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 |
|---|---|---|---|---|
| Colombia: General System of Social Security in Health |
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One of the central aspects of the 1993 reform involved separating the financing, stewardship, and delivery functions within the health system. While hospitals still receive some supply-side subsidies through the SGP, the spirit of the reform is to eventually transform them into demand-side subsidies. Health service providers must now compete on the basis of quality for the majority of services provided. Under this scheme EPSs and EPSSs negotiate contracts with service providers. They also coordinate service delivery between patients and a network of public and private providers. Preventive and primary care services are primarily contracted by capitation, with EPSs providing such services through vertically integrated networks and EPSSs providing such services mainly through public hospitals. Most specialist and hospital care is paid for either by service packages or on a fee-for-service basis. Read full sectionOne of the central aspects of the 1993 reform involved separating the financing, stewardship, and delivery functions within the health system. While hospitals still receive some supply-side subsidies through the SGP, the spirit of the reform is to eventually transform them into demand-side subsidies. Health service providers must now compete on the basis of quality for the majority of services provided. Under this scheme EPSs and EPSSs negotiate contracts with service providers. They also coordinate service delivery between patients and a network of public and private providers. Preventive and primary care services are primarily contracted by capitation, with EPSs providing such services through vertically integrated networks and EPSSs providing such services mainly through public hospitals. Most specialist and hospital care is paid for either by service packages or on a fee-for-service basis. Colombia’s provider market features two levels of market competition. On the first level, enrollees choose their EPS or EPSS based on the quality of its provider network. On the second level, the EPSs and EPSSs select their provider network based on their price and quality. Therefore, there are real incentives within the system for providers to supply better quality services at lower prices. Services are organized by levels of care. The first level includes facilities that offer general medicine. This level is supposed to provide the majority of services. The second level comprises providers of basic specialized medical and surgical services. Finally, the third level includes institutions that provide specialty and sub-specialty care as well as high complexity hospitalization. Providers must meet minimum quality, financial, and administrative standards that are enforced by the Ministry of Social Protection (MPS). Providers must also register at the local health authority, which issues a three year certificate. The health authority verification is met through an on-site inspection. Furthermore, since 2002 the Obligatory System to Guarantee the Quality of Health Services (SOGCS) has helped to maintain and improve the quality of health services by focusing on accreditation, audit, and information management. In terms of monitoring service providers, Law 100 mandated the establishment of a compulsory quality assurance system. However, the creation of such a mechanism lagged behind the implementation of other facets of the reform. In 2002, a quality assurance system was finally implemented that introduced a licensing and accreditation process for both public and private facilities. And in 2006 a systematic dissemination of hospitals’ quality began to take place on a regular basis. General System of Social Security in HealthService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: One of the central aspects of the 1993 reform involved separating the financing, stewardship, and delivery functions within the health system. While hospitals still receive some supply-side subsidies through the SGP, the spirit of the reform is to eventually transform them into demand-side subsidies. Health service providers must now compete on the basis of quality for the majority of services provided. Under this scheme EPSs and EPSSs negotiate contracts with service providers. They also coordinate service delivery between patients and a network of public and private providers. Preventive and primary care services are primarily contracted by capitation, with EPSs providing such services through vertically integrated networks and EPSSs providing such services mainly through public hospitals. Most specialist and hospital care is paid for either by service packages or on a fee-for-service basis. Colombia’s provider market features two levels of market competition. On the first level, enrollees choose their EPS or EPSS based on the quality of its provider network. On the second level, the EPSs and EPSSs select their provider network based on their price and quality. Therefore, there are real incentives within the system for providers to supply better quality services at lower prices. Services are organized by levels of care. The first level includes facilities that offer general medicine. This level is supposed to provide the majority of services. The second level comprises providers of basic specialized medical and surgical services. Finally, the third level includes institutions that provide specialty and sub-specialty care as well as high complexity hospitalization. Providers must meet minimum quality, financial, and administrative standards that are enforced by the Ministry of Social Protection (MPS). Providers must also register at the local health authority, which issues a three year certificate. The health authority verification is met through an on-site inspection. Furthermore, since 2002 the Obligatory System to Guarantee the Quality of Health Services (SOGCS) has helped to maintain and improve the quality of health services by focusing on accreditation, audit, and information management. In terms of monitoring service providers, Law 100 mandated the establishment of a compulsory quality assurance system. However, the creation of such a mechanism lagged behind the implementation of other facets of the reform. In 2002, a quality assurance system was finally implemented that introduced a licensing and accreditation process for both public and private facilities. And in 2006 a systematic dissemination of hospitals’ quality began to take place on a regular basis. |
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| Indonesia: Jamkesmas |
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926 | 220 |
Jamkesmas beneficiaries are able to seek care at both public and private outlets, though covered ambulatory services are solely public. The scheme contracts with 926 hospitals for service provision, including 220 private hospitals for certain procedures. Health services across each public scheme in Indonesia are delivered by a mix of providers, with most schemes relying heavily on the public sector for delivery of care. Read full sectionJamkesmas beneficiaries are able to seek care at both public and private outlets, though covered ambulatory services are solely public. The scheme contracts with 926 hospitals for service provision, including 220 private hospitals for certain procedures. Health services across each public scheme in Indonesia are delivered by a mix of providers, with most schemes relying heavily on the public sector for delivery of care. JamkesmasService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 926
Number of non-state providers: 220 Jamkesmas beneficiaries are able to seek care at both public and private outlets, though covered ambulatory services are solely public. The scheme contracts with 926 hospitals for service provision, including 220 private hospitals for certain procedures. Health services across each public scheme in Indonesia are delivered by a mix of providers, with most schemes relying heavily on the public sector for delivery of care. |
| 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. |
| 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. |