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.
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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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| : Taiwan: National Health Insurance |
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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. Read full sectionTaiwan 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 Health InsuranceService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: 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. |
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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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| Thailand: Universal Coverage Scheme |
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The UCS service delivery network includes both public and private health care facilities. However, prior to registration, private health facilities must submit required documentation and are investigated according to standard criteria of the UCS. No similar process exists for public health care facilities and they are automatically registered in the delivery network. Read full sectionThe UCS service delivery network includes both public and private health care facilities. However, prior to registration, private health facilities must submit required documentation and are investigated according to standard criteria of the UCS. No similar process exists for public health care facilities and they are automatically registered in the delivery network. The Thai insurance system is based on the health system that is founded on the principles of primary care. For UCS in particular, primary care provider units (PCUs) have been designated as gatekeepers to provide care for UCS beneficiaries. As gatekeepers, PCUs are expected to provide people in their catchment areas with continuous and comprehensive care with a holistic approach. According to the services provided, health facilities under the UCS can be classified into three groups:
Private health facilities are investigated by the UCS before contracts are signed. There is no such investigation for public health care facilities as they are automatically registered in the delivery network. In principle, UCS beneficiaries are free to choose their primary providers. However, because of limited number of primary providers in rural areas, beneficiaries are assigned mainly to public primary providers close to their communities or their workplaces. Universal Coverage SchemeService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The UCS service delivery network includes both public and private health care facilities. However, prior to registration, private health facilities must submit required documentation and are investigated according to standard criteria of the UCS. No similar process exists for public health care facilities and they are automatically registered in the delivery network. The Thai insurance system is based on the health system that is founded on the principles of primary care. For UCS in particular, primary care provider units (PCUs) have been designated as gatekeepers to provide care for UCS beneficiaries. As gatekeepers, PCUs are expected to provide people in their catchment areas with continuous and comprehensive care with a holistic approach. According to the services provided, health facilities under the UCS can be classified into three groups:
Private health facilities are investigated by the UCS before contracts are signed. There is no such investigation for public health care facilities as they are automatically registered in the delivery network. In principle, UCS beneficiaries are free to choose their primary providers. However, because of limited number of primary providers in rural areas, beneficiaries are assigned mainly to public primary providers close to their communities or their workplaces. |