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 | ||||||||||||||||||||||||||||||
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| Vietnam: Compulsory and Voluntary Health Insurance Schemes |
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980 | 85 |
Beneficiaries of the national health insurance scheme are able to seek care at all public facilities. Additionally, the VSS has begun contracting with a small number private providers. Of those currently registered with the VSS, the majority are general practitioner clinics. Enrollees in all public schemes are required to register with a local facility and are expected to use that facility when they require treatment. Referrals are sanctioned when the registered facility lacks the necessary expertise to treat the patient’s condition. Health services in Vietnam are delivered by both public and private providers. Read full sectionBeneficiaries of the national health insurance scheme are able to seek care at all public facilities. Additionally, the VSS has begun contracting with a small number private providers. Of those currently registered with the VSS, the majority are general practitioner clinics. Enrollees in all public schemes are required to register with a local facility and are expected to use that facility when they require treatment. Referrals are sanctioned when the registered facility lacks the necessary expertise to treat the patient’s condition. Health services in Vietnam are delivered by both public and private providers. The health public care network is organized under state administrative units: central, provincial, district, commune and village level, with the MoH at the central level. In the public sector, there are 980 hospitals (39 central, 331 provincial and 610 district hospitals) and 11,544 primary health centers. Communes Health Centers (CHCs) provide primary health care services, including consultation, outbreak prevention and surveillance, treatment of common diseases, maternal and child health care, family planning, hygiene, and health promotion. Although CHCs are widespread, they are underutilized. On average, a CHC serves just 7,000 people. Hospitals, on the other hand, exhibit high occupancy rates, often exceeding 100%. This trend may reflect perceptions in quality of care, or may represent the strong bias in reimbursements towards higher-level facilities and inpatient care. Across Vietnam, there are approximately 35,000 private clinics and 85 private hospitals, accounting for 8.7 % of the total number of hospitals nationwide, with 5,800 beds, accounting for 3.8% of the total number of hospital beds nationwide. VSS has begun contracting with private providers, but they still represent a small portion of care provided under the national insurance program. Of private providers registered with VSS, general practitioner clinics represent the largest groups. VSS reimburses approved facilities, which include all public facilities and some contracted private facilities. Enrollees may also use non-contracted facilities, including providers abroad, but reimbursement in this case is to the patient, who pays the facility directly and subsequently files a claim, and is limited to the costs incurred on average by public facilities in Vietnam. Compulsory and Voluntary Health Insurance SchemesService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 980
Number of non-state providers: 85 Beneficiaries of the national health insurance scheme are able to seek care at all public facilities. Additionally, the VSS has begun contracting with a small number private providers. Of those currently registered with the VSS, the majority are general practitioner clinics. Enrollees in all public schemes are required to register with a local facility and are expected to use that facility when they require treatment. Referrals are sanctioned when the registered facility lacks the necessary expertise to treat the patient’s condition. Health services in Vietnam are delivered by both public and private providers. The health public care network is organized under state administrative units: central, provincial, district, commune and village level, with the MoH at the central level. In the public sector, there are 980 hospitals (39 central, 331 provincial and 610 district hospitals) and 11,544 primary health centers. Communes Health Centers (CHCs) provide primary health care services, including consultation, outbreak prevention and surveillance, treatment of common diseases, maternal and child health care, family planning, hygiene, and health promotion. Although CHCs are widespread, they are underutilized. On average, a CHC serves just 7,000 people. Hospitals, on the other hand, exhibit high occupancy rates, often exceeding 100%. This trend may reflect perceptions in quality of care, or may represent the strong bias in reimbursements towards higher-level facilities and inpatient care. Across Vietnam, there are approximately 35,000 private clinics and 85 private hospitals, accounting for 8.7 % of the total number of hospitals nationwide, with 5,800 beds, accounting for 3.8% of the total number of hospital beds nationwide. VSS has begun contracting with private providers, but they still represent a small portion of care provided under the national insurance program. Of private providers registered with VSS, general practitioner clinics represent the largest groups. VSS reimburses approved facilities, which include all public facilities and some contracted private facilities. Enrollees may also use non-contracted facilities, including providers abroad, but reimbursement in this case is to the patient, who pays the facility directly and subsequently files a claim, and is limited to the costs incurred on average by public facilities in Vietnam. |
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| 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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| Rwanda: Mutuelles de Sante |
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165 | 411 |
