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 |
|---|---|---|---|---|
| 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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| 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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| 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: Rajiv Aarogyasri |
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98 | 244 |
The Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals. Read full sectionThe Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals. As of January 2010, there were a total of 342 hospitals in the network. The principal reason Aarogyasri Trust decided to work with private providers was the lack of resources in the public system. The government has been unable to attract the needed specialists to public facilities, while the private sector has rapidly expanded high quality healthcare services. A hospital or nursing home in Andhra Pradesh is eligible to be a part of the Aarogyasri network of care, established for indoor medical care and treatment of disease and injuries. The hospital should comply with the following minimum criteria:
All hospitals that qualify to be in-network must sign a memorandum of understanding with the insurance company. This Memorandum is subject to the approval of the Trust. A provision is made in the Memorandum for non-compliance/default; all such matters are looked into by the Trust. From the perspective of beneficiaries, the path to seeking care is made as simple as possible, as indicated in Figure 1.
Rajiv AarogyasriService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 98
Number of non-state providers: 244 The Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals. As of January 2010, there were a total of 342 hospitals in the network. The principal reason Aarogyasri Trust decided to work with private providers was the lack of resources in the public system. The government has been unable to attract the needed specialists to public facilities, while the private sector has rapidly expanded high quality healthcare services. A hospital or nursing home in Andhra Pradesh is eligible to be a part of the Aarogyasri network of care, established for indoor medical care and treatment of disease and injuries. The hospital should comply with the following minimum criteria:
All hospitals that qualify to be in-network must sign a memorandum of understanding with the insurance company. This Memorandum is subject to the approval of the Trust. A provision is made in the Memorandum for non-compliance/default; all such matters are looked into by the Trust. From the perspective of beneficiaries, the path to seeking care is made as simple as possible, as indicated in Figure 1.
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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. |
