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.
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| Colombia: General System of Social Security in Health |
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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. Read full sectionIn 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 HealthInstitutional 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. |
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| Indonesia: Jamkesmas |
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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. Read full sectionPresently, 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:
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. JamkesmasInstitutional 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:
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. |
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| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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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. Read full sectionThe 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:
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:
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| Kenya: National Hospital Insurance Fund |
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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. Read full sectionWhen 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).
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. National Hospital Insurance FundInstitutional structures Key Actors in Insurance Administration: Central Government, District/Local Government
Organization: Decentralized to district/local level
Collections Responsibility: District/Local Government
Operations Responsibility: District/Local Government
Oversight Responsibility: Central Government 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).
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. |
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| India: Rajiv Aarogyasri |
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Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme. Read full sectionAarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme. The administrative structure of Aarogyasri is comprised of four main organizations:
The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:
Rajiv AarogyasriInstitutional structures Key Actors in Insurance Administration:
Organization: Centralized
Collections Responsibility: State Government
Operations Responsibility: State Government, Commercial insurers
Oversight Responsibility: State Government Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme. The administrative structure of Aarogyasri is comprised of four main organizations:
The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:
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| India: RSBY |
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Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Read full sectionSeveral stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household. Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time. The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals. The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states. Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing. The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
RSBYInstitutional structures Key Actors in Insurance Administration: Central Government, State Government, Commercial insurers, NGOs
Organization: Decentralized to state level
Collections Responsibility: State Government, Commercial insurers
Operations Responsibility: Commercial insurers
Oversight Responsibility: Central Government, State Government Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household. Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time. The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals. The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states. Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing. The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
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| Brazil: Unified Health System (SUS) |
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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. Read full sectionThe 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. Unified Health System (SUS)Institutional structures Key Actors in Insurance Administration: Central Government, State Government, District/Local Government
Organization: Decentralized to district/local level
Collections Responsibility: Central Government, State Government, District/Local Government
Operations Responsibility: State Government, District/Local Government
Oversight Responsibility: Central Government, State Government 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. |
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| Thailand: Universal Coverage Scheme |
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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. Read full sectionUCS 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.
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 SchemeInstitutional 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.
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. |
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.
