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 |
|---|---|---|
| Colombia: General System of Social Security in Health |
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EPSs and EPSSs are free to establish payment levels and payment mechanisms for services that they purchase from providers. Both entities have used the fee schedules, adjusted for inflation, developed by the pre-reform public health plans as ceilings for price negotiations. As of 2008, provider associations were forcefully seeking the establishment of price floors by the MPS. Read full sectionEPSs and EPSSs are free to establish payment levels and payment mechanisms for services that they purchase from providers. Both entities have used the fee schedules, adjusted for inflation, developed by the pre-reform public health plans as ceilings for price negotiations. As of 2008, provider associations were forcefully seeking the establishment of price floors by the MPS. There are two payment mechanisms common to both EPSs and EPSSs. In general, preventive and primary care services are contracted on a capitation basis. Most specialist and hospital care, however, is paid for either on a fee-for-service basis or by a services package. The CR and SR enrollees must also pay copayments, which vary according to an individual’s income. CR copayments are charged according to salary income. Enrollees with salaries lower than 2 minimum monthly salaries (mms) have a maximum copayment of USD46.70 annually. The maximum copayment for enrollees with incomes in the range of 2-5 mms is USD 195.20 annually. Finally, enrollees with incomes greater than 5 mms have a maximum copayment of USD390.30 annually. SR copayments are set according to SISBEN category. The poorest enrollees, who are classified in category 1, pay co copayments. On the opposite end of the scale, enrollees classified in category 3 pay 10% of the service value. General System of Social Security in HealthProvider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation EPSs and EPSSs are free to establish payment levels and payment mechanisms for services that they purchase from providers. Both entities have used the fee schedules, adjusted for inflation, developed by the pre-reform public health plans as ceilings for price negotiations. As of 2008, provider associations were forcefully seeking the establishment of price floors by the MPS. There are two payment mechanisms common to both EPSs and EPSSs. In general, preventive and primary care services are contracted on a capitation basis. Most specialist and hospital care, however, is paid for either on a fee-for-service basis or by a services package. The CR and SR enrollees must also pay copayments, which vary according to an individual’s income. CR copayments are charged according to salary income. Enrollees with salaries lower than 2 minimum monthly salaries (mms) have a maximum copayment of USD46.70 annually. The maximum copayment for enrollees with incomes in the range of 2-5 mms is USD 195.20 annually. Finally, enrollees with incomes greater than 5 mms have a maximum copayment of USD390.30 annually. SR copayments are set according to SISBEN category. The poorest enrollees, who are classified in category 1, pay co copayments. On the opposite end of the scale, enrollees classified in category 3 pay 10% of the service value. |
| Chile: National Health Fund (FONASA) |
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FONASA transfers money to public health care providers through fee-for-service mechanisms for certain services and groups of services that are assigned a fixed value. The remainder of resources for health care services and facility maintenance in the public sector is transferred based on historical budgets, which tend to be antiquated and therefore undervalued. In terms of transfer mechanisms, FONASA funds are not transferred directly to the individual health care providers. Read full sectionFONASA transfers money to public health care providers through fee-for-service mechanisms for certain services and groups of services that are assigned a fixed value. The remainder of resources for health care services and facility maintenance in the public sector is transferred based on historical budgets, which tend to be antiquated and therefore undervalued. In terms of transfer mechanisms, FONASA funds are not transferred directly to the individual health care providers. Rather, funds are transferred to the regional health entity (under the purview of the MOH) for the geographical region where the provider is located. The regional health entity pools the funds for all public health care providers in the area and then is charged with determining the budget of each provider. FONASA also transfers funds prospectively to the regional health entities for primary care facilities through capitation mechanisms. These funds are based on a region’s health care needs and its disease burden. FONASA and the ISAPREs transfer funds to private providers on a retrospective fee-for-service basis. Private providers always receive funds through fee-for-service mechanisms, and they have no ceiling on income, regardless of whether the source of the funds is FONASA or an ISAPRE. National Health Fund (FONASA)Provider payment mechanisms Provider Payment Mechanisms: Fee-for-service, Capitation FONASA transfers money to public health care providers through fee-for-service mechanisms for certain services and groups of services that are assigned a fixed value. The remainder of resources for health care services and facility maintenance in the public sector is transferred based on historical budgets, which tend to be antiquated and therefore undervalued. In terms of transfer mechanisms, FONASA funds are not transferred directly to the individual health care providers. Rather, funds are transferred to the regional health entity (under the purview of the MOH) for the geographical region where the provider is located. The regional health entity pools the funds for all public health care providers in the area and then is charged with determining the budget of each provider. FONASA also transfers funds prospectively to the regional health entities for primary care facilities through capitation mechanisms. These funds are based on a region’s health care needs and its disease burden. FONASA and the ISAPREs transfer funds to private providers on a retrospective fee-for-service basis. Private providers always receive funds through fee-for-service mechanisms, and they have no ceiling on income, regardless of whether the source of the funds is FONASA or an ISAPRE. |