UHC Forward: Towards Universal Health Coverage

Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:

• Primary care offered by family doctors who are either private entities or salaried employees of private firms owned by family doctors. Family doctors contract with the EHIF for the care of their patient list. The average number of patients on a practice list equaled 1,800 in 2008. Family doctors are responsible for referring patients to specialist care.
• Emergency care
• Specialized medical care, most of which is in the hands of private entities within the different specialties. Patients can freely access certain specialties such as ophthalmology, gynecology, psychiatry, dentistry, and pulmonology in the case of TB. If a patient seeks the care of a specialist outside of those previously mentioned they must pay out of pocket for services.
• Nursing care

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.

Taiwan has a market-driven health care delivery system with a mix of publicly and privately owned hospitals. The National Health Insurance (NHI) program provides medical services to the insured population through contracts between the Bureau of National Health Insurance (BNHI) and providers, including hospitals, clinics, pharmacies, medical laboratories, and home nursing care. For hospitals and dental clinics, the contracted rate is 98% of all health facilities in Taiwan, suggesting that the contract serves as a comprehensive and inclusive network for consumers to access providers’ services. The contracted rate of clinics for both Western medicine and Chinese medicine are in the range of 84 to 90%. The broad and inclusive range of institutions that contract with NHI allows patients to see almost any doctor within the country.

Most health providers operate in the private sector and form a competitive market. Citizens have almost complete freedom of choice among providers and therapies. There is no rationing of care, no referral system, and patients are also allowed to seek out care at tertiary institutions regardless of the severity or nature of their illness. This has allowed patients large degrees of freedom in provider choice. However, doctors who practice in private clinics do not have hospital admitting privileges, thus hospitals have developed large outpatient departments and affiliated clinics for primary care, to maintain inpatient flows. Many private clinics also maintain about a dozen beds for their patients. One criticism of this system is that its delivery system is somewhat fragmented, because private physicians can practice, but have no hospital admitting privileges. This occasionally results in duplicative facilities and equipment, and can disrupt continuity of care.

Table 1: Health Service Delivery System in Taiwan, 2004

Source: Health Statistics (2006)

In total, there are about 5.7 beds per thousand people, 35% of which are public and 65% are private. In 2000, about 86% of hospitals were privately owned. Doctors in Taiwan are either salaried staff physicians in the hospitals or self-employed owners of clinics. A majority of clinics, about 97%, are privately owned. About 63% of physicians are employed by hospitals and paid on a salaried basis and the remaining 36% of doctors are private practitioners.

Since the NHI’s inception in 1995, the capacity and use of Taiwan’s health care system has expanded. While Taiwan’s population grew by 5.2% between 1994 and 2000, the supply of health professionals overall increased by 39.6%, and the number of physicians increased by 33.5%. Over the same period the number of hospital beds increased by 32.3%. While Taiwan’s population grew 5.2% between 1994 and 2000, the volume of hospital outpatient visits increased by 16.6%, emergency room visits by 42.2%, outpatient surgery by 56.4%, and inpatient hospitalization by 18%. With the exception of certain costly high-tech treatments which require prior authorization from BNHI, there are effectively no ceilings on utilization, which has resulted in high health care usage rates, especially for outpatient care.

The use of services has expanded unevenly across hospital types and locations. Services in low income and remote areas are not well-distributed and offer varying degrees of service. While the overall ratio of physicians per 1,000 people in 2001 was 1.37, it was only 0.33 among Taiwan’s aboriginal people and 0.8 in the mountainous areas and offshore islands. BNHI has since introduced incentives for providers to practice in remote areas and has exempted cost sharing for the poor and for those who live in remote areas.

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.

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.