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 | Provider Payment Mechanisms | Provider payment mechanisms |
|---|---|---|
| Estonia: Estonian Health Insurance Fund |
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The EHIF negotiates capped cost and volume contracts with hospitals at the start of each year. These contracts contain provisions on service quality and access, as well as an extended cost and volume section. The contracting process begins with a needs assessment based on historical data regarding health service utilization along with existing waiting times. The EHIF does not have to contract with all providers. Still most of the services are purchased from hospital master plan hospitals with which EHIF has contracts. A small amount of funds go to selective contracting which provides private providers the opportunity to get some health insurance funding. These private providers, however, tend to be primarily funded through OOP payments. A large part of the standard contract conditions are negotiated with the Hospital Association, but there are also financial appendices that are negotiated with each provider individually. Contracts are monitored quarterly using the Management Information System. Read full sectionThe EHIF negotiates capped cost and volume contracts with hospitals at the start of each year. These contracts contain provisions on service quality and access, as well as an extended cost and volume section. The contracting process begins with a needs assessment based on historical data regarding health service utilization along with existing waiting times. The EHIF does not have to contract with all providers. Still most of the services are purchased from hospital master plan hospitals with which EHIF has contracts. A small amount of funds go to selective contracting which provides private providers the opportunity to get some health insurance funding. These private providers, however, tend to be primarily funded through OOP payments. A large part of the standard contract conditions are negotiated with the Hospital Association, but there are also financial appendices that are negotiated with each provider individually. Contracts are monitored quarterly using the Management Information System.
Actual payment methods and prices are regulated in a single government health service list that lies outside of the contract negotiation process and which is updated at least once per year. All providers are paid the same prices. The list includes over 2,000 different items and a range of different payment methods. Outpatient care is normally paid on a fee-for-service basis and inpatient care is paid with a mix of fee-for-service, per diem, and diagnosis-related group (DRG) methods. Primary care family physicians are paid through per capita payments that are adjusted based on the age of the patients. If a family physician has fewer than 1,200 patients, he will still receive a capitation payment for 1,200 patients in order to cover fixed costs. Family physicians can also receive additional fee-for-service payments up to 32% of the capitation amount received. Contracts for family medicine are agreed to between the EHIF and the Estonian Association of Family Doctors. The financial stipulations of the contracts with particular family doctors are reviewed every quarter in order to align with changes in the number of patients on the practice list. Specialist care is also compensated using different types of payment methods depending on the services provided. These methods include fee-for-service, visit fees, per diem, diagnosis-related group, and case-based complex pricing. Since the 1990s, there has been a gradual move away from fee-for service toward case-based payments.
Estonian Health Insurance FundProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation, Diagnosis-Related Groups The EHIF negotiates capped cost and volume contracts with hospitals at the start of each year. These contracts contain provisions on service quality and access, as well as an extended cost and volume section. The contracting process begins with a needs assessment based on historical data regarding health service utilization along with existing waiting times. The EHIF does not have to contract with all providers. Still most of the services are purchased from hospital master plan hospitals with which EHIF has contracts. A small amount of funds go to selective contracting which provides private providers the opportunity to get some health insurance funding. These private providers, however, tend to be primarily funded through OOP payments. A large part of the standard contract conditions are negotiated with the Hospital Association, but there are also financial appendices that are negotiated with each provider individually. Contracts are monitored quarterly using the Management Information System.
Actual payment methods and prices are regulated in a single government health service list that lies outside of the contract negotiation process and which is updated at least once per year. All providers are paid the same prices. The list includes over 2,000 different items and a range of different payment methods. Outpatient care is normally paid on a fee-for-service basis and inpatient care is paid with a mix of fee-for-service, per diem, and diagnosis-related group (DRG) methods. Primary care family physicians are paid through per capita payments that are adjusted based on the age of the patients. If a family physician has fewer than 1,200 patients, he will still receive a capitation payment for 1,200 patients in order to cover fixed costs. Family physicians can also receive additional fee-for-service payments up to 32% of the capitation amount received. Contracts for family medicine are agreed to between the EHIF and the Estonian Association of Family Doctors. The financial stipulations of the contracts with particular family doctors are reviewed every quarter in order to align with changes in the number of patients on the practice list. Specialist care is also compensated using different types of payment methods depending on the services provided. These methods include fee-for-service, visit fees, per diem, diagnosis-related group, and case-based complex pricing. Since the 1990s, there has been a gradual move away from fee-for service toward case-based payments.
