UHC Forward: Towards Universal Health Coverage

The Estonian Health System is centralized at the national level. Funds collection is managed by the Estonian Tax and Customs Board. The tax board then transfers the health contribution to the Estonian Health Insurance Fund (EHIF). The EHIF is also responsible for the operations of the financing system, as it is the only purchaser for health care services within the country. Health system oversight is carried out by both the EHIF supervisory board as well as the health division of the Ministry of Social Affairs.

The Estonian Health Insurance Fund (EHIF) is responsible for the financing of the health system. Its responsibilities include:

• Purchasing health care services by contracting with service providers
• Paying for services rendered
• Reimbursing enrollees for pharmaceuticals, sick leave, and maternity leave.

A 15 member supervisory board is responsible for EHIF results. This board is composed of representatives from employer organizations, insured individuals’ organizations, and the state. This board approves the four year development plan and the annual budget. The supervisory board also composes necessary reports and selects providers for contracting. It also has the authority to examine and audit all documents. The management board is responsible for daily EHIF operations. Under the management board, the central and four regional departments conduct needs assessments, contract with providers, and process claims.

The government plays a role in planning and regulating the health system by:

• Approving acts regulating public health issues
• Approving development plans for the hospital network
• Nominating members to the EHIF Supervisory Board

The health division of the Ministry of Social Affairs is responsible for:

• Developing and implementing health policy
• Supervising health service quality and access

Table 2: Influence on decisions made by the EHIF

(++ Strong Influence; + Moderate Influence; -- No Influence)
Source: Habicht T

County governments are responsible for:

• Announcing family doctor vacancies
• Approving family doctor post appointments
• Assigning family doctor service areas
• Organizing the supervision of practices at the county level

All health care providers within Estonia function as private parties operating under the purview of private law. Family practices are organized as private businesses or joint-stock companies, while hospitals are organized as for-profit joint stock companies or non-profit foundations.

The Kyrgyz health system is centralized at the national level. The Ministry of Health is responsible for health policy, regulation and the oversight of the health care system. Funds collection, pooling, and health purchasing is managed by the Mandatory Health Insurance Fund (MHIF) in the capital city of Bishkek. The MHIF is also responsible for the operations of the financing system, as it is the sole purchasing agency for health services within the Kyrgyz health system.

The MHIF is an agency of the MOH responsible for collecting premiums and for funding individual health services in the SGBP and the Additional Outpatient Drug Benefit. The MHIF is responsible for contracting with primary health care providers and hospitals and for paying them for services they provide to enrollees.

The Ministry of Health is responsible for creating a unified state policy for the health sector, functioning as the steward of health care in Kyrgyzstan. Under this banner, the MOH has the following responsibilities:

• Develop the State Guarantee Benefits Package (SGBP).
• Develop draft laws and other regulations in the health sector and submit them for consideration to the Government.
• Organize and implement the registration, licensing, and accounting of medical and pharmaceutical personnel.
• Supervise and coordinate the quality of medical education within the country.
• Provide for continuous operation of high-tech medical equipment and introduce new technologies at the tertiary level.
• Coordinate the activities of the Mandatory Health Insurance Fund (MHIF) although the relationship between the MOH and MHIF is further evolving due to the recent separation of the MHIF.
• Serve as the purchaser for some of the health program budgets including public health, medical education, and high-technology services.
• Coordinate public health activities.
• Support the charitable and humanitarian activities of NGOs, associations, movements and individuals within the health sector.
• Conduct internal audits of compliance with procurement procedures, financial operations, accounting systems in health organizations and their subordinate institutions.

When the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. The NHIF has decentralized its operations to 31 local branches and 82 service points across the country. These branches are responsible for claims processing and quality assurance, enrollment and collection of premiums (especially from informal sector employees and other ‘voluntary’ enrollees), and marketing of the program. The branches also implement quality programs alongside contracted providers, and execute most of the monitoring and evaluation programs within the NHIF.

Since its separation from the MOH, the NHIF is no longer held directly accountable by the MOH. Several new mechanisms for ensuring accountability have been instituted, however. These include the Board’s Audit and Integrity Subcommittee, the Auditor General of the Kenyan Government (which files annual reports to the Parliament on the performance of each government agency, including the NHIF), the NHIF’s Efficiency Monitoring Unit (which handles complaints and performs periodic audits of the operations of the agency) and finally the NHIF Ombudsman (which receives and mediates complaints).

Source: National Hospital Insurance Fund The Kenyan health system is administered from the top down by the Ministry of Health (MOH), which was broken into two Ministries after the post-election turmoil of 2007: the Ministry of Medical Services, and the Ministry of Public Health and Sanitation. Kenya has a Sector Wide Approach (SWAp) to coordinate and support the health care system, which incorporates health partners on all levels. The role of the central government is to formulate policy, set priorities, budget and allocate resources, and regulate service provision through a decentralized framework. Provinces, districts and local community areas are increasingly responsible for implementation and day to day management of the health system.

Implementing partners and development partners aid the MOH in implementing health plans by providing services such as funding, specialized care, research, training or health insurance. The majority of them are parastatals who receive a portion of their annual funds from the Government of Kenya and have to raise the other part themselves through cost sharing or other sources, such as the National Hospital Insurance Fund, the Kenyatta National Hospital, and Kenya Medical Research Institute, though they can also be private organizations.