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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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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| Colombia: General System of Social Security in Health |
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One of the central aspects of the 1993 reform involved separating the financing, stewardship, and delivery functions within the health system. While hospitals still receive some supply-side subsidies through the SGP, the spirit of the reform is to eventually transform them into demand-side subsidies. Health service providers must now compete on the basis of quality for the majority of services provided. Under this scheme EPSs and EPSSs negotiate contracts with service providers. They also coordinate service delivery between patients and a network of public and private providers. Preventive and primary care services are primarily contracted by capitation, with EPSs providing such services through vertically integrated networks and EPSSs providing such services mainly through public hospitals. Most specialist and hospital care is paid for either by service packages or on a fee-for-service basis. Read full sectionOne of the central aspects of the 1993 reform involved separating the financing, stewardship, and delivery functions within the health system. While hospitals still receive some supply-side subsidies through the SGP, the spirit of the reform is to eventually transform them into demand-side subsidies. Health service providers must now compete on the basis of quality for the majority of services provided. Under this scheme EPSs and EPSSs negotiate contracts with service providers. They also coordinate service delivery between patients and a network of public and private providers. Preventive and primary care services are primarily contracted by capitation, with EPSs providing such services through vertically integrated networks and EPSSs providing such services mainly through public hospitals. Most specialist and hospital care is paid for either by service packages or on a fee-for-service basis. Colombia’s provider market features two levels of market competition. On the first level, enrollees choose their EPS or EPSS based on the quality of its provider network. On the second level, the EPSs and EPSSs select their provider network based on their price and quality. Therefore, there are real incentives within the system for providers to supply better quality services at lower prices. Services are organized by levels of care. The first level includes facilities that offer general medicine. This level is supposed to provide the majority of services. The second level comprises providers of basic specialized medical and surgical services. Finally, the third level includes institutions that provide specialty and sub-specialty care as well as high complexity hospitalization. Providers must meet minimum quality, financial, and administrative standards that are enforced by the Ministry of Social Protection (MPS). Providers must also register at the local health authority, which issues a three year certificate. The health authority verification is met through an on-site inspection. Furthermore, since 2002 the Obligatory System to Guarantee the Quality of Health Services (SOGCS) has helped to maintain and improve the quality of health services by focusing on accreditation, audit, and information management. In terms of monitoring service providers, Law 100 mandated the establishment of a compulsory quality assurance system. However, the creation of such a mechanism lagged behind the implementation of other facets of the reform. In 2002, a quality assurance system was finally implemented that introduced a licensing and accreditation process for both public and private facilities. And in 2006 a systematic dissemination of hospitals’ quality began to take place on a regular basis. General System of Social Security in HealthService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: One of the central aspects of the 1993 reform involved separating the financing, stewardship, and delivery functions within the health system. While hospitals still receive some supply-side subsidies through the SGP, the spirit of the reform is to eventually transform them into demand-side subsidies. Health service providers must now compete on the basis of quality for the majority of services provided. Under this scheme EPSs and EPSSs negotiate contracts with service providers. They also coordinate service delivery between patients and a network of public and private providers. Preventive and primary care services are primarily contracted by capitation, with EPSs providing such services through vertically integrated networks and EPSSs providing such services mainly through public hospitals. Most specialist and hospital care is paid for either by service packages or on a fee-for-service basis. Colombia’s provider market features two levels of market competition. On the first level, enrollees choose their EPS or EPSS based on the quality of its provider network. On the second level, the EPSs and EPSSs select their provider network based on their price and quality. Therefore, there are real incentives within the system for providers to supply better quality services at lower prices. Services are organized by levels of care. The first level includes facilities that offer general medicine. This level is supposed to provide the majority of services. The second level comprises providers of basic specialized medical and surgical services. Finally, the third level includes institutions that provide specialty and sub-specialty care as well as high complexity hospitalization. Providers must meet minimum quality, financial, and administrative standards that are enforced by the Ministry of Social Protection (MPS). Providers must also register at the local health authority, which issues a three year certificate. The health authority verification is met through an on-site inspection. Furthermore, since 2002 the Obligatory System to Guarantee the Quality of Health Services (SOGCS) has helped to maintain and improve the quality of health services by focusing on accreditation, audit, and information management. In terms of monitoring service providers, Law 100 mandated the establishment of a compulsory quality assurance system. However, the creation of such a mechanism lagged behind the implementation of other facets of the reform. In 2002, a quality assurance system was finally implemented that introduced a licensing and accreditation process for both public and private facilities. And in 2006 a systematic dissemination of hospitals’ quality began to take place on a regular basis. |
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| Indonesia: Jamkesmas |
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926 | 220 |
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. Read full sectionJamkesmas 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. JamkesmasService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 926
Number of non-state providers: 220 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. |
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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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| : 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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| Brazil: Unified Health System (SUS) |
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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. Read full sectionPrimary 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%. 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. Unified Health System (SUS)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: 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%. 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. |
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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. |