The Joint Learning Network for Universal Health Coverage systematically documents the reforms of its member countries and other countries that have expanded health coverage through demand-side financing. The case studies contained in these pages are brief, comparative and modular in nature, describing the key highlights and technical features of each program.
Compare various dimensions of country reform efforts using our interactive tool.
| Program | Service delivery system | Public providers | Non-state providers | Service delivery system |
|---|---|---|---|---|
| Estonia: Estonian Health Insurance Fund |
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Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:
Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:
All health care providers operate as private, independent, legal entities. These entities can be private individuals, limited liability companies, or foundations. Most hospitals belong to local governments. They are managed as either limited companies or as non-profit foundations. Hospitals function as true business entities, with managers able to strive for better clinical practice and empowered to achieve improved financial performance. Management structures are explicit with a supervisory board and a management board governing the process. Maximum waiting times for specialized services vary by type. Ambulatory care is capped at four weeks, inpatient care and day surgeries are capped at eight months, and other interventions such as joint replacements have maximum waiting times of up to two and a half years. This initially led some patients to jump the queue by seeking care privately. However, queue jumping rules have recently been established to prevent private patients from getting quicker access to treatment. Cutting in the queue is only permitted in cases where the waiting list is caused by a provider having reached the EHIF contract volume. Service delivery must take place within agreed time limits. Emergency care must be provided immediately, outpatient specialist care must be provided within four weeks, and inpatient care must be provided within six months. Estonian Health Insurance FundService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:
All health care providers operate as private, independent, legal entities. These entities can be private individuals, limited liability companies, or foundations. Most hospitals belong to local governments. They are managed as either limited companies or as non-profit foundations. Hospitals function as true business entities, with managers able to strive for better clinical practice and empowered to achieve improved financial performance. Management structures are explicit with a supervisory board and a management board governing the process. Maximum waiting times for specialized services vary by type. Ambulatory care is capped at four weeks, inpatient care and day surgeries are capped at eight months, and other interventions such as joint replacements have maximum waiting times of up to two and a half years. This initially led some patients to jump the queue by seeking care privately. However, queue jumping rules have recently been established to prevent private patients from getting quicker access to treatment. Cutting in the queue is only permitted in cases where the waiting list is caused by a provider having reached the EHIF contract volume. Service delivery must take place within agreed time limits. Emergency care must be provided immediately, outpatient specialist care must be provided within four weeks, and inpatient care must be provided within six months. |
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| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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The reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%. Read full sectionThe reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%. Enrollees are free to choose a family group practice for their primary care and they can switch once per year during the annual registration period. In large urban settings, practices that offer higher quality services will attract a larger number of patients, leading to higher capitation payments for the practice. Rural areas, however, have too few providers in order to create this type of quality incentive. After the primary care reforms created the undergraduate, postgraduate, and continuing education curricula, the number of primary care physicians rose significantly from 5.8 per 1,000 population in 2001 to 8.2 per 1,000 population in 2005. Furthermore, by the end of 2004, 75 percent of primary care physicians and nurses had been retrained as family physicians and family medicine nurses. Kyrgyzstan has three types of primary care providers. First, the core of the old rural health system, Feldsher-Obstetric Ambulatory Points (FAPs) are facilities in the most remote reaches of the country that offer basic services such as neonatal care, immunizations, and health education. As of 2006 there were 875 FAPs across Kyrgyzstan, each serving between 500 and 2,000 people. Second, Family Group Practices (FGPs) are the major providers of primary care in Kyrgyzstan. FGPs are normally made up of three to five doctors. They can be freestanding and autonomous entities or units within large hospital polyclinics. Finally, Family Medicine Centers (FMCs) are large outpatient facilities staffed by varying numbers of specialists, often 10 to 20 health care professionals in addition to their affiliated FGPs. Their service offerings range from primary care to specialized care, including instrumental diagnostics. In 2006, approximately 93% of FAPs and 96% of FGPs were part of Family Medicine Centers. Secondary care is provided by hospitals at the oblast level (generally one oblast merged hospital in each oblast), and by territorial hospitals in rayons and cities (51 hospitals nationally). The main difference between these two types of hospitals lies in the variety and complexity of conditions that they can handle. Tertiary care that provides highly specialized services is conducted in eight central-level