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 |
|---|---|---|
| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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Outpatient care is funded through capitation-based payments while hospital services are funded through case-based payments. The capitation formula for primary care is adjusted by coefficients for rural, small towns, and mountainous areas. This leads to cross-subsidization across geographical boundaries. Read full sectionOutpatient care is funded through capitation-based payments while hospital services are funded through case-based payments. The capitation formula for primary care is adjusted by coefficients for rural, small towns, and mountainous areas. This leads to cross-subsidization across geographical boundaries. The base primary care capitation rate (before adjustment coefficients) is based on two variables, the estimated number of enrollees that are expected to be enrolled in a family group practice over the coming year, and the size of the budget. The case-based payments for hospital services introduced the idea of output-based payments to the Kyrgyz health system. The system for grouping cases, generally called clinical statistical groups, was based on American diagnosis-related-groups, but was created with Kyrgyz utilization and cost data. This new system enabled an expansion of the budget management autonomy of hospital administrators, although hospital autonomy and management capacity is still an issue on the reform agenda. The republican MHIF and its territorial branches administer the national pool of funds for the SGBP and are responsible for making all case- and capitation-based payments. Per-case payment rates are defined prospectively but payments are made on a monthly basis. In order to avoid provider selection, providers receive higher payments for treating exempt patients and those with lower copayments. A key to the success of the MHIF as the single-payer for the SGBP has been the continuous development and refinement of financial and clinical information systems to operate the provider payment systems and ensure good financial reporting and fiduciary risk mitigation. Mandatory Health Insurance Fund (MHIF)Provider payment mechanisms Provider Payment Mechanisms: Capitation, Diagnosis-Related Groups Outpatient care is funded through capitation-based payments while hospital services are funded through case-based payments. The capitation formula for primary care is adjusted by coefficients for rural, small towns, and mountainous areas. This leads to cross-subsidization across geographical boundaries. The base primary care capitation rate (before adjustment coefficients) is based on two variables, the estimated number of enrollees that are expected to be enrolled in a family group practice over the coming year, and the size of the budget. The case-based payments for hospital services introduced the idea of output-based payments to the Kyrgyz health system. The system for grouping cases, generally called clinical statistical groups, was based on American diagnosis-related-groups, but was created with Kyrgyz utilization and cost data. This new system enabled an expansion of the budget management autonomy of hospital administrators, although hospital autonomy and management capacity is still an issue on the reform agenda. The republican MHIF and its territorial branches administer the national pool of funds for the SGBP and are responsible for making all case- and capitation-based payments. Per-case payment rates are defined prospectively but payments are made on a monthly basis. In order to avoid provider selection, providers receive higher payments for treating exempt patients and those with lower copayments. A key to the success of the MHIF as the single-payer for the SGBP has been the continuous development and refinement of financial and clinical information systems to operate the provider payment systems and ensure good financial reporting and fiduciary risk mitigation. |
| 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. |
| Ghana: National Health Insurance Scheme (NHIS) |
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In 2004, a memorandum of understanding regarding the services covered and prices charged was signed by the NHIC and service provider representatives. Claims are filed by the health facilities and the district schemes pay providers on a DRG basis. Typically, a reimbursement check comes 6 months after a claim is submitted. Read full sectionIn 2004, a memorandum of understanding regarding the services covered and prices charged was signed by the NHIC and service provider representatives. Claims are filed by the health facilities and the district schemes pay providers on a DRG basis. Typically, a reimbursement check comes 6 months after a claim is submitted. This memorandum now forms the basis of all contracts between the health schemes and providers. Claims processing is a manual process, with some automation in enrollment verifications and claims documentation. The amount of the reimbursement is often less than 100%, with some schemes, for example, paying 70% (e.g., Ossu Kottery – urban scheme in higher income area of Accra), others paying as low as 40% (e.g., Dodowah, rural area outside Accra). The balance is supposed to be paid at later date. National Health Insurance Scheme (NHIS)Provider payment mechanisms Provider Payment Mechanisms: Diagnosis-Related Groups In 2004, a memorandum of understanding regarding the services covered and prices charged was signed by the NHIC and service provider representatives. Claims are filed by the health facilities and the district schemes pay providers on a DRG basis. Typically, a reimbursement check comes 6 months after a claim is submitted. This memorandum now forms the basis of all contracts between the health schemes and providers. Claims processing is a manual process, with some automation in enrollment verifications and claims documentation. The amount of the reimbursement is often less than 100%, with some schemes, for example, paying 70% (e.g., Ossu Kottery – urban scheme in higher income area of Accra), others paying as low as 40% (e.g., Dodowah, rural area outside Accra). The balance is supposed to be paid at later date. |
| Nigeria: National Health Insurance System |
