UHC Forward: Towards Universal Health Coverage

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.

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.

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.

Primary care delivery happens through primary care units and primary care teams under the Family Health Program (PSF). Primary care units are run by municipalities and are mostly managed by government-employed clinicians. These units are funded on a per capita basis based on the population size within the catchment area. While patients can use clinics outside of their area, they may be encouraged or referred back to their corresponding primary care unit. In some municipalities, primary care units are contracted-out through RFP on a winner-take-all basis to NGOs, who receive similar per capita budgets as government health centers but are not subject to civil service rules. They can more easily hire and fire and some are experimenting with pay for performance mechanisms.

Service delivery within the Family Health Program (PSF) and the Community Health Agents Program (PACS) is the responsibility of the Municipal Health Secretariat. The PSF is the program through which the government reorganized some of the organization and delivery of publicly financed primary health care (In recent years, the PSF has also covered chronic diseases). In essence, it has turned a passive, facility-based delivery system into a dynamic, outreach model in which family healthcare providers deliver care to households and communities. There is a primary care team responsible for a territory of 800-1,000 families, or up to 4,000 people. The team includes a generalist physician, a nurse, a community health agent, and an odontologist or dental hygienist. The team monitors and evaluates the health situation of the population, provides primary care services, and makes referrals to other levels of the system. The number of PSF teams increased from zero in 1994 to close to 32,000 by 2008.

The primary purpose of the PACS is to improve the health and quality of life of the community. PACS utilizes community personnel with no higher education to engage in a wide variety of activities such as registering families, general diagnostics, sanitary health, looking out for critical situations in need of intervention, and overall follow-up with families and patients.

The delivery of secondary and tertiary health care services under the SUS is conducted through both public and private providers. Public contracting of private hospitals has a long history in Brazil, where the SUS contracts for private beds. In 1999, 67% of all SUS hospitals were privately owned, 8% were state owned, and 23% were municipally owned. In terms of clinics, 27% were privately owned, 3% were state owned, and 69% were municipally owned. Such ratios make it clear that while the SUS is a publicly funded system, the private sector is responsible for a large proportion of the services provided.

The role of the private sector in service delivery appears to be waning slightly. Between 1988 and 2005, public establishments offering hospitalizations grew by 50%, while private establishments offering the same grew by 23%.
In 2005, 34% of Brazil’s hospital beds were in public facilities while 66% were in private facilities. Of the beds in the private sector, 82.1% have indicated that they are providing services under the SUS. Thus, there were 55% more beds offering SUS services within the private sector as compared to the public sector.

Public contracting of services with private providers is allowed under MOH guidelines. Managers can complement the supply of services with private providers only when all public health capacity is being used and when the need is proven and justified. Charitable and non-profit organizations, however, are given the status of public sector partners. Furthermore, in order for private entities to be able to provide service to the SUS, they must agree to make available 60% of their capacity to the SUS. These private entities can only serve private users once capacity has been exhausted by SUS patients.