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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| 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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| 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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| Chile: National Health Fund (FONASA) |
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In 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Read full sectionIn 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Chile’s service delivery system is composed of 26 autonomous health authorities responsible for hospital care. Primary health care was decentralized down to the level of the municipality. In Chile, 80% of hospital beds are public. FONASA is required to purchase most of its health services from public institutions, although it does provide a subsidy to its enrollees wishing to purchase services from private providers. Public health care providers must sell most of their services to FONASA and have strict guidelines on the type and number of services they can make available to private patients or ISAPRE beneficiaries. FONASA categories B, C, and D can elect to receive care outside of the public system for a higher co-payment. Category A enrollees must receive services from the public provider system. Of all the AUGE procedures carried out, 86% are conducted at the primary health level. Meanwhile, of the AUGE procedures for FONASA beneficiaries performed in the private sector, 90% correspond to dialysis treatment. Whenever there is a risk of falling behind on the guarantees, services must be purchased from elsewhere. For example, in the case of cancer a public hospital will normally purchase services from another public hospital. In the case of cataracts, however, a public hospital will normally purchase services from the private sector. The AUGE plan has changed the manner in which health service delivery is viewed. In the past, supply determined how many cataract interventions were performed based on the internal capacity of the institution. But now, with certain services explicitly guaranteed, the health system has to detect the prevalence of cataracts and determine how to best reorganize resources in order to satisfy demand. Chile has also instituted a free telephone line that responds to inquiries regarding a number of different health situations. It is staffed by a team that has the ability to provide medical advice and set up consultations. This service has led to a significant reduction in emergency room visits, as problems that are deemed non-urgent can be resolved through primary care personnel. Finally, it is worth noting that ISAPREs are not allowed to provide health services directly to their enrollees. They must rely on horizontal networks of health care providers and hospitals for the delivery of services. National Health Fund (FONASA)Service delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: In 1985, two modalities of health service provision were established for FONASA beneficiaries. Under the Institutional Modality (IM), FONASA beneficiaries can access the public system in order to use public hospitals. Financial coverage under this modality is dependent upon the income of the beneficiary. Under the Free Election Modality (FEM), FONASA beneficiaries can opt to use private health service providers that have entered into agreements with FONASA. Financial coverage under this modality depends on the category to which the health service provider is subscribed. Generally, FEM copayments are larger than IM copayments. Chile’s service delivery system is composed of 26 autonomous health authorities responsible for hospital care. Primary health care was decentralized down to the level of the municipality. In Chile, 80% of hospital beds are public. FONASA is required to purchase most of its health services from public institutions, although it does provide a subsidy to its enrollees wishing to purchase services from private providers. Public health care providers must sell most of their services to FONASA and have strict guidelines on the type and number of services they can make available to private patients or ISAPRE beneficiaries. FONASA categories B, C, and D can elect to receive care outside of the public system for a higher co-payment. Category A enrollees must receive services from the public provider system. Of all the AUGE procedures carried out, 86% are conducted at the primary health level. Meanwhile, of the AUGE procedures for FONASA beneficiaries performed in the private sector, 90% correspond to dialysis treatment. Whenever there is a risk of falling behind on the guarantees, services must be purchased from elsewhere. For example, in the case of cancer a public hospital will normally purchase services from another public hospital. In the case of cataracts, however, a public hospital will normally purchase services from the private sector. The AUGE plan has changed the manner in which health service delivery is viewed. In the past, supply determined how many cataract interventions were performed based on the internal capacity of the institution. But now, with certain services explicitly guaranteed, the health system has to detect the prevalence of cataracts and determine how to best reorganize resources in order to satisfy demand. Chile has also instituted a free telephone line that responds to inquiries regarding a number of different health situations. It is staffed by a team that has the ability to provide medical advice and set up consultations. This service has led to a significant reduction in emergency room visits, as problems that are deemed non-urgent can be resolved through primary care personnel. Finally, it is worth noting that ISAPREs are not allowed to provide health services directly to their enrollees. They must rely on horizontal networks of health care providers and hospitals for the delivery of services. |
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| India: Rajiv Aarogyasri |
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98 | 244 |
The Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals. Read full sectionThe Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals. As of January 2010, there were a total of 342 hospitals in the network. The principal reason Aarogyasri Trust decided to work with private providers was the lack of resources in the public system. The government has been unable to attract the needed specialists to public facilities, while the private sector has rapidly expanded high quality healthcare services. A hospital or nursing home in Andhra Pradesh is eligible to be a part of the Aarogyasri network of care, established for indoor medical care and treatment of disease and injuries. The hospital should comply with the following minimum criteria:
All hospitals that qualify to be in-network must sign a memorandum of understanding with the insurance company. This Memorandum is subject to the approval of the Trust. A provision is made in the Memorandum for non-compliance/default; all such matters are looked into by the Trust. From the perspective of beneficiaries, the path to seeking care is made as simple as possible, as indicated in Figure 1.
Rajiv AarogyasriService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 98
Number of non-state providers: 244 The Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals. As of January 2010, there were a total of 342 hospitals in the network. The principal reason Aarogyasri Trust decided to work with private providers was the lack of resources in the public system. The government has been unable to attract the needed specialists to public facilities, while the private sector has rapidly expanded high quality healthcare services. A hospital or nursing home in Andhra Pradesh is eligible to be a part of the Aarogyasri network of care, established for indoor medical care and treatment of disease and injuries. The hospital should comply with the following minimum criteria:
All hospitals that qualify to be in-network must sign a memorandum of understanding with the insurance company. This Memorandum is subject to the approval of the Trust. A provision is made in the Memorandum for non-compliance/default; all such matters are looked into by the Trust. From the perspective of beneficiaries, the path to seeking care is made as simple as possible, as indicated in Figure 1.
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| 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. |