hospitals. In terms of legal organization, most health care organizations tend to be public. The exceptions are optic, dental, urologic, and gynecological services, which tend to be private facilities and are mostly concentrated in the capital city of Bishkek. Mandatory Health Insurance Fund (MHIF)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%. Enrollees are free to choose a family group practice for their primary care and they can switch once per year during the annual registration period. In large urban settings, practices that offer higher quality services will attract a larger number of patients, leading to higher capitation payments for the practice. Rural areas, however, have too few providers in order to create this type of quality incentive. After the primary care reforms created the undergraduate, postgraduate, and continuing education curricula, the number of primary care physicians rose significantly from 5.8 per 1,000 population in 2001 to 8.2 per 1,000 population in 2005. Furthermore, by the end of 2004, 75 percent of primary care physicians and nurses had been retrained as family physicians and family medicine nurses. Kyrgyzstan has three types of primary care providers. First, the core of the old rural health system, Feldsher-Obstetric Ambulatory Points (FAPs) are facilities in the most remote reaches of the country that offer basic services such as neonatal care, immunizations, and health education. As of 2006 there were 875 FAPs across Kyrgyzstan, each serving between 500 and 2,000 people. Second, Family Group Practices (FGPs) are the major providers of primary care in Kyrgyzstan. FGPs are normally made up of three to five doctors. They can be freestanding and autonomous entities or units within large hospital polyclinics. Finally, Family Medicine Centers (FMCs) are large outpatient facilities staffed by varying numbers of specialists, often 10 to 20 health care professionals in addition to their affiliated FGPs. Their service offerings range from primary care to specialized care, including instrumental diagnostics. In 2006, approximately 93% of FAPs and 96% of FGPs were part of Family Medicine Centers. Secondary care is provided by hospitals at the oblast level (generally one oblast merged hospital in each oblast), and by territorial hospitals in rayons and cities (51 hospitals nationally). The main difference between these two types of hospitals lies in the variety and complexity of conditions that they can handle. Tertiary care that provides highly specialized services is conducted in eight central-level hospitals. In terms of legal organization, most health care organizations tend to be public. The exceptions are optic, dental, urologic, and gynecological services, which tend to be private facilities and are mostly concentrated in the capital city of Bishkek. |
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| Ghana: National Health Insurance Scheme (NHIS) |
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1368 | 966 |
In order to provide the basic package of services, NHIS covers both public and private health care providers at all levels of the health system, subject to their accreditation by the NHIA. As of December 2009, 966 private, 1,368 public and 163 CHAG providers were enrolled in NHIS. Read full sectionIn order to provide the basic package of services, NHIS covers both public and private health care providers at all levels of the health system, subject to their accreditation by the NHIA. As of December 2009, 966 private, 1,368 public and 163 CHAG providers were enrolled in NHIS. At present all public facilities have been given a provisional accreditation and 800 private providers (many of them pharmacies and ‘chemical shops’) have been accredited by the NHIA. National Health Insurance Regulations (LI 1809, Regulation 19 (1)) state that the first point of attendance for accessing health care under the NHIS should be a primary healthcare facility. This includes CHPS, health centers, district hospitals, polyclinics, quasi public hospitals, private hospitals, clinics and maternity homes. Where the only facility is a Regional Hospital, it will also be considered a primary healthcare facility. In emergencies, any accredited healthcare facility may be utilized. National Health Insurance Scheme (NHIS)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 1368
Number of non-state providers: 966 In order to provide the basic package of services, NHIS covers both public and private health care providers at all levels of the health system, subject to their accreditation by the NHIA. As of December 2009, 966 private, 1,368 public and 163 CHAG providers were enrolled in NHIS. At present all public facilities have been given a provisional accreditation and 800 private providers (many of them pharmacies and ‘chemical shops’) have been accredited by the NHIA. National Health Insurance Regulations (LI 1809, Regulation 19 (1)) state that the first point of attendance for accessing health care under the NHIS should be a primary healthcare facility. This includes CHPS, health centers, district hospitals, polyclinics, quasi public hospitals, private hospitals, clinics and maternity homes. Where the only facility is a Regional Hospital, it will also be considered a primary healthcare facility. In emergencies, any accredited healthcare facility may be utilized. |
| Nigeria: National Health Insurance System |
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The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
In addition, an accreditation fee is required. Currently 61 HMOs have been accredited and registered by NHIS in addition to about 6,000 primary care providers, 1,000 ancillary providers, and over 600 secondary and tertiary providers. Recently the NHIS announced the suspension of accreditation of new HMOs and providers because there is a need to strengthen the scheme and improve quality of healthcare services delivery through reaccreditation. In general, the service delivery system in Nigeria is organized on a tiered basis:
