Compare: Institutional structure

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
Rwanda: Mutuelles de Sante	Central Government District/Local Government	Decentralized to district/local level	Mutuelles	District/Local Government Mutuelles	Central Government District/Local Government	The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals. Read full section The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals. The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels. The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers. In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making. Mutuelles de Sante Institutional structures Key Actors in Insurance Administration: Central Government, District/Local Government Organization: Decentralized to district/local level Collections Responsibility: Mutuelles Operations Responsibility: District/Local Government, Mutuelles Oversight Responsibility: Central Government, District/Local Government The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals. The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels. The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers. In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.
Chile: National Health Fund (FONASA)	Central Government State Government	Centralized	Central Government	Central Government State Government	Central Government	The National Health Fund (FONASA) is a public insurer responsible for providing health coverage to persons who contribute 7% of their monthly wages as well as to the indigent. FONASA provides health coverage to all its beneficiaries without exclusions based on age, sex, income, number of family members, or preexisting conditions. It is also responsible for financing both the Institutional and Free Election modalities by collecting, administering, and distributing health resources. FONASA also finances the purchase of equipment, instruments, implements and other infrastructure elements that are needed for the public health system. Read full section The National Health Fund (FONASA) is a public insurer responsible for providing health coverage to persons who contribute 7% of their monthly wages as well as to the indigent. FONASA provides health coverage to all its beneficiaries without exclusions based on age, sex, income, number of family members, or preexisting conditions. It is also responsible for financing both the Institutional and Free Election modalities by collecting, administering, and distributing health resources. FONASA also finances the purchase of equipment, instruments, implements and other infrastructure elements that are needed for the public health system. The Ministry of Health (MOH) exercises many responsibilities within the health system: (1) it formulates, controls, and evaluates general plans and programs within the health sector; (2) it defines national health objectives; (3) it directs all national activities related to the provision of health activities; (4) it establishes general norms relating to technical, administrative, and financial matters within the health sector; (5) it monitors the fulfillment of health norms through the Regional Ministerial Health Secretariats; (6) it evaluates the states of public health issues; and (7) it formulates, evaluates, and implements the Universal Access with Explicit Guarantees (AUGE) plan. The National Health Superintendence was established in 2005 and charged with the responsibility of watching and controlling FONASA and the ISAPREs. Its primary tasks are to license both public and private health providers and to oversee AUGE compliance by both FONASA and the ISAPREs. The Health Insurance Institutions (ISAPREs) are for-profit or non-profit private insurers that must offer a minimum benefits package that is equal to the benefits covered under GES. However, they are free to provide additional coverage to those willing to purchase it. National Health Fund (FONASA) Institutional structures Key Actors in Insurance Administration: Central Government, State Government Organization: Centralized Collections Responsibility: Central Government Operations Responsibility: Central Government, State Government Oversight Responsibility: Central Government The National Health Fund (FONASA) is a public insurer responsible for providing health coverage to persons who contribute 7% of their monthly wages as well as to the indigent. FONASA provides health coverage to all its beneficiaries without exclusions based on age, sex, income, number of family members, or preexisting conditions. It is also responsible for financing both the Institutional and Free Election modalities by collecting, administering, and distributing health resources. FONASA also finances the purchase of equipment, instruments, implements and other infrastructure elements that are needed for the public health system. The Ministry of Health (MOH) exercises many responsibilities within the health system: (1) it formulates, controls, and evaluates general plans and programs within the health sector; (2) it defines national health objectives; (3) it directs all national activities related to the provision of health activities; (4) it establishes general norms relating to technical, administrative, and financial matters within the health sector; (5) it monitors the fulfillment of health norms through the Regional Ministerial Health Secretariats; (6) it evaluates the states of public health issues; and (7) it formulates, evaluates, and implements the Universal Access with Explicit Guarantees (AUGE) plan. The National Health Superintendence was established in 2005 and charged with the responsibility of watching and controlling FONASA and the ISAPREs. Its primary tasks are to license both public and private health providers and to oversee AUGE compliance by both FONASA and the ISAPREs. The Health Insurance Institutions (ISAPREs) are for-profit or non-profit private insurers that must offer a minimum benefits package that is equal to the benefits covered under GES. However, they are free to provide additional coverage to those willing to purchase it.
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. Read full section 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. 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.
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. Read full section 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. 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. 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.