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
Vietnam: Compulsory and Voluntary Health Insurance Schemes
  • Central Government
  • State Government
  • Centralized
  • Central Government
  • Central Government
  • Central Government

The MoH is responsible for overseeing all health insurance programs, while the VSS is the main agency implementing the schemes. The Ministry of Labor - Invalids and Social Affairs (MOLISA) is tasked with identifying the beneficiaries of the HCFP.

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The MoH is responsible for overseeing all health insurance programs, while the VSS is the main agency implementing the schemes. The Ministry of Labor - Invalids and Social Affairs (MOLISA) is tasked with identifying the beneficiaries of the HCFP.

The VSS is a government agency responsible for the administration of the various social insurance programs, including the collection of insurance premiums. In addition to collecting revenues, VSS’s main responsibility is to issue health insurance cards and reimburse service providers.

The MoF manages the tax-transfer process that provides the resources that local governments use to provide budget support to public facilities and to pay the VSS for subsidized enrollees. VSS collects mandatory (and voluntary) contributions to the health insurance program, then pools these with the subsidies from the MoF, and pays the providers for care received by people covered by VSS.

Compulsory and Voluntary Health Insurance Schemes

Institutional structures

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

The MoH is responsible for overseeing all health insurance programs, while the VSS is the main agency implementing the schemes. The Ministry of Labor - Invalids and Social Affairs (MOLISA) is tasked with identifying the beneficiaries of the HCFP.

The VSS is a government agency responsible for the administration of the various social insurance programs, including the collection of insurance premiums. In addition to collecting revenues, VSS’s main responsibility is to issue health insurance cards and reimburse service providers.

The MoF manages the tax-transfer process that provides the resources that local governments use to provide budget support to public facilities and to pay the VSS for subsidized enrollees. VSS collects mandatory (and voluntary) contributions to the health insurance program, then pools these with the subsidies from the MoF, and pays the providers for care received by people covered by VSS.
Estonia: Estonian Health Insurance Fund
  • Centralized
  • Central Government
  • Central Government
  • Central Government

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.

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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

Decision-makingAppointment of supervisory boardAppointment of management boardFinancingServicesPricesPayment methodsContractingReservesFund management
President------------------
Parliament----+++++--+--
Government+++++++++++++--
Ministry of Social Affairs+++++++++++--
Ministry of Finance----++--------+--
Supervisory board--++++++++++++
Management board--+--++++++++
Providers------+++++----

(++ 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

Organization Structure of the Health Care System

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.

Estonian Health Insurance Fund

Institutional structures

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

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

Decision-makingAppointment of supervisory boardAppointment of management boardFinancingServicesPricesPayment methodsContractingReservesFund management
President------------------
Parliament----+++++--+--
Government+++++++++++++--
Ministry of Social Affairs+++++++++++--
Ministry of Finance----++--------+--
Supervisory board--++++++++++++
Management board--+--++++++++
Providers------+++++----

(++ 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

Organization Structure of the Health Care System

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.
Colombia: General System of Social Security in Health
  • Commercial insurers
  • Centralized
  • Commercial insurers
  • Commercial insurers
  • Central Government

In 2002, what had been the Ministry of Labor and the Ministry of Health were merged together to form the Ministry of Social Protection (MPS). The MPS is responsible for pensions, health insurance, public health programs, and other social assistance programs.

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In 2002, what had been the Ministry of Labor and the Ministry of Health were merged together to form the Ministry of Social Protection (MPS). The MPS is responsible for pensions, health insurance, public health programs, and other social assistance programs.

The National Council on Social Security in Health (CNSSS)—which is composed of representatives from the government, insurers, unions, employers, and pensioners among others—had been responsible for setting the UPC and content of the benefits packages. However, law 1122 of 2007 called for the CNSSS to take on a solely advisory role. As such, some of its duties include defining medications to be part of the CR and SR plans, designing the criteria by which beneficiaries of the SR are selected, and developing the necessary measures to avoid adverse selection on the part of EPSs and EPSSs.

Law 1122 passed the responsibility for setting the UPC and the content of the benefits packages to a new entity, the Health Regulatory Commission (CRES). This commission is presided by the MPS and also includes the Treasury as well as five expert commissioners as established under decree 1429. The shift in responsibility took place in order to have a more technically competent body overseeing what are by nature more technical issues.

The Health Superintendence is an entity separate from the MPS that is responsible for authorizing the entrance of new insurers into the regulated marketplace. It also supervises the performance of insurers, paying particular attention to their risk management practices. Finally, it functions as the entity through which complaints can be brought by the different actors within the health system.

General System of Social Security in Health

Institutional structures

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

In 2002, what had been the Ministry of Labor and the Ministry of Health were merged together to form the Ministry of Social Protection (MPS). The MPS is responsible for pensions, health insurance, public health programs, and other social assistance programs.

