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
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
Philippines: PhilHealth
  • Central Government
  • Centralized
  • Central Government
  • Central Government
  • 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.

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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.

PhilHealth

Institutional 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
  • 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
Brazil: Unified Health System (SUS)
  • Central Government
  • State Government
  • District/Local Government
  • Decentralized to district/local level
  • Central Government
  • State Government
  • District/Local Government
  • State Government
  • District/Local Government
  • 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.

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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.

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).

Institutional Makeup of the Brazilian Health System

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).

Institutional Makeup of the Brazilian Health System

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.