Compare: Institutional structure

Joint Learning Network for Universal Health Coverage

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 Key Actors in Insurance Administration Organizational Structure Collections Responsibility Operations Responsibility Oversight Responsibility Institutional structures
Indonesia: Jamkesmas
  • Central Government
  • District/Local Government
  • Commercial insurers
  • Decentralized to district/local level
  • District/Local Government
  • Central Government
  • District/Local Government
  • Central Government

Presently, five main actors are involved in the administration of the Jamkesmas scheme (1) the National Social Security Council (DJSN), (2) national government agencies, including Depkes (MoH), the Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA), Ministry of Social Affairs (Menkokesra), and the Ministry of National Development Planning (Bappenas), (3) provincial and district governments, (4) public and private providers of care, and (5) the insurer/third-party administrator.

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Presently, five main actors are involved in the administration of the Jamkesmas scheme (1) the National Social Security Council (DJSN), (2) national government agencies, including Depkes (MoH), the Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA), Ministry of Social Affairs (Menkokesra), and the Ministry of National Development Planning (Bappenas), (3) provincial and district governments, (4) public and private providers of care, and (5) the insurer/third-party administrator.

A revised institutional structure of Indonesia’s Jamkesmas scheme is currently being developed. The table below summarizes the roles and responsibilities of all of the organizations involved in implementing national health insurance, including Jamkesmas:

National Soc Sec Council (DJSN)National government agencies (MoH, MoF, MoHA, Menkokesra, Bappenas)Provincial and district governmentsProviders of careInsurer/TPA (Askes/ Jamsostek)
Oversight of schemeX (LR)X (SR)
Financing schemeXX
Setting parameters (benefits package, definitions of poor, etc.)X (LR)X (SR)
Accreditation/Empanelment of providersXX
EnrollmentXXX
Financial management/planningX (LR)X (SR)
Actuarial analysisX (LR)
Setting rate schedules for services/reimbursement ratesX (LR)X (SR)
Claims processing and paymentX (Under Review)XX (District level)
Outreach, Marketing to beneficiaries X
Service deliveryX
Developing clinical information system for monitoring/evalX (LR)X (SR)
Monitoring local-level utilization and other patient informationX (LR) X (SR)
Monitoring national aggregate informationX (LR)
Customer serviceXX

LR = long run; SR = short run

Note that the Ministry of Finance has an office overseeing insurance programs and carriers of all types. They also have actuarial capacity available when required.

Jamkesmas

Institutional structures

Key Actors in Insurance Administration: Central Government, District/Local Government, Commercial insurers
Organization: Decentralized to district/local level
Collections Responsibility: District/Local Government
Operations Responsibility: Central Government, District/Local Government
Oversight Responsibility: Central Government

Presently, five main actors are involved in the administration of the Jamkesmas scheme (1) the National Social Security Council (DJSN), (2) national government agencies, including Depkes (MoH), the Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA), Ministry of Social Affairs (Menkokesra), and the Ministry of National Development Planning (Bappenas), (3) provincial and district governments, (4) public and private providers of care, and (5) the insurer/third-party administrator.

A revised institutional structure of Indonesia’s Jamkesmas scheme is currently being developed. The table below summarizes the roles and responsibilities of all of the organizations involved in implementing national health insurance, including Jamkesmas:

National Soc Sec Council (DJSN)National government agencies (MoH, MoF, MoHA, Menkokesra, Bappenas)Provincial and district governmentsProviders of careInsurer/TPA (Askes/ Jamsostek)
Oversight of schemeX (LR)X (SR)
Financing schemeXX
Setting parameters (benefits package, definitions of poor, etc.)X (LR)X (SR)
Accreditation/Empanelment of providersXX
EnrollmentXXX
Financial management/planningX (LR)X (SR)
Actuarial analysisX (LR)
Setting rate schedules for services/reimbursement ratesX (LR)X (SR)
Claims processing and paymentX (Under Review)XX (District level)
Outreach, Marketing to beneficiaries X
Service deliveryX
Developing clinical information system for monitoring/evalX (LR)X (SR)
Monitoring local-level utilization and other patient informationX (LR) X (SR)
Monitoring national aggregate informationX (LR)
Customer serviceXX

LR = long run; SR = short run

Note that the Ministry of Finance has an office overseeing insurance programs and carriers of all types. They also have actuarial capacity available when required.
Mali: Mutuelles
  • Central Government
  • District/Local Government
  • Mutuelles
  • Decentralized to district/local level
  • Mutuelles
  • Mutuelles
  • Central Government
  • District/Local Government

Although the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one.

