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. |
||||||||||||||||||||||||||||||||
| Rwanda: Mutuelles de Sante |
|
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.
|
||||||||||||||||||||||||||||||
| Chile: National Health Fund (FONASA) |
|
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. |
||||||||||||||||||||||||||||||||
| Nigeria: National Health Insurance System |
|
The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
In addition, an accreditation fee is required. Currently 61 HMOs have been accredited and registered by NHIS in addition to about 6,000 primary care providers, 1,000 ancillary providers, and over 600 secondary and tertiary providers. Recently the NHIS announced the suspension of accreditation of new HMOs and providers because there is a need to strengthen the scheme and improve quality of healthcare services delivery through reaccreditation. In general, the service delivery system in Nigeria is organized on a tiered basis:
The service delivery system is mixed between private and public providers. The private health care system has grown substantially since the 1980s, to currently provide about 80% of the total health services. This sector, however, is not well regulated or supported. Of all the private facilities in Nigeria, about 50% are for-profit. Despite the large number of service providers, coverage of most key preventative and curative health services is relatively low. There are large disparities in geo-political zones, between rural and urban zones, and with regard to socio-economic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20% of the population. National Health Insurance SystemService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The National Health Insurance system (NHIS) accredits both service providers and the Health Maintenance Organizations (HMOs) that interface between providers, the NHIS and its beneficiaries. To receive accreditation, health facilities must meet a number of requirements for the physical facility and the personnel, including:
In addition, an accreditation fee is required. Currently 61 HMOs have been accredited and registered by NHIS in addition to about 6,000 primary care providers, 1,000 ancillary providers, and over 600 secondary and tertiary providers. Recently the NHIS announced the suspension of accreditation of new HMOs and providers because there is a need to strengthen the scheme and improve quality of healthcare services delivery through reaccreditation. In general, the service delivery system in Nigeria is organized on a tiered basis:
The service delivery system is mixed between private and public providers. The private health care system has grown substantially since the 1980s, to currently provide about 80% of the total health services. This sector, however, is not well regulated or supported. Of all the private facilities in Nigeria, about 50% are for-profit. Despite the large number of service providers, coverage of most key preventative and curative health services is relatively low. There are large disparities in geo-political zones, between rural and urban zones, and with regard to socio-economic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20% of the population. |
||||||||||||||||||||||||||||||||
| 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. |
||||||||||||||||||||||||||||||||
| India: RSBY |
|
551 | 1516 |
As of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers. Read full sectionAs of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers. After an insurance company is selected by the state, the insurance company is tasked with empaneling/certifying both public and private care providers in the program. The process is based on prescribed criteria (e.g., the service providers should possess specified basic facilities, like: have at least 10 inpatient medical beds; have specified medical and surgical facilities and diagnostic facilities, etc.). In addition, hospitals must agree to need to install necessary hardware and software to be able to process beneficiaries’ SmartCard transactions. They must also set up a dedicated RSBY desk with trained staff. The insurer must empanel enough hospitals in each district so that beneficiaries do not need to travel great distances to get to health care services. For empanelment of public hospitals, the insurer needs to coordinate with the respective health department of the state. Once a hospital is empanelled, a nationally-unique hospital ID number is generated so that transactions can be tracked at each hospital. Each empanelled hospital is connected with the district server of the insurance company and thus able to transfer data related to hospitalization on a daily basis. RSBYService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers: 551
Number of non-state providers: 1516 As of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers. After an insurance company is selected by the state, the insurance company is tasked with empaneling/certifying both public and private care providers in the program. The process is based on prescribed criteria (e.g., the service providers should possess specified basic facilities, like: have at least 10 inpatient medical beds; have specified medical and surgical facilities and diagnostic facilities, etc.). In addition, hospitals must agree to need to install necessary hardware and software to be able to process beneficiaries’ SmartCard transactions. They must also set up a dedicated RSBY desk with trained staff. The insurer must empanel enough hospitals in each district so that beneficiaries do not need to travel great distances to get to health care services. For empanelment of public hospitals, the insurer needs to coordinate with the respective health department of the state. Once a hospital is empanelled, a nationally-unique hospital ID number is generated so that transactions can be tracked at each hospital. Each empanelled hospital is connected with the district server of the insurance company and thus able to transfer data related to hospitalization on a daily basis. |
||||||||||||||||||||||||||||||
| Mexico: Seguro Popular |
|
The Social Protection in Health Regime (REPSS) at the state level is responsible for forming and coordinating the network of health service providers. In practice, the first option (and often the only one due to political factors or lack of technical competence) is to contract for health services from the network of State Health Services (SESA), followed by limited contracting with the private sector. These contracts are signed on a yearly basis. Out of nine states analyzed in a recent study, only two actively contracted for services with private health care providers. As of 2009, the SP has started buying services from the IMSS-Oportunidades Program and it is expected that contracting for services will extend to both IMSS and ISSSTE. Read full sectionThe Social Protection in Health Regime (REPSS) at the state level is responsible for forming and coordinating the network of health service providers. In practice, the first option (and often the only one due to political factors or lack of technical competence) is to contract for health services from the network of State Health Services (SESA), followed by limited contracting with the private sector. These contracts are signed on a yearly basis. Out of nine states analyzed in a recent study, only two actively contracted for services with private health care providers. As of 2009, the SP has started buying services from the IMSS-Oportunidades Program and it is expected that contracting for services will extend to both IMSS and ISSSTE. Some expect that such contracting schemes will lead to the ultimate financial integration of the system. The reform also created a long-term framework for expanding health care facilities. As of 2006, nearly 1,800 new facilities had been built, including four high-specialty regional hospitals in the least developed regions of Mexico. Service delivery for services that fall under the essential benefits package is decentralized at the state level due to the low-risk, high-probability nature of the interventions. High-cost tertiary care that falls under the FPGC, however, is delivered at regional or national health centers that offer highly specialized services. These types of procedures are often performed at private facilities. Seguro PopularService delivery system Types of Providers Empanelled: Both Public & Non-state
Number of public providers:
Number of non-state providers: The Social Protection in Health Regime (REPSS) at the state level is responsible for forming and coordinating the network of health service providers. In practice, the first option (and often the only one due to political factors or lack of technical competence) is to contract for health services from the network of State Health Services (SESA), followed by limited contracting with the private sector. These contracts are signed on a yearly basis. Out of nine states analyzed in a recent study, only two actively contracted for services with private health care providers. As of 2009, the SP has started buying services from the IMSS-Oportunidades Program and it is expected that contracting for services will extend to both IMSS and ISSSTE. Some expect that such contracting schemes will lead to the ultimate financial integration of the system. The reform also created a long-term framework for expanding health care facilities. As of 2006, nearly 1,800 new facilities had been built, including four high-specialty regional hospitals in the least developed regions of Mexico. Service delivery for services that fall under the essential benefits package is decentralized at the state level due to the low-risk, high-probability nature of the interventions. High-cost tertiary care that falls under the FPGC, however, is delivered at regional or national health centers that offer highly specialized services. These types of procedures are often performed at private facilities. |
||||||||||||||||||||||||||||||||
| Brazil: Unified Health System (SUS) |
|
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. |