UHC Forward: Towards Universal Health Coverage

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.

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

Table 4: Institutional system for the Mutuelle system

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

Source: Ministry of Social Protection

The scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services.

PhilHealth is responsible for oversight and administration of public sector insurance schemes. It has a governing board chaired by the Secretary of Health with representation from other government departments (ministries) and agencies, and the private sector including the OFW sector.

PhilHealth also features a governing board composed of 13 individuals, chaired by the Secretary of Health, with the president and CEO of Philhealth as vice-chariman. The president and CEO have a fixed term of 6 years.

Salaries and other operating expenses are derived from premium payments and the income of the funds under management. PhilHealth can use up to 12% of the previous year’s premium and 3% of the income of the fund it manages towards operating expenses.

For monitoring and evaluation, Congress has mandated the National Institutes of Health (based in the University of the Philippines) to conduct studies that will verify and validate the performance of PhilHealth.

The Brazilian health system is largely decentralized. Funds collection takes place at the federal, state, and municipal levels, with the municipal level as the final destination for resources. Operations within the Brazilian health system are managed primarily at the state and municipal levels. Finally, federal and state governments have primary responsibility for overseeing the health system, with the Ministry of Health and the state health secretariats taking lead roles.

The Brazilian health system is divided into the Unified Health System (SUS), which encompasses the public provision of health care, and the Supplementary Health System (SHS), which encompasses the private provision of health services. Under the SUS, the federal government is responsible for developing national policies, controlling national regulation, providing technical and financial assistance to states and municipalities, and regulating public-private relations as well as private sector activity. The states are responsible for the regional network, as well as for supervising and providing technical and financial support to the municipalities. The municipalities are responsible for providing health services and health planning.

At the federal level, the Ministry of Health (MOH) is responsible for the health sector. The MOH has counterparts at the state and municipal level which are organized into Secretariats. Each of the secretariats has a health fund responsible for consolidating the financial resources that come from the different sources (i.e. the municipal fund consolidates municipal, state and federal resources while the state fund consolidates state and federal resources).

Planning and allocation decisions occur every four years at National Health Conferences (NHC). The most recent one was the 13th NHC in 2007. Conferences occur in stages whereby municipal health councils meet first, followed by state councils, and finally ending with the national conference. The councils are formed by the following types of members: 50% are users of the SUS, 25% are elected representatives from the health professions, and 25% are elected representatives of managers and providers of public health services. The health councils are bodies of the executive branch which include the Ministry of Health, the State Secretary of Health, and the Municipal Secretary of Health. As of 2006, Brazil had 4,390 municipal health councils with at least 100,000 members in total. Most of these municipal councils were formed in 1991. The National Health Council has 48 members and holds monthly plenary meetings, organizes commissions and work groups, and has an executive secretary.

In preparation for each conference, each council produces a priority-setting health policy report concerning a core subject that is predetermined by the NHC. Municipal reports are sent to the state committee and the state reports are sent to the national committee. During the last five days of the last NHC, ten discussion groups debated and voted for the health legislation proposed by the state jurisdictions. Those that received at least 70% of the vote and were approved by 6 out of the 10 discussion groups became policy. Proposals that received between 30% and 69% of the vote could become policy if during a final voting round they received 50% plus one vote.