For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.

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Although the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one.

For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.

Organization chart of the Mutuelle system

Table 4 illustrates the institutional framework planned for the Mutuelle system.

Table 4: Institutional system for the Mutuelle system

CommitteeRoleCompositionOperating procedures
Pilot Phase Steering and Monitoring Committee (CPSPP) at the national levelStrategic management and decision-making that contribute to achieving the following goals:
  • Validate the annual development operating plans for the Mutuelle system, including the financial framework
  • Recruit the implementation agencies
  • Raise the funds needed to implement the strategy
  • Assess the results of the activities carried out under this strategy
  • Give orientation and instructions to achieve the strategy’s results
Chairs - Secretaries General MDSSPA, MS, MPFEF

Members - CPS/SSDSPF, DNS, DNPSES, DNDS, APCAM, APCMM, CCIM, CNC, AMM, UTM, DNI, HCCT, DNB, ANAM, CANAM, FENASCOM, Health professional associations, technical and financial partners, National Federation of Mutuelles		The Committee meets twice a year and reports on its work to the Ministers of Social Protection and Health
National level Technical Committee (TC)Technical coordination of activities carried out under the Strategy Pilot:
  • Validate the training materials
  • Validate the Mutuelle management tools
  • Validate the communication plan
  • Assess the investment requirements
  • Assess the results of activities carried out as part of this strategy
  • Send the assessment of the results achieved to the CPSPP
  • Submit all the corrections it deems necessary to promote achieving the objectives to the CPSPP
Chair - DNPSES Director

Members - DNDS, DNPSES, CPS, DNS, UTM, CAMASC, DNB, AMM, National Federation of Mutuelles		The TC meets at least three times a year and reports on its work to the CPSPP
Regional Monitoring Committee (CSR)Monitoring of the activities that are planned under the strategy at the regional level. All the technical parameters, the draft laws and the organizing of unions of district Mutuelles are determined and the Local (District) Monitoring Committee is fully involved:
  • Facilitate the implementation of scheduled activities
  • Mobilize local resources
  • Assess the results of the activities carried out under this strategy
  • Send the evaluation of the results to the TC
  • Propose to the TC all the corrections it deems necessary to help achieve the objectives
Chair - Governor

Members - Decentralized government units (Finances, Social Development and Health), Regional Assembly, Regional Federation of Mutuelles, FERASCOM, cooperatives, women’s associations and decentralized financing systems (microfinance networks)		The CSR meets at least four times a year and reports on its work to the TC
District Monitoring Committee (CSL)Monitoring of the activities planned under the strategy at the district level:
  • Facilitate the implementation of the scheduled activities
  • Mobilize local resources
  • Assess the results of the activities carried out under this strategy
  • Submit the evaluation of the results to the CSR
  • Propose to the CSR all the corrections it deems necessary to help achieve the objectives
Chair - District prefect

Members - Decentralized government units (Finance, Social Development and Health), District Council, District Federation of Mutuelles, FELASCOM, agricultural cooperatives, women’s associations and decentralized financing systems (microfinance networks)		The CSL meets at least four times a year and reports to the CSR on its work
Communal Monitoring Committee (CSC)Monitoring of the status of strategy implementation at the commune level:
  • Report on the status of implementation of the planned activities
  • Make decisions to remove the obstacles that prevent the communal Mutuelle from working properly
  • Report to the CSL
Chair - Mayor(s)

Members - Decentralized technical entities, ASACO, Communal health Mutuelle, local NGOs, village councils

Source: Ministry of Social Protection

For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5.

Table 5: Organization and operating procedures– AMO and RAMED

Body and systemRoleRepresentation
Board of directors (RAMED and AMO)
  • Adopt the budget and annual activities program
  • Determine the annual qualitative and quantitative Objectives that the CANAM or the ANAM is to achieve
  • Authorize the implementing regulations for the system
  • Authorize the Managing Director (MD) to sign all the contracts and conventions that are binding on CANAM or ANAM for a period longer than 24 months (for CANAM) or that exceed CFAF 10 million (for ANAM)
  • Determine the organization of the Fund or the Agency
  • Approve the financial statements for the fiscal year and the report on the MD’s activities
  • Approve other investment and real estate transactions and real estate guarantees
AMO - Ministry of Social Protection, Ministry of Finance, Ministry of the Civil Service, Ministry of Health, Ministry of Defense, Associations of employers, workers, retires, MPs, and CANAM

