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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Colombia: General System of Social Security in Health |
|
|
|
|
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Mali: Mutuelles |
|
|
|
|
|
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. Read full sectionAlthough the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one. For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.
Table 4 illustrates the institutional framework planned for the Mutuelle system. Table 4: Institutional system for the Mutuelle system
Source: Ministry of Social Protection For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5. Table 5: Organization and operating procedures– AMO and RAMED
Source: Ministry of Social Protection MutuellesInstitutional 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.
Table 4 illustrates the institutional framework planned for the Mutuelle system. Table 4: Institutional system for the Mutuelle system
Source: Ministry of Social Protection For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5. Table 5: Organization and operating procedures– AMO and RAMED
Source: Ministry of Social Protection |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| : Taiwan: National Health Insurance |
|
|
|
|
|
The organization of health administration in Taiwan is divided into two structures: The National level and the local level. The National Health Insurance (NHI) system is administered by the central government, which has the overall responsibility for the formulation of health care policies and the regulation of health care services throughout Taiwan. Read full sectionThe organization of health administration in Taiwan is divided into two structures: The National level and the local level. The National Health Insurance (NHI) system is administered by the central government, which has the overall responsibility for the formulation of health care policies and the regulation of health care services throughout Taiwan. The Department of Health (DOH) has jurisdiction over the Bureau of National Health Insurance (BNHI), the NHI supervisory Committee, the NHI Dispute Mediation Committee, and the NHI Medical Expenditure Negotiation Committee, all of which plan and monitor tasks that relate to the NHI. BNHI acts as the primary executive of the NHI. BNHI contracts with health care facilities and is the primary organization responsible for administering the National Health Insurance system, collecting premiums from the insured and regulating health care services for the insured. Under the executive branch, Taiwan has 6 regional divisions divided into 25 local health bureaus under city or county local governments. These local bureaus are responsible for daily operations of health management and directly handle underwriting operations, insurance premium collection, review and payment of medical claims, and management of NHI-contracted medical care institutions. The bureaus all have close relationships to local level health and aid in managing the contracted medical institutions through quality counseling, and management of emergency rescue services, mental health services, and human resources. In addition, each of the 25 county governments in Taiwan has a health liaison bureau, which is responsible for the operation of public health centers within their geographical region under the guidance of the health department. While the NHI is governed by the central government, most management of NHI is decentralized. The BNHI is the primary overseer of NHI, acts to set the annual national budget, and implements most policy in a centralized, top-down fashion. The BNHI also acts as the primary intermediary between the insured and the providers. Oversight of the NHI is also provided by the NHI Supervisory Committee (NHISC), which provides a forum for social associations, employers and providers to communicate with one another; the NHI Disputes Mediation Committee (NHIDM), which mediates disputes between the insured and providers; the NHI Expenditure Negotiation Committee (NHIENC), which negotiates the payments for providers under the Global Budget Payment; and the NHI Task Force. The daily management of the NHI, however, is highly decentralized. The BNHI distributes responsibilities to the 6 regional divisions and local governments. National Health InsuranceInstitutional 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: Central Government, District/Local Government
Oversight Responsibility: Central Government The organization of health administration in Taiwan is divided into two structures: The National level and the local level. The National Health Insurance (NHI) system is administered by the central government, which has the overall responsibility for the formulation of health care policies and the regulation of health care services throughout Taiwan. The Department of Health (DOH) has jurisdiction over the Bureau of National Health Insurance (BNHI), the NHI supervisory Committee, the NHI Dispute Mediation Committee, and the NHI Medical Expenditure Negotiation Committee, all of which plan and monitor tasks that relate to the NHI. BNHI acts as the primary executive of the NHI. BNHI contracts with health care facilities and is the primary organization responsible for administering the National Health Insurance system, collecting premiums from the insured and regulating health care services for the insured. Under the executive branch, Taiwan has 6 regional divisions divided into 25 local health bureaus under city or county local governments. These local bureaus are responsible for daily operations of health management and directly handle underwriting operations, insurance premium collection, review and payment of medical claims, and management of NHI-contracted medical care institutions. The bureaus all have close relationships to local level health and aid in managing the contracted medical institutions through quality counseling, and management of emergency rescue services, mental health services, and human resources. In addition, each of the 25 county governments in Taiwan has a health liaison bureau, which is responsible for the operation of public health centers within their geographical region under the guidance of the health department. While the NHI is governed by the central government, most management of NHI is decentralized. The BNHI is the primary overseer of NHI, acts to set the annual national budget, and implements most policy in a centralized, top-down fashion. The BNHI also acts as the primary intermediary between the insured and the providers. Oversight of the NHI is also provided by the NHI Supervisory Committee (NHISC), which provides a forum for social associations, employers and providers to communicate with one another; the NHI Disputes Mediation Committee (NHIDM), which mediates disputes between the insured and providers; the NHI Expenditure Negotiation Committee (NHIENC), which negotiates the payments for providers under the Global Budget Payment; and the NHI Task Force. The daily management of the NHI, however, is highly decentralized. The BNHI distributes responsibilities to the 6 regional divisions and local governments. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Korea, Rep.: National Health Insurance Program |
|
|
|
|
|
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. Read full sectionThe 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 ProgramInstitutional 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.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ghana: National Health Insurance Scheme (NHIS) |
|
|
|
|
|
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. Read full sectionThe 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.
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.
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.
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.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Philippines: PhilHealth |
|
|
|
|
|
The scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services. PhilHealth is responsible for oversight and administration of public sector insurance schemes. Read full sectionThe scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services. PhilHealth is responsible for oversight and administration of public sector insurance schemes. It has a governing board chaired by the Secretary of Health with representation from other government departments (ministries) and agencies, and the private sector including the OFW sector. PhilHealth also features a governing board composed of 13 individuals, chaired by the Secretary of Health, with the president and CEO of Philhealth as vice-chariman. The president and CEO have a fixed term of 6 years. Salaries and other operating expenses are derived from premium payments and the income of the funds under management. PhilHealth can use up to 12% of the previous year’s premium and 3% of the income of the fund it manages towards operating expenses. For monitoring and evaluation, Congress has mandated the National Institutes of Health (based in the University of the Philippines) to conduct studies that will verify and validate the performance of PhilHealth. PhilHealthInstitutional structures Key Actors in Insurance Administration: Central Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government The scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services. PhilHealth is responsible for oversight and administration of public sector insurance schemes. It has a governing board chaired by the Secretary of Health with representation from other government departments (ministries) and agencies, and the private sector including the OFW sector. PhilHealth also features a governing board composed of 13 individuals, chaired by the Secretary of Health, with the president and CEO of Philhealth as vice-chariman. The president and CEO have a fixed term of 6 years. Salaries and other operating expenses are derived from premium payments and the income of the funds under management. PhilHealth can use up to 12% of the previous year’s premium and 3% of the income of the fund it manages towards operating expenses. For monitoring and evaluation, Congress has mandated the National Institutes of Health (based in the University of the Philippines) to conduct studies that will verify and validate the performance of PhilHealth. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Mexico: Seguro Popular |
|
|
|
|
|
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 sectionMexico’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 PopularInstitutional 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.
|