The National Council on Social Security in Health (CNSSS)—which is composed of representatives from the government, insurers, unions, employers, and pensioners among others—had been responsible for setting the UPC and content of the benefits packages. However, law 1122 of 2007 called for the CNSSS to take on a solely advisory role. As such, some of its duties include defining medications to be part of the CR and SR plans, designing the criteria by which beneficiaries of the SR are selected, and developing the necessary measures to avoid adverse selection on the part of EPSs and EPSSs.

Law 1122 passed the responsibility for setting the UPC and the content of the benefits packages to a new entity, the Health Regulatory Commission (CRES). This commission is presided by the MPS and also includes the Treasury as well as five expert commissioners as established under decree 1429. The shift in responsibility took place in order to have a more technically competent body overseeing what are by nature more technical issues.

The Health Superintendence is an entity separate from the MPS that is responsible for authorizing the entrance of new insurers into the regulated marketplace. It also supervises the performance of insurers, paying particular attention to their risk management practices. Finally, it functions as the entity through which complaints can be brought by the different actors within the health system.
Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF)
  • Central Government
  • Centralized
  • Central Government
  • Central Government
  • Central Government

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.

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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.

Mandatory Health Insurance Fund (MHIF)

Institutional structures

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

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.
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
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
Ghana: National Health Insurance Scheme (NHIS)
  • Central Government
  • District/Local Government
  • Decentralized to district/local level
  • Central Government
  • District/Local Government
  • District/Local Government
  • Central Government

The National Health Insurance Authority is the national governing body of the NHIS. Each DWMHI scheme is managed by a Board, which is elected by a General Assembly comprised of Community Health Insurance Committee (CHIC) representatives. Monitoring is carried out at all levels, including by the NHIS, district schemes, and health care providers.

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The National Health Insurance Authority is the national governing body of the NHIS. Each DWMHI scheme is managed by a Board, which is elected by a General Assembly comprised of Community Health Insurance Committee (CHIC) representatives. Monitoring is carried out at all levels, including by the NHIS, district schemes, and health care providers.

See Figure 1 below for an illustrative depiction of the institutional structure of the NHIS.

National Health Insurance Scheme, Ghana, Institutional Framework

Its mandate is “to secure the implementation of a national health insurance policy that ensures basic healthcare services to all residents.” Section 3 of the Act establishes the governing body of the Authority, known as the National Health Insurance Council (NHIC), which administers the National Health Insurance Fund. The President of Ghana is given sole power to appoint the chairperson and members of the Council.

CHIC representatives represent geographically determined ‘Health Insurance Communities’ within each district. The CHIC exists officially to oversee the collection of contributions within its designated Health Insurance Community, to supervise the deposit of these into the District Health Insurance Fund, and to represent community interests in the management structures of the DWMHIS.

The figure below presents an illustrative depiction of the financial structure of the NHIS, including sources of cash flow and the organizational structure of the management of NHIS financial resources.

Cash flow of the NHIS

National Health Insurance Scheme (NHIS)

Institutional structures

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

The National Health Insurance Authority is the national governing body of the NHIS. Each DWMHI scheme is managed by a Board, which is elected by a General Assembly comprised of Community Health Insurance Committee (CHIC) representatives. Monitoring is carried out at all levels, including by the NHIS, district schemes, and health care providers.

See Figure 1 below for an illustrative depiction of the institutional structure of the NHIS.

National Health Insurance Scheme, Ghana, Institutional Framework

Its mandate is “to secure the implementation of a national health insurance policy that ensures basic healthcare services to all residents.” Section 3 of the Act establishes the governing body of the Authority, known as the National Health Insurance Council (NHIC), which administers the National Health Insurance Fund. The President of Ghana is given sole power to appoint the chairperson and members of the Council.

CHIC representatives represent geographically determined ‘Health Insurance Communities’ within each district. The CHIC exists officially to oversee the collection of contributions within its designated Health Insurance Community, to supervise the deposit of these into the District Health Insurance Fund, and to represent community interests in the management structures of the DWMHIS.

The figure below presents an illustrative depiction of the financial structure of the NHIS, including sources of cash flow and the organizational structure of the management of NHIS financial resources.

Cash flow of the NHIS
Mexico: Seguro Popular
  • Central Government
  • State Government
  • Decentralized to state level
  • State Government
  • State Government
  • Central Government

Mexico’s health system is guided by the federal government but operations are decentralized to the state level. Family premiums as well as federal transfers are collected at the state level. The states are also responsible for the provision of health services. Health system oversight is carried out at the national level by the MOH.

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Mexico’s health system is guided by the federal government but operations are decentralized to the state level. Family premiums as well as federal transfers are collected at the state level. The states are also responsible for the provision of health services. Health system oversight is carried out at the national level by the MOH.