RAMED - Ministry of Social Protection, Ministry of Finance, Ministry of National Administration, Ministry of Health, High Council of Territorial Governments, Association of District and Regional Governments of Mali, Association of Municipalities of Mali, National Federation of Community Health Associations (FENASCOM), ANAM
Managing Director (RAMED and AMO)
  • Manage, coordinate, lead and oversee all CANAM or ANAM activities
MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection
Delegated management bodies (AMO)
  • Collect dues
  • Pay for care services
The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS)

Source: Ministry of Social Protection

Mutuelles

Institutional structures

Key Actors in Insurance Administration: Central Government, District/Local Government, Mutuelles
Organization: Decentralized to district/local level
Collections Responsibility: Mutuelles
Operations Responsibility: Mutuelles
Oversight Responsibility: Central Government, District/Local Government

Although the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one.

For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.

Organization chart of the Mutuelle system

Table 4 illustrates the institutional framework planned for the Mutuelle system.

Table 4: Institutional system for the Mutuelle system

CommitteeRoleCompositionOperating procedures
Pilot Phase Steering and Monitoring Committee (CPSPP) at the national levelStrategic management and decision-making that contribute to achieving the following goals:
  • Validate the annual development operating plans for the Mutuelle system, including the financial framework
  • Recruit the implementation agencies
  • Raise the funds needed to implement the strategy
  • Assess the results of the activities carried out under this strategy
  • Give orientation and instructions to achieve the strategy’s results
Chairs - Secretaries General MDSSPA, MS, MPFEF

Members - CPS/SSDSPF, DNS, DNPSES, DNDS, APCAM, APCMM, CCIM, CNC, AMM, UTM, DNI, HCCT, DNB, ANAM, CANAM, FENASCOM, Health professional associations, technical and financial partners, National Federation of Mutuelles		The Committee meets twice a year and reports on its work to the Ministers of Social Protection and Health
National level Technical Committee (TC)Technical coordination of activities carried out under the Strategy Pilot:
  • Validate the training materials
  • Validate the Mutuelle management tools
  • Validate the communication plan
  • Assess the investment requirements
  • Assess the results of activities carried out as part of this strategy
  • Send the assessment of the results achieved to the CPSPP
  • Submit all the corrections it deems necessary to promote achieving the objectives to the CPSPP
Chair - DNPSES Director

Members - DNDS, DNPSES, CPS, DNS, UTM, CAMASC, DNB, AMM, National Federation of Mutuelles		The TC meets at least three times a year and reports on its work to the CPSPP
Regional Monitoring Committee (CSR)Monitoring of the activities that are planned under the strategy at the regional level. All the technical parameters, the draft laws and the organizing of unions of district Mutuelles are determined and the Local (District) Monitoring Committee is fully involved:
  • Facilitate the implementation of scheduled activities
  • Mobilize local resources
  • Assess the results of the activities carried out under this strategy
  • Send the evaluation of the results to the TC
  • Propose to the TC all the corrections it deems necessary to help achieve the objectives
Chair - Governor

Members - Decentralized government units (Finances, Social Development and Health), Regional Assembly, Regional Federation of Mutuelles, FERASCOM, cooperatives, women’s associations and decentralized financing systems (microfinance networks)		The CSR meets at least four times a year and reports on its work to the TC
District Monitoring Committee (CSL)Monitoring of the activities planned under the strategy at the district level:
  • Facilitate the implementation of the scheduled activities
  • Mobilize local resources
  • Assess the results of the activities carried out under this strategy
  • Submit the evaluation of the results to the CSR
  • Propose to the CSR all the corrections it deems necessary to help achieve the objectives
Chair - District prefect

Members - Decentralized government units (Finance, Social Development and Health), District Council, District Federation of Mutuelles, FELASCOM, agricultural cooperatives, women’s associations and decentralized financing systems (microfinance networks)		The CSL meets at least four times a year and reports to the CSR on its work
Communal Monitoring Committee (CSC)Monitoring of the status of strategy implementation at the commune level:
  • Report on the status of implementation of the planned activities
  • Make decisions to remove the obstacles that prevent the communal Mutuelle from working properly
  • Report to the CSL
Chair - Mayor(s)

Members - Decentralized technical entities, ASACO, Communal health Mutuelle, local NGOs, village councils

Source: Ministry of Social Protection

For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5.

