The COVID-19 pandemic has highlighted the importance of well-functioning health-care systems. Health is a major element of the 2030 Sustainable Development Goals (SDGs) agenda adopted by the UN General Assembly in 2015, with one broad goal – SDG 3: “Ensure healthy lives and promote well-being for all at all ages”. Affordable, efficient and equitable access to quality care is crucial for maintaining and improving health and avoiding financial hardships. Access to quality care is essential to tackle needless suffering and to achieve the fundamental goals of social justice. Entwined with the goal of equal opportunities, it is key to maintain a person’s functional abilities, allowing him or her to pursue a broad range of opportunities that society offers.

Health insurance is a pre-payment and risk pooling mechanism to cover medical expenses that arise due to an illness. These expenses can be related to costs of hospitalisation, medicines or doctor consultations. Social and national health insurance has the potential to improve equitable access to health care and protect people from the financial risks of diseases. It has proven instrumental to maintain or extend universal health coverage, even more during the COVID-19 pandemic. Still, improvements and innovative solutions are required to provide and secure access to quality care for all.

The International Social Security Association (ISSA) therefore organized a webinar on Improving health insurance systems, coverage and service quality. It discussed experiences from ISSA member organisations in Indonesia, the Republic of Korea, Rwanda and Turkey, sharing their challenges, strategies and innovative approaches to improve health insurance systems, coverage and service quality. This article summarizes the key issues raised in the webinar.

Comparative health system analysis terminology

Health systems differ at many levels. Even if all countries’ health systems are unique and crafted by historical evolutions and political compromises, the typology commonly used to group health systems into broad categories concerns how revenues are pooled and who provides health-care services.

Pooling

Most health insurance systems can be divided into one of two different financing arrangements: some have a single health insurance pool (single-payer) while others use multiple health insurance pools (multi-payer). Within this broad rubric of single-payer vs. multi-payer systems, there are many variations. Single-payer systems generally offer greater government control over the provision of care and tend to emphasize equity. Multi-payer systems generally allow for consumer choice of insurance, which can drive innovation and competition.  Many countries have some combination of single- and multi-payer insurance, be it substitutive, supplementary of complementary.

Provision of services

Health services can be divided into the direct or indirect provision of services. In systems with direct provision, a single integrated entity both finances and delivers health services, with a larger degree of public control over the provision of services. In systems with indirect provision, independent providers contract with purchasers.

Major types of health systems

Based on the pooling and provision of services, we distinguish four major types of systems representing specific combinations:

• Social health insurance: Public multi-payer systems with indirect provision.
• National health service: Centralized single-payer systems with direct provision.
• National health insurance: Centralized single-payer systems with generally private provision of medical services.
• Private insurance: Some countries have private multi-payer systems with indirect provision.

Some of these variations are illustrated in the image below, featuring examples from member countries of the Organisation for Economic Co-operation and Development (OECD):

Table 1. Provision of basic primary coverage (for the "typical" employed adult)

Main source of basic health care coverage		List of countries
Tax-funded health system	National health system	Australia, Canada, Denmark, Finland, Iceland, Ireland, Italy, New Zealand, Norway, Portugal, Spain, Sweden, United Kingdom
Health insurance system	Single payer	Greece, Hungary, Korea, Luxembourg, Poland, Slovenia, Turkey
	Multiple insurers, with automatic affiliation	Austria, Belgium, France, Japan
	Multiple insurers, with choice of insurer	Chile, Czechia, Germany, Israel, Mexico, the Netherlands, Slovakia, Switzerland, United States
Source: OECD, 2014

The next paragraphs provide a short overview of the health insurance systems, major challenges and key issues raised during the ISSA Webinar on health insurance systems. 

Country experiences

Indonesia

In 2014, the Indonesian government rolled out the world’s largest single-payer health insurance programme, Jaminan Kesehatan Nasional (JKN) to achieve universal health care, replacing all previous fragmented social health insurance schemes. The National Health Insurance (NHI) provides coverage of the costs of treatment for most outpatient and inpatient visits in public and registered private facilities. Covering 84 per cent of the eligible population, the target is to extend health coverage to informal sector workers to reach 98 per cent by 2024. Investment into digitalization and information and communication technology (ICT), support the achievement of this goal, taking into account the geography of the country that is composed of hundreds of islands.

Turkey

Health insurance was introduced in Turkey in 1945, at first covering blue-collar workers. In 2003, the Health Transformation Program (HTP) was initiated to improve public health, providing health insurance for all citizens, extending access to care and developing a patient-centred system to address health inequities and improve outcomes – especially for women and children. Turkey's health insurance system is administered by the Social Security Institution (Sosyal Güvenlik Kurumu − SGK), established in 2006 as a single payer. Responsible for purchasing from providers, it is mandated to improve service quality and efficiency to provide comprehensive, fair and equitable healthcare benefits for the whole population.