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Patients are allowed to choose their primary provider from the list of accredited facilities, which includes both public and private providers. The provider network is used for access and secondary referrals, which acts to control costs and maintain viability of the system. Provider payment mechanisms are primarily determined by the National Health Insurance System (NHIS) Governing Council. Read full sectionPatients are allowed to choose their primary provider from the list of accredited facilities, which includes both public and private providers. The provider network is used for access and secondary referrals, which acts to control costs and maintain viability of the system. Provider payment mechanisms are primarily determined by the National Health Insurance System (NHIS) Governing Council. For private insurers, this is determined between HMOs and Providers, with oversight from the central government, and referral to specialist care follows guidelines that are managed accordingly. Decree 35 determined that the only lawful payment systems to be included in NHIS are capitation, fee-for-service, per diem, or case payment. A capitation system is the predominant form of provider payment used to pay primary healthcare facilities, while secondary and tertiary healthcare facilities are paid by fee for service and per diem. National Health Insurance SystemProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation Patients are allowed to choose their primary provider from the list of accredited facilities, which includes both public and private providers. The provider network is used for access and secondary referrals, which acts to control costs and maintain viability of the system. Provider payment mechanisms are primarily determined by the National Health Insurance System (NHIS) Governing Council. For private insurers, this is determined between HMOs and Providers, with oversight from the central government, and referral to specialist care follows guidelines that are managed accordingly. Decree 35 determined that the only lawful payment systems to be included in NHIS are capitation, fee-for-service, per diem, or case payment. A capitation system is the predominant form of provider payment used to pay primary healthcare facilities, while secondary and tertiary healthcare facilities are paid by fee for service and per diem. |
| Mexico: Seguro Popular |
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The interventions included in the CAUSES are paid for by capitation. Meanwhile, the interventions carried out under the FPGC are paid for on a per-case basis. The payment mechanism for contracts with private providers is vague. The reform stated that health services should be provided by state health secretariats in accordance with the state of residence of the insured family or by other public health institutions that have contracted with the state health secretariats. After the passage of the law, however, the executive branch issued a by-law that introduced the option of contracting with the private sector. The problem with this by-law is that it does not specify the form that payments to private sector will take. Thus, such payments take place on an ad-hoc, non-systematic basis. Read full sectionThe interventions included in the CAUSES are paid for by capitation. Meanwhile, the interventions carried out under the FPGC are paid for on a per-case basis. The payment mechanism for contracts with private providers is vague. The reform stated that health services should be provided by state health secretariats in accordance with the state of residence of the insured family or by other public health institutions that have contracted with the state health secretariats. After the passage of the law, however, the executive branch issued a by-law that introduced the option of contracting with the private sector. The problem with this by-law is that it does not specify the form that payments to private sector will take. Thus, such payments take place on an ad-hoc, non-systematic basis. Seguro PopularProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation, Diagnosis-Related Groups The interventions included in the CAUSES are paid for by capitation. Meanwhile, the interventions carried out under the FPGC are paid for on a per-case basis. The payment mechanism for contracts with private providers is vague. The reform stated that health services should be provided by state health secretariats in accordance with the state of residence of the insured family or by other public health institutions that have contracted with the state health secretariats. After the passage of the law, however, the executive branch issued a by-law that introduced the option of contracting with the private sector. The problem with this by-law is that it does not specify the form that payments to private sector will take. Thus, such payments take place on an ad-hoc, non-systematic basis. |
| Brazil: Unified Health System (SUS) |
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Primary care providers at the municipal level are paid on a per capita basis. Transfers from state and federal resources trickle down to the municipal level through streams such as the basic health program (PAB), the PSF, and the PACS. Read full sectionPrimary care providers at the municipal level are paid on a per capita basis. Transfers from state and federal resources trickle down to the municipal level through streams such as the basic health program (PAB), the PSF, and the PACS. The same method of provider payments is used for both private and public providers under the SUS. Payments for hospital stays and complex procedures are based on Hospital Stay Authorization (AIH) codes. The AIH payment system is a procedure- or service-based rate system that is not linked to resource usage or costs. Fixed values are established per disease and necessary procedures. Hospitals that undertake complex procedures receive additional resources to maintain their facilities. Ambulatory services are paid by the health funds based on Ambulatory Care Units (UCA) plus an additional fixed amount for each service rendered.
Unified Health System (SUS)Provider payment mechanisms Provider Payment Mechanisms: Capitation, Diagnosis-Related Groups Primary care providers at the municipal level are paid on a per capita basis. Transfers from state and federal resources trickle down to the municipal level through streams such as the basic health program (PAB), the PSF, and the PACS. The same method of provider payments is used for both private and public providers under the SUS. Payments for hospital stays and complex procedures are based on Hospital Stay Authorization (AIH) codes. The AIH payment system is a procedure- or service-based rate system that is not linked to resource usage or costs. Fixed values are established per disease and necessary procedures. Hospitals that undertake complex procedures receive additional resources to maintain their facilities. Ambulatory services are paid by the health funds based on Ambulatory Care Units (UCA) plus an additional fixed amount for each service rendered.
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| 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. |