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| Mali: Mutuelles |
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In Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included. Read full sectionIn Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included. For the AMO and RAMED, the health institutions, dispensing pharmacies, drug warehouses, and the laboratories approved by the Ministry of Health may sign contracts with the Government Management Agency, the National Health Insurance Fund (CANAM) for the AMO, and the National Medical Assistance Agency (ANAM) for RAMED. Although an accreditation system is planned in Mali, at startup time for the AMO and RAMED, all public and community facilities were temporarily accredited until the system became operational. MutuellesProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service In Mali, the provider payment system for all three systems is fee-for-service. The Mutuelles sign individual agreements with the care providers and reimburse them according to the payment rates under a fee-for-service system. Services are paid for directly by the CANAM and the ANAM to the providers by submitting invoices based on the national pricing system and health care services coverage rates (minus the copayment). A medical control is also included. For the AMO and RAMED, the health institutions, dispensing pharmacies, drug warehouses, and the laboratories approved by the Ministry of Health may sign contracts with the Government Management Agency, the National Health Insurance Fund (CANAM) for the AMO, and the National Medical Assistance Agency (ANAM) for RAMED. Although an accreditation system is planned in Mali, at startup time for the AMO and RAMED, all public and community facilities were temporarily accredited until the system became operational. |
| Rwanda: Mutuelles de Sante |
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The health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI. Read full sectionThe health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI.
On the supply side, financing flows from the central government towards health providers through multiple block grants, which provide hospitals with greater degrees of autonomy. A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers.
A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers. In addition, the substantial amount of donor funding incurs high overhead costs and involves a lack of clarity. Mutuelles de SanteProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation The health insurance system in Rwanda has two main channels for financing: the demand side – the insurance programs, and the supply side – transfers from the treasury to districts and health facilities. On the demand side, services are financed through three main channels: demand-based user payments, demand-based payments from Mutuelles, and demand-based payments from RAMA and MMI.
On the supply side, financing flows from the central government towards health providers through multiple block grants, which provide hospitals with greater degrees of autonomy. A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers.
A key issue on the supply-side financing is the equity of the needs based transfers against the historical criteria. The government hopes to progressively move towards increasing the importance of needs-based transfers and decreasing historical transfers. In addition, the substantial amount of donor funding incurs high overhead costs and involves a lack of clarity. |
| : Taiwan: National Health Insurance |
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Providers obtain their revenues from 3 sources: 1) payments by the NHI; 2) patient user fees and co-payments; and 3) proceeds from the sale of products and services not covered by the NHI. The government acts as the single-payer system with a uniform payment schedule that has effectively controlled the cost shifting that occurred frequently before the implementation of NHI. Read full sectionProviders obtain their revenues from 3 sources: 1) payments by the NHI; 2) patient user fees and co-payments; and 3) proceeds from the sale of products and services not covered by the NHI. The government acts as the single-payer system with a uniform payment schedule that has effectively controlled the cost shifting that occurred frequently before the implementation of NHI. Initially, NHI providers were paid on a fee-for-service basis, however providers were able to make sizable profits by overprescribing medications and ordering unnecessary procedures, leading to quickly rising per person expenditures. Hospitals in Taiwan reward their staff physicians individually for bringing in revenue, known as a “professional fee,” further encouraging physician-induced over-prescription. The Bureau of National Health Insurance (BNHI) estimates that overuse and misuse of health care may constitute up to a third of BNHI’s expenditures. Facing the need for cost containment, BNHI introduced a reasonable volume standard for outpatient visits coupled with a sliding fee schedule for visits above the volume standard, which discouraged supply-induced demand and reduced the number of visits per person. BNHI also reduced the high profit margin that clinics and hospitals can obtain from dispensing drugs by reducing the reimbursement rates for drugs, using reference pricing, and encouraging the use of generic drugs. The NHI experimented with different payment systems, such as diagnosis-related groups (DRGs) for hospitals, primary care capitation for certain population groups, and even performance-based payments. DRGs were phased in for the 50 most common diseases and treatments, which effectively reduced the average length-of-stay in hospitals. The ultimate cost control measure, however, has been the imposition of global budgets for