The function of the Social Protection in Health Regimes (REPSS) at the state level is to integrate and coordinate the network of health care providers in order to guarantee that SP enrollees have access to the services offered under the benefits package. The mechanisms used to control the network of providers are subscription agreements and contracts with public, private, and civil society institutions.

The General Health Committee, which is chaired by the Health Minister, includes the leaders of all the public health institutions in Mexico as well as experts in the field, non-governmental organizations, professional associations and the private sector. This Committee is responsible for defining the diseases, treatments, and medications that are covered under the FPGC.

Organization of the System of Social Protection in Health

Seguro Popular

Institutional structures

Key Actors in Insurance Administration: Central Government, State Government
Organization: Decentralized to state level
Collections Responsibility: State Government
Operations Responsibility: State Government
Oversight Responsibility: Central Government

Mexico’s health system is guided by the federal government but operations are decentralized to the state level. Family premiums as well as federal transfers are collected at the state level. The states are also responsible for the provision of health services. Health system oversight is carried out at the national level by the MOH.

The function of the Social Protection in Health Regimes (REPSS) at the state level is to integrate and coordinate the network of health care providers in order to guarantee that SP enrollees have access to the services offered under the benefits package. The mechanisms used to control the network of providers are subscription agreements and contracts with public, private, and civil society institutions.

The General Health Committee, which is chaired by the Health Minister, includes the leaders of all the public health institutions in Mexico as well as experts in the field, non-governmental organizations, professional associations and the private sector. This Committee is responsible for defining the diseases, treatments, and medications that are covered under the FPGC.

Organization of the System of Social Protection in Health
Thailand: Universal Coverage Scheme
  • Central Government
  • Centralized
  • Central Government
  • Central Government
  • Central Government

UCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board.

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UCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board. Furthermore, the NHSO has regional and provincial branch offices to handle beneficiary questions and requests.

Governance in the Thai public health insurance system is fragmented. The National Health Security Office manages and oversees the UCS, while the Ministry of Finance and Ministry of Labor oversee the other public insurance schemes as well as the private insurance market. The figure below presents a snapshot of the governance structure of Thai public insurance.

Thailand, the Health Insurance Model, 2007

While there are no standardized coding and reporting systems among Thai health care facilities and among insurers, the various public health insurance schemes have joined an initiative to integrate utilization databases among the schemes to develop statistical analysis of utilization activity, planning and monitoring processes.

The National Health Security Board has autonomy by law to steer overall management of the scheme. Co-payments, benefits package, standard guidelines, quality standards, contract processes, and payment mechanisms are decided by Board. There is a Standard Board which is responsible to prepare quality standards and oversee beneficiary complaints and grievances.

The UCS has its own IT infrastructure. While the clinical information system of the UCS is similar to other schemes, it is not identical. The UCS has also developed specific applications for health facilities to collect data for reimbursement in specific disease management programs (e.g. leukemia, diabetic mellitus, HIV/AIDS, etc.).

The UCS also has dedicated customer service facilities including a dedicated call centre. Branch offices and the call centre are available to beneficiaries to answer questions and request. Complaints and grievances are reviewed at branch offices and at the central office. Finally, outstanding grievances are decided in a subcommittee of the Standard Board.

The NHSO has regional branches offices and province branch offices to handle beneficiary questions and requests.

Universal Coverage Scheme

Institutional structures

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

UCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board. Furthermore, the NHSO has regional and provincial branch offices to handle beneficiary questions and requests.

Governance in the Thai public health insurance system is fragmented. The National Health Security Office manages and oversees the UCS, while the Ministry of Finance and Ministry of Labor oversee the other public insurance schemes as well as the private insurance market. The figure below presents a snapshot of the governance structure of Thai public insurance.

Thailand, the Health Insurance Model, 2007

While there are no standardized coding and reporting systems among Thai health care facilities and among insurers, the various public health insurance schemes have joined an initiative to integrate utilization databases among the schemes to develop statistical analysis of utilization activity, planning and monitoring processes.

The National Health Security Board has autonomy by law to steer overall management of the scheme. Co-payments, benefits package, standard guidelines, quality standards, contract processes, and payment mechanisms are decided by Board. There is a Standard Board which is responsible to prepare quality standards and oversee beneficiary complaints and grievances.

The UCS has its own IT infrastructure. While the clinical information system of the UCS is similar to other schemes, it is not identical. The UCS has also developed specific applications for health facilities to collect data for reimbursement in specific disease management programs (e.g. leukemia, diabetic mellitus, HIV/AIDS, etc.).

The UCS also has dedicated customer service facilities including a dedicated call centre. Branch offices and the call centre are available to beneficiaries to answer questions and request. Complaints and grievances are reviewed at branch offices and at the central office. Finally, outstanding grievances are decided in a subcommittee of the Standard Board.

The NHSO has regional branches offices and province branch offices to handle beneficiary questions and requests.