The service delivery system is mixed between private and public providers. The private health care system has grown substantially since the 1980s, to currently provide about 80% of the total health services. This sector, however, is not well regulated or supported. Of all the private facilities in Nigeria, about 50% are for-profit. Despite the large number of service providers, coverage of most key preventative and curative health services is relatively low. There are large disparities in geo-political zones, between rural and urban zones, and with regard to socio-economic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20% of the population. National Health Insurance SystemService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
In addition, an accreditation fee is required. Currently 61 HMOs have been accredited and registered by NHIS in addition to about 6,000 primary care providers, 1,000 ancillary providers, and over 600 secondary and tertiary providers. Recently the NHIS announced the suspension of accreditation of new HMOs and providers because there is a need to strengthen the scheme and improve quality of healthcare services delivery through reaccreditation. In general, the service delivery system in Nigeria is organized on a tiered basis:
The service delivery system is mixed between private and public providers. The private health care system has grown substantially since the 1980s, to currently provide about 80% of the total health services. This sector, however, is not well regulated or supported. Of all the private facilities in Nigeria, about 50% are for-profit. Despite the large number of service providers, coverage of most key preventative and curative health services is relatively low. There are large disparities in geo-political zones, between rural and urban zones, and with regard to socio-economic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20% of the population. |
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| Kenya: National Hospital Insurance Fund |
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150 | 450 |
National Hospital Insurance Fund contracts with about 600 health facilities that are managed by both the public and private sector throughout Kenya’s 8 provinces. About 150 of these facilities are state-run, while the remaining hospitals are managed by private and mission organizations. Individuals who are members of NHIF are able to access their benefits at any of the hospitals affiliated with NHIF regardless of locations. Read full sectionNational Hospital Insurance Fund contracts with about 600 health facilities that are managed by both the public and private sector throughout Kenya’s 8 provinces. About 150 of these facilities are state-run, while the remaining hospitals are managed by private and mission organizations. Individuals who are members of NHIF are able to access their benefits at any of the hospitals affiliated with NHIF regardless of locations. NHIF has an accreditation and contracting process with is administered at the branch level of the NHIF. This process begins with the hospital submitting an application to join the NHIF network. The NHIF branch manager then visits the hospital and uses a master checklist to rate the hospital based on a diverse set of standards including physical infrastructure, personnel, and services offered. The NHIF then works with hospital management to set up a Quality training process and a Quality improvement program, and train hospital staff on the operational procedures of the NHIF. Contracts are generally signed for a period of 2 years, with evaluations by the NHIF branch management at 6-month intervals which are submitted to the NHIF board for review. Outpatient services are not currently covered by the NHIF. In 2008 there were 4,700 health facilities nationwide, 51% of which were owned and operated by the central government, 34% were operated privately, and 15% were maintained by non-governmental organizations, foreign-based organizations, or religious groups. The private sector provides about 60% of the total medical equipment and supplies. The private sector plays a large role healthcare system, especially in the field of facilities and personnel; 47% of the poorest quintile of Kenyans uses a private facility when a child is sick. All health facilities are integrated in a hierarchy with the most sophisticated services available at the national level. The next best level of care is found in the provincial hospitals, followed by sub-district hospitals. At local and sub location levels service is provided through health centers and dispensaries, these account for about 85% of all health facilities in the country. The focus on decentralization has delegated increasing amounts of daily management to the community and district levels as the health system has progressed. The quality of care provided by health facilities is unequally distributed across the country; only 30% of the rural population has access to health facilities within 4 kilometers, while such access is available to 70% of urban dwellers. National Hospital Insurance FundService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 150
Number of non-state providers: 450 National Hospital Insurance Fund contracts with about 600 health facilities that are managed by both the public and private sector throughout Kenya’s 8 provinces. About 150 of these facilities are state-run, while the remaining hospitals are managed by private and mission organizations. Individuals who are members of NHIF are able to access their benefits at any of the hospitals affiliated with NHIF regardless of locations. NHIF has an accreditation and contracting process with is administered at the branch level of the NHIF. This process begins with the hospital submitting an application to join the NHIF network. The NHIF branch manager then visits the hospital and uses a master checklist to rate the hospital based on a diverse set of standards including physical infrastructure, personnel, and services offered. The NHIF then works with hospital management to set up a Quality training process and a Quality improvement program, and train hospital staff on the operational procedures of the NHIF. Contracts are generally signed for a period