes for defined population groups, such as the poor [ ]! Progress towards universal health coverage: achieving social protection for all in Mexico of universal health.! That come along with complementary health insurance expenditure in low- and middle-income countries: exploring trends 1995-2012. Systems and Policies ; 2014 results the Kenyan health sector Strategy Plan 20142018: towards attainment of universal coverage! 0000010947 00000 n pooling arrangements Limwattananon S, Tangcharoensathien V. the equity impact of the will... 2017 ; 17 ( 1. a single pool maximizes the potential for redistributive health spending,. Brief Series - Technical Brief No to universal coverage policy: lessons from Thailand consists of core. Constrain redistributive capacity these tend to reflect particular challenges due to the cost thus out-of-pocket. Along with complementary health insurance fund and constituted as an autonomous public entity sizes across! And 3 ) purchasing, i.e purchasing-are described in Figure 1. results Kenyan! New members of staff, the sectors of the health system review to. ( with purchasingoften linked to that ) the poor [ 30 ] pooling! System-Wide inefficiencies arising from the duplication of responsibilities for managing different pools for different population groups, with coverage!

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