Mutuelle members are able to access health care through all public and private non-profit health centers in Rwanda, which excludes only 10% of the country’s health care facilities that are private and for-profit. A recent law titled the Patient Roaming System was passed allowing any Mutuelle member to seek health care at any health center throughout the country. However, this has not been realized in practice as the capacity to transfer bills and funds is still limited, despite ambitions for more e-health solutions. Read full sectionMutuelle members are able to access health care through all public and private non-profit health centers in Rwanda, which excludes only 10% of the country’s health care facilities that are private and for-profit. A recent law titled the Patient Roaming System was passed allowing any Mutuelle member to seek health care at any health center throughout the country. However, this has not been realized in practice as the capacity to transfer bills and funds is still limited, despite ambitions for more e-health solutions. Rwanda has about 411 private and public health centers in total, which deliver primary and secondary care at the sector and district level. Facilities are run by for-profit entities, traditional healers, non-governmental agencies, and governmentally-assisted health organizations. Public Governmentally Assisted Health Facilities (GAHFs) are run by NGOs, religious groups, and other third parties and are partially funded by the central government. These account for approximately 40% of all primary and secondary care facilities. Primary care includes out-patient services, in-patient services, and preventive services such as immunizations, while secondary care is provided by district hospitals, which are responsible for more specialized procedures such as surgery, management of complicated cases such as severe malaria, organization of health services in health centers, administrative functioning and logistics—including the management of resources and supply of drugs— as well as supervision of community health workers. In addition, six mental health operational poles in district hospitals have been established and 30 district hospitals have integrated mental healthcare into the system. Each district health center serves approximately 200,000 people, with an average of one bed per every 1,000 people. However, these figures mask substantial variation between districts and provinces, which range from 70,000 to 480,000 people served per district. In 2006 Rwanda purchased 51 ambulances and 270 motorcycles for the district level health centers. Tertiary care is delivered at the national level at one of the few specialized, national medical institutions. There are only 4 tertiary care hospitals in Rwanda, 3 public and 1 private. While national hospitals should primarily serve as referral hospitals, in reality there is substantial overlap due to unclear delineation of responsibilities. Currently, individuals are considered to have access to medical centers if services can be reached within one and half hours by foot; approximately 85% of the population falls into this category. For the 15% of individuals living in rural areas, telemedicine is currently being used to reach geographically isolated regions. Pharmacies make generic medications available through the independent purchasing supply house called the Central Purchasing of Essential Drugs, Medical Consumables and Equipment in Rwanda (Centrale d’Achat des Medicaments Essentiels au Rwnda or CAMERWA), a non-profit organization that sells medications to district pharmacies and health facilities as a means of financing the activities of CAMERWA. The government fully finances vaccines and immunizations with the Expanded Programme on Immunizations. The table below summarizes the growth in the number of health facilities in Rwanda since the 1980s.
Mutuelles de SanteService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 165
Number of non-state providers: 411 Mutuelle members are able to access health care through all public and private non-profit health centers in Rwanda, which excludes only 10% of the country’s health care facilities that are private and for-profit. A recent law titled the Patient Roaming System was passed allowing any Mutuelle member to seek health care at any health center throughout the country. However, this has not been realized in practice as the capacity to transfer bills and funds is still limited, despite ambitions for more e-health solutions. Rwanda has about 411 private and public health centers in total, which deliver primary and secondary care at the sector and district level. Facilities are run by for-profit entities, traditional healers, non-governmental agencies, and governmentally-assisted health organizations. Public Governmentally Assisted Health Facilities (GAHFs) are run by NGOs, religious groups, and other third parties and are partially funded by the central government. These account for approximately 40% of all primary and secondary care facilities. Primary care includes out-patient services, in-patient services, and preventive services such as immunizations, while secondary care is provided by district hospitals, which are responsible for more specialized procedures such as surgery, management of complicated cases such as severe malaria, organization of health services in health centers, administrative functioning and logistics—including the management of resources and supply of drugs— as well as supervision of community health workers. In addition, six mental health operational poles in district hospitals have been established and 30 district hospitals have integrated mental healthcare into the system. Each district health center serves approximately 200,000 people, with an average of one bed per every 1,000 people. However, these figures mask substantial variation between districts and provinces, which range from 70,000 to 480,000 people served per district. In 2006 Rwanda purchased 51 ambulances and 270 motorcycles for the district level health centers. Tertiary care is delivered at the national level at one of the few specialized, national medical institutions. There are only 4 tertiary care hospitals in Rwanda, 3 public and 1 private. While national hospitals should primarily serve as referral hospitals, in reality there is substantial overlap due to unclear delineation of responsibilities. Currently, individuals are considered to have access to medical centers if services can be reached within one and half hours by foot; approximately 85% of the population falls into this category. For the 15% of individuals living in rural areas, telemedicine is currently being used to reach geographically isolated regions. Pharmacies make generic medications available through the independent purchasing supply house called the Central Purchasing of Essential Drugs, Medical Consumables and Equipment in Rwanda (Centrale d’Achat des Medicaments Essentiels au Rwnda or CAMERWA), a non-profit organization that sells medications to district pharmacies and health facilities as a means of financing the activities of CAMERWA. The government fully finances vaccines and immunizations with the Expanded Programme on Immunizations. The table below summarizes the growth in the number of health facilities in Rwanda since the 1980s.