hospital outpatient and inpatient services in 2002. This remains highly controversial because global budgeting incorporates an aggregate fixed sum budget imposed on all hospitals in Taiwan collectively, creating a zero-sum game in which the players cannot effectively police one another. Reimbursement contracts are negotiated with health care providers on a fee-for-service basis with a uniform pay schedule. A deflation mechanism engages once a service quota is reached, resulting in declining reimbursement rates. Under the global budget payment system, the NHI Medical Expenditure Negotiation Committee convenes and negotiates overall caps on total medical payments based on a set of equations and indicators prior to the beginning of a fiscal year. Along with the implementation of global budgets, the NHI took several measures to control the demand for selected types of health care, such as increasing copayments for high users of drugs and outpatient services. The global budget payment system with these measures has been successful in containing the annual growth in the health insurance system's expenditures with spending growth leveling out at below 5% a year since it was fully implemented in July 2002. National Health InsuranceProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Diagnosis-Related Groups, Global budgets Providers obtain their revenues from 3 sources: 1) payments by the NHI; 2) patient user fees and co-payments; and 3) proceeds from the sale of products and services not covered by the NHI. The government acts as the single-payer system with a uniform payment schedule that has effectively controlled the cost shifting that occurred frequently before the implementation of NHI. Initially, NHI providers were paid on a fee-for-service basis, however providers were able to make sizable profits by overprescribing medications and ordering unnecessary procedures, leading to quickly rising per person expenditures. Hospitals in Taiwan reward their staff physicians individually for bringing in revenue, known as a “professional fee,” further encouraging physician-induced over-prescription. The Bureau of National Health Insurance (BNHI) estimates that overuse and misuse of health care may constitute up to a third of BNHI’s expenditures. Facing the need for cost containment, BNHI introduced a reasonable volume standard for outpatient visits coupled with a sliding fee schedule for visits above the volume standard, which discouraged supply-induced demand and reduced the number of visits per person. BNHI also reduced the high profit margin that clinics and hospitals can obtain from dispensing drugs by reducing the reimbursement rates for drugs, using reference pricing, and encouraging the use of generic drugs. The NHI experimented with different payment systems, such as diagnosis-related groups (DRGs) for hospitals, primary care capitation for certain population groups, and even performance-based payments. DRGs were phased in for the 50 most common diseases and treatments, which effectively reduced the average length-of-stay in hospitals. The ultimate cost control measure, however, has been the imposition of global budgets for hospital outpatient and inpatient services in 2002. This remains highly controversial because global budgeting incorporates an aggregate fixed sum budget imposed on all hospitals in Taiwan collectively, creating a zero-sum game in which the players cannot effectively police one another. Reimbursement contracts are negotiated with health care providers on a fee-for-service basis with a uniform pay schedule. A deflation mechanism engages once a service quota is reached, resulting in declining reimbursement rates. Under the global budget payment system, the NHI Medical Expenditure Negotiation Committee convenes and negotiates overall caps on total medical payments based on a set of equations and indicators prior to the beginning of a fiscal year. Along with the implementation of global budgets, the NHI took several measures to control the demand for selected types of health care, such as increasing copayments for high users of drugs and outpatient services. The global budget payment system with these measures has been successful in containing the annual growth in the health insurance system's expenditures with spending growth leveling out at below 5% a year since it was fully implemented in July 2002. |
| Kenya: National Hospital Insurance Fund |
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The National Hospital Insurance Fund (NHIF) and private insurers have negotiated fixed reimbursement rates for in-patient care. The reimbursement amount varies slightly with the level of provider, the diagnosis, and the type of care required. “Contract A” and “Contract B” providers are typically reimbursed through case based or fee-for-service provider payments. “Contract C” providers are reimbursed through a per diem rebate system. Claims are submitted by hospitals directly to the National Hospital Insurance Fund (NHIF), and then hospitals are paid for procedures and users are reimbursed. Most claims are reimbursed within 14 days of the claim received. This process is computerized and is designed to be transparent to the providers. Read full sectionThe National Hospital Insurance Fund (NHIF) and private insurers have negotiated fixed reimbursement rates for in-patient care. The reimbursement amount varies slightly with the level of provider, the diagnosis, and the type of care required. “Contract A” and “Contract B” providers are typically reimbursed through case based or fee-for-service provider payments. “Contract C” providers are reimbursed through a per diem rebate system. Claims are submitted by hospitals directly to the National Hospital Insurance Fund (NHIF), and then hospitals are paid for procedures and users are reimbursed. Most claims are