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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Colombia: General System of Social Security in Health |
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| : Taiwan: National Health Insurance |
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kenya: National Hospital Insurance Fund |
|
150 | 450 |
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. Read full sectionNational 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. National Hospital Insurance FundService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 150
Number of non-state providers: 450 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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Philippines: PhilHealth |
|
The service delivery system includes both public and private centers; on average, the network is comprised of 61% private and 39% public providers. Read full sectionThe service delivery system includes both public and private centers; on average, the network is comprised of 61% private and 39% public providers. In order to achieve accreditation, all in-network hospitals and day-surgery centers must be licensed by the Department of Health. The network includes hospitals, day surgery centers, maternity care clinics, midwife-operated clinics, freestanding dialysis centers, physician clinics, dentists doing procedures in hospitals and day surgeries, government-run health centers for primary care benefits, TB DOTS and malaria, and private TB-DOTS clinics. Non-hospitals and day-surgery centers are not required to be licensed by the DOH; however, all facilities are evaluated by an accreditation team from PhilHealth. PhilHealthService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The service delivery system includes both public and private centers; on average, the network is comprised of 61% private and 39% public providers. In order to achieve accreditation, all in-network hospitals and day-surgery centers must be licensed by the Department of Health. The network includes hospitals, day surgery centers, maternity care clinics, midwife-operated clinics, freestanding dialysis centers, physician clinics, dentists doing procedures in hospitals and day surgeries, government-run health centers for primary care benefits, TB DOTS and malaria, and private TB-DOTS clinics. Non-hospitals and day-surgery centers are not required to be licensed by the DOH; however, all facilities are evaluated by an accreditation team from PhilHealth. |