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| Chile: National Health Fund (FONASA) |
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In 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Read full sectionIn 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Chile’s service delivery system is composed of 26 autonomous health authorities responsible for hospital care. Primary health care was decentralized down to the level of the municipality. In Chile, 80% of hospital beds are public. FONASA is required to purchase most of its health services from public institutions, although it does provide a subsidy to its enrollees wishing to purchase services from private providers. Public health care providers must sell most of their services to FONASA and have strict guidelines on the type and number of services they can make available to private patients or ISAPRE beneficiaries. FONASA categories B, C, and D can elect to receive care outside of the public system for a higher co-payment. Category A enrollees must receive services from the public provider system. Of all the AUGE procedures carried out, 86% are conducted at the primary health level. Meanwhile, of the AUGE procedures for FONASA beneficiaries performed in the private sector, 90% correspond to dialysis treatment. Whenever there is a risk of falling behind on the guarantees, services must be purchased from elsewhere. For example, in the case of cancer a public hospital will normally purchase services from another public hospital. In the case of cataracts, however, a public hospital will normally purchase services from the private sector. The AUGE plan has changed the manner in which health service delivery is viewed. In the past, supply determined how many cataract interventions were performed based on the internal capacity of the institution. But now, with certain services explicitly guaranteed, the health system has to detect the prevalence of cataracts and determine how to best reorganize resources in order to satisfy demand. Chile has also instituted a free telephone line that responds to inquiries regarding a number of different health situations. It is staffed by a team that has the ability to provide medical advice and set up consultations. This service has led to a significant reduction in emergency room visits, as problems that are deemed non-urgent can be resolved through primary care personnel. Finally, it is worth noting that ISAPREs are not allowed to provide health services directly to their enrollees. They must rely on horizontal networks of health care providers and hospitals for the delivery of services. National Health Fund (FONASA)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: In 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Chile’s service delivery system is composed of 26 autonomous health authorities responsible for hospital care. Primary health care was decentralized down to the level of the municipality. In Chile, 80% of hospital beds are public. FONASA is required to purchase most of its health services from public institutions, although it does provide a subsidy to its enrollees wishing to purchase services from private providers. Public health care providers must sell most of their services to FONASA and have strict guidelines on the type and number of services they can make available to private patients or ISAPRE beneficiaries. FONASA categories B, C, and D can elect to receive care outside of the public system for a higher co-payment. Category A enrollees must receive services from the public provider system. Of all the AUGE procedures carried out, 86% are conducted at the primary health level. Meanwhile, of the AUGE procedures for FONASA beneficiaries performed in the private sector, 90% correspond to dialysis treatment. Whenever there is a risk of falling behind on the guarantees, services must be purchased from elsewhere. For example, in the case of cancer a public hospital will normally purchase services from another public hospital. In the case of cataracts, however, a public hospital will normally purchase services from the private sector. The AUGE plan has changed the manner in which health service delivery is viewed. In the past, supply determined how many cataract interventions were performed based on the internal capacity of the institution. But now, with certain services explicitly guaranteed, the health system has to detect the prevalence of cataracts and determine how to best reorganize resources in order to satisfy demand. Chile has also instituted a free telephone line that responds to inquiries regarding a number of different health situations. It is staffed by a team that has the ability to provide medical advice and set up consultations. This service has led to a significant reduction in emergency room visits, as problems that are deemed non-urgent can be resolved through primary care personnel. Finally, it is worth noting that ISAPREs are not allowed to provide health services directly to their enrollees. They must rely on horizontal networks of health care providers and hospitals for the delivery of services. |
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| Korea, Rep.: National Health Insurance Program |
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Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided for-profit by the private sectorKorean patients with health insurance are able to go to any doctor or medical institution that they choose without being denied, except specialized general hospitals. If a patient wants to go to a secondary or tertiary care hospital, they must present a referral slip issued by the original medical practitioner. The exceptions to this include: childbirth, emergency medical care, dental care, rehabilitation, family medicine, and hemophiliac disease. Higher co-payments are requested for those patients without a referral letter. Read full sectionHealth care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided for-profit by the private sectorKorean patients with health insurance are able to go to any doctor or medical institution that they choose without being denied, except specialized general hospitals. If a patient wants to go to a secondary or tertiary care hospital, they must present a referral slip issued by the original medical practitioner. The exceptions to this include: childbirth, emergency medical care, dental care, rehabilitation, family medicine, and hemophiliac disease. Higher co-payments are requested for those patients without a referral letter. The Medical Law stipulates that only authorized and licensed healthcare professionals can provide health services. The Ministry of Health and Welfare (MoHW) licenses only doctors, dentists, nurses, oriental medical doctors, and midwives, while nurse’s aides, acupuncturists, and massage therapists are licensed as quasi-medical professionals. As of 2007, there were 91,400 physicians, 23,114 dentists, 16,663 oriental medical doctors, 57,176 pharmacists, 8,587 midwives, and 235,687 nurses. However, wide disparities exist between urban and rural areas; about 90% of physicians are concentrated in urban areas. Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided (de facto for-profit) by the private sector. The 10% of the public service system are composed of community public health centers known as Bogeunso, the National Medical Center, and provincial hospitals. There has been less of a push from the public sector to formulate policy alternatives to the private sector–dominated delivery system. National Health Insurance ProgramService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided for-profit by the private sectorKorean patients with health insurance are able to go to any doctor or medical institution that they choose without being denied, except specialized general hospitals. If a patient wants to go to a secondary or tertiary care hospital, they must present a referral slip issued by the original medical practitioner. The exceptions to this include: childbirth, emergency medical care, dental care, rehabilitation, family medicine, and hemophiliac disease. Higher co-payments are requested for those patients without a referral letter. The Medical Law stipulates that only authorized and licensed healthcare professionals can provide health services. The Ministry of Health and Welfare (MoHW) licenses only doctors, dentists, nurses, oriental medical doctors, and midwives, while nurse’s aides, acupuncturists, and massage therapists are licensed as quasi-medical professionals. As of 2007, there were 91,400 physicians, 23,114 dentists, 16,663 oriental medical doctors, 57,176 pharmacists, 8,587 midwives, and 235,687 nurses. However, wide disparities exist between urban and rural areas; about 90% of physicians are concentrated in urban areas. Health care delivery relies heavily on the private sector. Only about 10% of hospitals are public, while 90% of total health care resources are provided (de facto for-profit) by the private sector. The 10% of the public service system are composed of community public health centers known as Bogeunso, the National Medical Center, and provincial hospitals. There has been less of a push from the public sector to formulate policy alternatives to the private sector–dominated delivery system. |
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| 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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| Mexico: Seguro Popular |
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The Social Protection in Health Regime (REPSS) at the state level is responsible for forming and coordinating the network of health service providers. In practice, the first option (and often the only one due to political factors or lack of technical competence) is to contract for health services from the network of State Health Services (SESA), followed by limited contracting with the private sector. These contracts are signed on a yearly basis. Out of nine states analyzed in a recent study, only two actively contracted for services with private health care providers. As of 2009, the SP has started buying services from the IMSS-Oportunidades Program and it is expected that contracting for services will extend to both IMSS and ISSSTE. Read full sectionThe Social Protection in Health Regime (REPSS) at the state level is responsible for forming and coordinating the network of health service providers. In practice, the first option (and often the only one due to political factors or lack of technical competence) is to contract for health services from the network of State Health Services (SESA), followed by limited contracting with the private sector. These contracts are signed on a yearly basis. Out of nine states analyzed in a recent study, only two actively contracted for services with private health care providers. As of 2009, the SP has started buying services from the IMSS-Oportunidades Program and it is expected that contracting for services will extend to both IMSS and ISSSTE. Some expect that such contracting schemes will lead to the ultimate financial integration of the system. The reform also created a long-term framework for expanding health care facilities. As of 2006, nearly 1,800 new facilities had been built, including four high-specialty regional hospitals in the least developed regions of Mexico. Service delivery for services that fall under the essential benefits package is decentralized at the state level due to the low-risk, high-probability nature of the interventions. High-cost tertiary care that falls under the FPGC, however, is delivered at regional or national health centers that offer highly specialized services. These types of procedures are often performed at private facilities. Seguro PopularService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The Social Protection in Health Regime (REPSS) at the state level is responsible for forming and coordinating the network of health service providers. In practice, the first option (and often the only one due to political factors or lack of technical competence) is to contract for health services from the network of State Health Services (SESA), followed by limited contracting with the private sector. These contracts are signed on a yearly basis. Out of nine states analyzed in a recent study, only two actively contracted for services with private health care providers. As of 2009, the SP has started buying services from the IMSS-Oportunidades Program and it is expected that contracting for services will extend to both IMSS and ISSSTE. Some expect that such contracting schemes will lead to the ultimate financial integration of the system. The reform also created a long-term framework for expanding health care facilities. As of 2006, nearly 1,800 new facilities had been built, including four high-specialty regional hospitals in the least developed regions of Mexico. Service delivery for services that fall under the essential benefits package is decentralized at the state level due to the low-risk, high-probability nature of the interventions. High-cost tertiary care that falls under the FPGC, however, is delivered at regional or national health centers that offer highly specialized services. These types of procedures are often performed at private facilities. |