of 2 years, with evaluations by the NHIF branch management at 6-month intervals which are submitted to the NHIF board for review. Outpatient services are not currently covered by the NHIF. In 2008 there were 4,700 health facilities nationwide, 51% of which were owned and operated by the central government, 34% were operated privately, and 15% were maintained by non-governmental organizations, foreign-based organizations, or religious groups. The private sector provides about 60% of the total medical equipment and supplies. The private sector plays a large role healthcare system, especially in the field of facilities and personnel; 47% of the poorest quintile of Kenyans uses a private facility when a child is sick. All health facilities are integrated in a hierarchy with the most sophisticated services available at the national level. The next best level of care is found in the provincial hospitals, followed by sub-district hospitals. At local and sub location levels service is provided through health centers and dispensaries, these account for about 85% of all health facilities in the country. The focus on decentralization has delegated increasing amounts of daily management to the community and district levels as the health system has progressed. The quality of care provided by health facilities is unequally distributed across the country; only 30% of the rural population has access to health facilities within 4 kilometers, while such access is available to 70% of urban dwellers. |
| Philippines: PhilHealth |
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The service delivery system includes both public and private centers; on average, the network is comprised of 61% private and 39% public providers. Read full sectionThe service delivery system includes both public and private centers; on average, the network is comprised of 61% private and 39% public providers. In order to achieve accreditation, all in-network hospitals and day-surgery centers must be licensed by the Department of Health. The network includes hospitals, day surgery centers, maternity care clinics, midwife-operated clinics, freestanding dialysis centers, physician clinics, dentists doing procedures in hospitals and day surgeries, government-run health centers for primary care benefits, TB DOTS and malaria, and private TB-DOTS clinics. Non-hospitals and day-surgery centers are not required to be licensed by the DOH; however, all facilities are evaluated by an accreditation team from PhilHealth. PhilHealthService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The service delivery system includes both public and private centers; on average, the network is comprised of 61% private and 39% public providers. In order to achieve accreditation, all in-network hospitals and day-surgery centers must be licensed by the Department of Health. The network includes hospitals, day surgery centers, maternity care clinics, midwife-operated clinics, freestanding dialysis centers, physician clinics, dentists doing procedures in hospitals and day surgeries, government-run health centers for primary care benefits, TB DOTS and malaria, and private TB-DOTS clinics. Non-hospitals and day-surgery centers are not required to be licensed by the DOH; however, all facilities are evaluated by an accreditation team from PhilHealth. |
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| India: RSBY |
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551 | 1516 |
As of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers. Read full sectionAs of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers. After an insurance company is selected by the state, the insurance company is tasked with empaneling/certifying both public and private care providers in the program. The process is based on prescribed criteria (e.g., the service providers should possess specified basic facilities, like: have at least 10 inpatient medical beds; have specified medical and surgical facilities and diagnostic facilities, etc.). In addition, hospitals must agree to need to install necessary hardware and software to be able to process beneficiaries’ SmartCard transactions. They must also set up a dedicated RSBY desk with trained staff. The insurer must empanel enough hospitals in each district so that beneficiaries do not need to travel great distances to get to health care services. For empanelment of public hospitals, the insurer needs to coordinate with the respective health department of the state. Once a hospital is empanelled, a nationally-unique hospital ID number is generated so that transactions can be tracked at each hospital. Each empanelled hospital is connected with the district server of the insurance company and thus able to transfer data related to hospitalization on a daily basis. RSBYService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 551
Number of non-state providers: 1516 As of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers. After an insurance company is selected by the state, the insurance company is tasked with empaneling/certifying both public and private care providers in the program. The process is based on prescribed criteria (e.g., the service providers should possess specified basic facilities, like: have at least 10 inpatient medical beds; have specified medical and surgical facilities and diagnostic facilities, etc.). In addition, hospitals must agree to need to install necessary hardware and software to be able to process beneficiaries’ SmartCard transactions. They must also set up a dedicated RSBY desk with trained staff. The insurer must empanel enough hospitals in each district so that beneficiaries do not need to travel great distances to get to health care services. For empanelment of public hospitals, the insurer needs to coordinate with the respective health department of the state. Once a hospital is empanelled, a nationally-unique hospital ID number is generated so that transactions can be tracked at each hospital. Each empanelled hospital is connected with the district server of the insurance company and thus able to transfer data related to hospitalization on a daily basis. |