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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| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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The reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%. Read full sectionThe reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%. Enrollees are free to choose a family group practice for their primary care and they can switch once per year during the annual registration period. In large urban settings, practices that offer higher quality services will attract a larger number of patients, leading to higher capitation payments for the practice. Rural areas, however, have too few providers in order to create this type of quality incentive. After the primary care reforms created the undergraduate, postgraduate, and continuing education curricula, the number of primary care physicians rose significantly from 5.8 per 1,000 population in 2001 to 8.2 per 1,000 population in 2005. Furthermore, by the end of 2004, 75 percent of primary care physicians and nurses had been retrained as family physicians and family medicine nurses. Kyrgyzstan has three types of primary care providers. First, the core of the old rural health system, Feldsher-Obstetric Ambulatory Points (FAPs) are facilities in the most remote reaches of the country that offer basic services such as neonatal care, immunizations, and health education. As of 2006 there were 875 FAPs across Kyrgyzstan, each serving between 500 and 2,000 people. Second, Family Group Practices (FGPs) are the major providers of primary care in Kyrgyzstan. FGPs are normally made up of three to five doctors. They can be freestanding and autonomous entities or units within large hospital polyclinics. Finally, Family Medicine Centers (FMCs) are large outpatient facilities staffed by varying numbers of specialists, often 10 to 20 health care professionals in addition to their affiliated FGPs. Their service offerings range from primary care to specialized care, including instrumental diagnostics. In 2006, approximately 93% of FAPs and 96% of FGPs were part of Family Medicine Centers. Secondary care is provided by hospitals at the oblast level (generally one oblast merged hospital in each oblast), and by territorial hospitals in rayons and cities (51 hospitals nationally). The main difference between these two types of hospitals lies in the variety and complexity of conditions that they can handle. Tertiary care that provides highly specialized services is conducted in eight central-level hospitals. In terms of legal organization, most health care organizations tend to be public. The exceptions are optic, dental, urologic, and gynecological services, which tend to be private facilities and are mostly concentrated in the capital city of Bishkek. Mandatory Health Insurance Fund (MHIF)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%. Enrollees are free to choose a family group practice for their primary care and they can switch once per year during the annual registration period. In large urban settings, practices that offer higher quality services will attract a larger number of patients, leading to higher capitation payments for the practice. Rural areas, however, have too few providers in order to create this type of quality incentive. After the primary care reforms created the undergraduate, postgraduate, and continuing education curricula, the number of primary care physicians rose significantly from 5.8 per 1,000 population in 2001 to 8.2 per 1,000 population in 2005. Furthermore, by the end of 2004, 75 percent of primary care physicians and nurses had been retrained as family physicians and family medicine nurses. Kyrgyzstan has three types of primary care providers. First, the core of the old rural health system, Feldsher-Obstetric Ambulatory Points (FAPs) are facilities in the most remote reaches of the country that offer basic services such as neonatal care, immunizations, and health education. As of 2006 there were 875 FAPs across Kyrgyzstan, each serving between 500 and 2,000 people. Second, Family Group Practices (FGPs) are the major providers of primary care in Kyrgyzstan. FGPs are normally made up of three to five doctors. They can be freestanding and autonomous entities or units within large hospital polyclinics. Finally, Family Medicine Centers (FMCs) are large outpatient facilities staffed by varying numbers of specialists, often 10 to 20 health care professionals in addition to their affiliated FGPs. Their service offerings range from primary care to specialized care, including instrumental diagnostics. In 2006, approximately 93% of FAPs and 96% of FGPs were part of Family Medicine Centers. Secondary care is provided by hospitals at the oblast level (generally one oblast merged hospital in each oblast), and by territorial hospitals in rayons and cities (51 hospitals nationally). The main difference between these two types of hospitals lies in the variety and complexity of conditions that they can handle. Tertiary care that provides highly specialized services is conducted in eight central-level hospitals. In terms of legal organization, most health care organizations tend to be public. The exceptions are optic, dental, urologic, and gynecological services, which tend to be private facilities and are mostly concentrated in the capital city of Bishkek. |
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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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| 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. |
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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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| 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. |