reimbursed within 14 days of the claim received. This process is computerized and is designed to be transparent to the providers. Moving forward, the NHIF intends to increasingly employ case-based payments for inpatient services. As the NHIF adds outpatient care to the benefits package with implementation of the recently gazette changes, capitation to comprehensive-care facilities will be the intended payment mechanisms. The fee-for-service system has been identified as one of the key drivers of escalating health care costs, as it creates incentives to encourage over-servicing and supplier-induced demand. The majority of services covered by the NHIF are delivered through private facilities, indicating a preference by the bulk of salaried workers (who make up the majority of those covered by NHIF) toward private providers rather than public institutions. Of overall health expenditures in Kenya, Secondary and Tertiary care providers traditionally absorb approximately 70% of health expenditures, though health centers and primary care units provide the bulk of services. Health personnel expenditures are high—accounting for about 50% of the budget—compared to expenditures on drugs, pharmaceuticals, and operations and maintenance. Expenditures for curative care constitute more than 48% of the total MOH budget. Health care facilities also receive payments from the Ministry of Health (MOH), which releases funds to the district and national level hospitals. Allocations to the district health centers and dispensaries are in the form of line-item budgets, whereas national level hospitals receive global budgets. Salaries to staff are paid directly by the MOH. Drugs are also procured centrally, by the Kenya Medical Suppliers Agency (KEMSA) and then delivered to district and local level facilities. At the local level, the process of disbursement of funds is slow, which causes uncertainty for the providers, impedes their planning process, and encourages district level managers to await funding before they procure services, and creates an incentive to under-service clients. National Hospital Insurance FundProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Diagnosis-Related Groups, Other The National Hospital Insurance Fund (NHIF) and private insurers have negotiated fixed reimbursement rates for in-patient care. The reimbursement amount varies slightly with the level of provider, the diagnosis, and the type of care required. “Contract A” and “Contract B” providers are typically reimbursed through case based or fee-for-service provider payments. “Contract C” providers are reimbursed through a per diem rebate system. Claims are submitted by hospitals directly to the National Hospital Insurance Fund (NHIF), and then hospitals are paid for procedures and users are reimbursed. Most claims are reimbursed within 14 days of the claim received. This process is computerized and is designed to be transparent to the providers. Moving forward, the NHIF intends to increasingly employ case-based payments for inpatient services. As the NHIF adds outpatient care to the benefits package with implementation of the recently gazette changes, capitation to comprehensive-care facilities will be the intended payment mechanisms. The fee-for-service system has been identified as one of the key drivers of escalating health care costs, as it creates incentives to encourage over-servicing and supplier-induced demand. The majority of services covered by the NHIF are delivered through private facilities, indicating a preference by the bulk of salaried workers (who make up the majority of those covered by NHIF) toward private providers rather than public institutions. Of overall health expenditures in Kenya, Secondary and Tertiary care providers traditionally absorb approximately 70% of health expenditures, though health centers and primary care units provide the bulk of services. Health personnel expenditures are high—accounting for about 50% of the budget—compared to expenditures on drugs, pharmaceuticals, and operations and maintenance. Expenditures for curative care constitute more than 48% of the total MOH budget. Health care facilities also receive payments from the Ministry of Health (MOH), which releases funds to the district and national level hospitals. Allocations to the district health centers and dispensaries are in the form of line-item budgets, whereas national level hospitals receive global budgets. Salaries to staff are paid directly by the MOH. Drugs are also procured centrally, by the Kenya Medical Suppliers Agency (KEMSA) and then delivered to district and local level facilities. At the local level, the process of disbursement of funds is slow, which causes uncertainty for the providers, impedes their planning process, and encourages district level managers to await funding before they procure services, and creates an incentive to under-service clients. |
| Thailand: Universal Coverage Scheme |
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UCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003. Read full sectionUCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003. The current payment mechanism for UCS is a mixed system of risk-adjusted capitation for primary care, a DRG-based capped global budget, and fixed rate fees for some services. It should be noted that health promotion and prevention services for all Thai citizens are paid by the UCS. Universal Coverage SchemeProvider payment mechanisms Provider Payment Mechanisms: Capitation UCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003. The current payment mechanism for UCS is a mixed system of risk-adjusted capitation for primary care, a DRG-based capped global budget, and fixed rate fees for some services. It should be noted that health promotion and prevention services for all Thai citizens are paid by the UCS. |