Table 5: Organization and operating procedures– AMO and RAMED

Body and systemRoleRepresentation
Board of directors (RAMED and AMO)
  • Adopt the budget and annual activities program
  • Determine the annual qualitative and quantitative Objectives that the CANAM or the ANAM is to achieve
  • Authorize the implementing regulations for the system
  • Authorize the Managing Director (MD) to sign all the contracts and conventions that are binding on CANAM or ANAM for a period longer than 24 months (for CANAM) or that exceed CFAF 10 million (for ANAM)
  • Determine the organization of the Fund or the Agency
  • Approve the financial statements for the fiscal year and the report on the MD’s activities
  • Approve other investment and real estate transactions and real estate guarantees
AMO - Ministry of Social Protection, Ministry of Finance, Ministry of the Civil Service, Ministry of Health, Ministry of Defense, Associations of employers, workers, retires, MPs, and CANAM

RAMED - Ministry of Social Protection, Ministry of Finance, Ministry of National Administration, Ministry of Health, High Council of Territorial Governments, Association of District and Regional Governments of Mali, Association of Municipalities of Mali, National Federation of Community Health Associations (FENASCOM), ANAM
Managing Director (RAMED and AMO)
  • Manage, coordinate, lead and oversee all CANAM or ANAM activities
MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection
Delegated management bodies (AMO)
  • Collect dues
  • Pay for care services
The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS)

Source: Ministry of Social Protection
Rwanda: Mutuelles de Sante
  • Central Government
  • District/Local Government
  • Decentralized to district/local level
  • Mutuelles
  • District/Local Government
  • Mutuelles
  • Central Government
  • District/Local Government

The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

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The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels.

The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers.

In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.

Reformed Rwandan Health System

Mutuelles de Sante

Institutional structures

Key Actors in Insurance Administration: Central Government, District/Local Government
Organization: Decentralized to district/local level
Collections Responsibility: Mutuelles
Operations Responsibility: District/Local Government, Mutuelles
Oversight Responsibility: Central Government, District/Local Government

The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels.

The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers.

In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.

Reformed Rwandan Health System
Korea, Rep.: National Health Insurance Program
  • Central Government
  • Centralized
  • Central Government
  • Central Government
  • Central Government

The Ministry of Health and Welfare (MoHW) supervises the overall matters relating to health insurance and health sector. MoHW is in charge of the centralized policy formation and implementation, regulating the health insurance system, and approving the annual plans and budgets set by the National Health Insurance Corporation (NHIC) and the Health Insurance Review Agency (HIRA), both of which are discrete non-profit organizations that are supervised and regulated by the MoHW.

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The Ministry of Health and Welfare (MoHW) supervises the overall matters relating to health insurance and health sector. MoHW is in charge of the centralized policy formation and implementation, regulating the health insurance system, and approving the annual plans and budgets set by the National Health Insurance Corporation (NHIC) and the Health Insurance Review Agency (HIRA), both of which are discrete non-profit organizations that are supervised and regulated by the MoHW.

The National Health Insurance Program (NHIP) is managed directly by the National Health Insurance Corporation (NHIC), the single purchaser in Korea. NHIC is in charge of managing the enrollment of insured people and their dependents, collecting contributions, and setting the medical fee schedule.

The Health Insurance Review Agency (HIRA) reviews medical fees and health care evaluation. The HIRA also receives and reimburses claims from health care providers. The HIRA committee consists of 10 full-time and 630 part-time medical specialists divided into a central committee and local committees. The committee reviews the appropriateness of medical care claims based on health benefits standards and fees that are determined by the MoHW.

National Health Insurance Program

National Health Insurance Program

Institutional structures

Key Actors in Insurance Administration: Central Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government

The Ministry of Health and Welfare (MoHW) supervises the overall matters relating to health insurance and health sector. MoHW is in charge of the centralized policy formation and implementation, regulating the health insurance system, and approving the annual plans and budgets set by the National Health Insurance Corporation (NHIC) and the Health Insurance Review Agency (HIRA), both of which are discrete non-profit organizations that are supervised and regulated by the MoHW.

The National Health Insurance Program (NHIP) is managed directly by the National Health Insurance Corporation (NHIC), the single purchaser in Korea. NHIC is in charge of managing the enrollment of insured people and their dependents, collecting contributions, and setting the medical fee schedule.

The Health Insurance Review Agency (HIRA) reviews medical fees and health care evaluation. The HIRA also receives and reimburses claims from health care providers. The HIRA committee consists of 10 full-time and 630 part-time medical specialists divided into a central committee and local committees. The committee reviews the appropriateness of medical care claims based on health benefits standards and fees that are determined by the MoHW.

National Health Insurance Program