UHC Forward: Towards Universal Health Coverage

Health care provision in Estonia is completely decentralized. Care within the Estonian system is characterized by four tiers:

• Primary care offered by family doctors who are either private entities or salaried employees of private firms owned by family doctors. Family doctors contract with the EHIF for the care of their patient list. The average number of patients on a practice list equaled 1,800 in 2008. Family doctors are responsible for referring patients to specialist care.
• Emergency care
• Specialized medical care, most of which is in the hands of private entities within the different specialties. Patients can freely access certain specialties such as ophthalmology, gynecology, psychiatry, dentistry, and pulmonology in the case of TB. If a patient seeks the care of a specialist outside of those previously mentioned they must pay out of pocket for services.
• Nursing care

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.

The provision of care in Mali is organized in a pyramid with four levels. At the base there are the health districts (60), divided into health areas that have a community health center (CSCOM) with a dispensary, a maternity center, and a pharmacy warehouse, altogether offering a minimum package of activities (MPA). The professional team at the CSCOM is often managed by a nurse. In 2010, about 900 of the 1,030 health areas had a CSCOM. The health area, and thus the CSCOM, is run by a community health association (ASACO). There were 954 ASACOs in 2010. The ASACO signs a contract with the government of Mali, which agrees to work toward providing public health services, for which it has some available grants. However, it manages the CSCOM staff and the operating budget. CSCOM has the status of a non-profit private institution, and thus the system is “community” based. Roughly 87% of the population of Mali lives less than 15 km from a CSCOM. The CSCOMs account for 56% of all consultations, versus 20% for the entirely public entities (BCG 2010). The first referral takes place at the referral health center (CSRef), which is basically a district hospital. There is a CSRef in every health district. The CSRef has a more sophisticated technical support center and more highly skilled staff than at the CSCM level. The CSRef treats the cases that are referred from the CSCOMs. At the CSRef level, which has public status, there are about 25 private facilities (BCG 2010). At the third level (second referral), there are seven (7) public hospitals (EPH) located in the regional capitals. On the private side there are approximately 70 clinics at this level of the pyramid. (BCG 2010). At the top there are four level-three referring EPHs, two of which are for general medicine, while the other two are for specialized medicine.

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:

• Have at least 50 inpatient medical beds
• Be fully equipped and engaged in providing in-patient medical and surgical facilities along with diagnostic facilities (e.g., pathological tests and X-rays, E.C.G. etc.) for the care and treatment of injured or sick persons
• Have at least one operation theater of its own where surgical operations are carried out
• Have fully qualified nursing staff under its employment 24 hours a day
• Have fully qualified specialist doctor(s) on premises 24 hours a day
• Maintain complete records as required by Aarogyasri on a daily basis and able to provide necessary insured patients’ records to the insurer or his representative as and when required
• Have sufficient experience in the specific identified field
• Agree to deliver the package of services at the rate specified for each identified intervention/surgery as approved by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, and hospital charges, etc. The package price should cover the entire cost of treatment of the patient from date of reporting to discharge from hospital, as well as 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient.
• Include the services of a Radiation Oncologist and Medical Oncologist if it desires to be empaneled for Chemo- and Radio-therapies
• Include services of trained ENT Surgeon(s) and Auditory Verbal Therapist(s) if it desires to be empanelled for Cochlear Implant Surgery

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.

• Beneficiaries approach nearby health facility (either public health clinic or area hospital) where an Aarogya Mithra is placed to help beneficiary navigate the health system. Alternatively, the beneficiary can utilize the Aarogyasri 24x7 customer care toll free number (by dialing 1800-474-7788), state’s emergency medical service (by dialing 108), or telemedicine service (by dialing 104) to reach a network hospital. Follow the links for more information on the state’s emergency medical and telemedicine services.
• Beneficiary is seen and diagnosed by a doctor with the support of an Aarogya Mithra to ensure proper care is delivered.
• If beneficiary needs to seek care elsewhere, he/she will be given a referral card to the appropriate network hospital(s)—the beneficiary can select which network hospital they would like to visit for the next step of care.
• Beneficiaries may also attend the Health Camps being conducted by a network hospital in a village and can get the referral card based on the diagnosis done at the Health Camp.

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.