The Republic of Korea

In 1977, the Republic of Korea implemented a compulsory health insurance scheme. Facilitated by strong political will, universal health coverage was achieved within 12 years. Based on social solidarity, it provides equal insurance benefits to all citizens. The National Health Insurance Service (NHIS) covers almost the entire population, starting with the mandatory enrolment of workers at large workplaces and including the informal sector.

Rwanda

Rwanda has achieved the highest health coverage rates in Sub-Saharan Africa as part of coordinated mutual insurance programmes. After the genocide in 1994, the level of primary health services fell significantly and health indicators deteriorated considerably. Since 2000, Rwanda has developed the long-term strategy Vision 2020 to provide sufficient financial resources for universal access to quality health care for all citizens. To achieve this goal, Rwanda introduced Community-Based Health Insurance (CBHI) that are instrumental in covering the rural population and the informal sector. In 2019, Rwanda won the ISSA Award for Outstanding Achievements in Social Security for its achievements.

Challenges

Undeniable, all countries face major challenges in maintaining a sustainable health-care system. Depending on the country, these challenges include issues such as the impact of ageing populations, the rising chronic disease burden, health infrastructure development and generally the financing of health-care services.

In Indonesia, additional issues relate to reaching the “missing middle” and the informal sector.  Improving service quality is also an issue, partly due to the rapid growth of the population covered by NHIS.

In Turkey, universal health insurance has significantly reduced out-of-pocket and catastrophic health expenditures. Enforcing the compliance with regulations and managing payment expectations from health care providers remains a challenge.

Notwithstanding the rapid development of health care over the past 30 years through the NHI system in the Republic of Korea, a more than 30 per cent co-payment rate still limits financial protection. This is a major challenge in addition to improving the health-care delivery system.

In Rwanda, the CBHI financial deficit is steadily rising which points the major focus on ensuring the financial sustainability of the health-care system. The shortage of professional health-care workers is also raising concerns about how to ensure effective and timely access to quality health-care services.

Strategies and responses

Improving service quality

Indonesia's health-care service improvement can be noticed through the increase in the number of visits to health facilities, which nearly tripled in just five years. The Social Security Administering Body for the Health Sector (BPJS Kesehatan) enhances the efficiency and effectiveness of service delivery, for example by performance-based capitation, linking payment with performance in primary care facilities. Disease management and special referral programmes for chronic disease patients are developed to increase health service efficiency.

In the Republic of Korea, NHIS has monopsony power in negotiations with medical providers.  This improves access to medical services and the control of medical fees, even in an environment where private medical providers account for 94.5 per cent. The country’s health-care expenditure is 8 per cent of GDP (2019). Despite being lower than the 8.8 per cent OECD average, it provides a high level of quality health care and accessibility. It operates through a separate organization called Health Insurance Review & Assessment Service (HIRA) for the reimbursement and claims review. Efforts are being made to reduce the level of out-of-pocket expenses to less than 30 per cent and to protect lower-income groups through an out-of-pocket ceiling system.

Technological innovation and digital health

eHealth or digital health has been increasingly used during the COVID-19 crisis, accelerating the process of digitalisation in many countries. The pandemic forced social security institutions to transform their healthcare service delivery at the speed of light and adapt to new forms of care delivery, such as telemedicine (read also our analysis Telemedicine: Good practices from Latin America).

In addition to simplifying administrative procedures (e-prescriptions), eHealth or digital health has the potential to improve health care. It can lead to more systematic and high quality care, by allowing for the use of clinical information for decision support. By means of real-time patient monitoring or mHealth applications, more proactive and targeted care can be delivered, which can reduce costs and improve outcomes. It also facilitates patient engagement and self-management by providing better and real-time information to patients about the status of their health.

The ISSA has also analysed how telemedicine is a discipline that involves the use of information and communication technology (ICT) to provide remote medical services, but it does not replace face-to-face care. The two should be developed in a complementary and coordinated manner, and carried out to the patient’s benefit.  

In 2020, BPJS Kesehatan introduced telemedicine services in Indonesia to minimize face-to-face care through mobile applications and messaging services in the context of COVID-19. To verify membership eligibility, BPJS Kesehatan is further developing artificial intelligence-based technologies and facial recognition. (Read also our analysis of artificial intelligence in social security.)

As discussed during the ISSA Virtual Symposium on Information and Communication Technology, there is a need for better availability, integration and use of health data. Data is important for research and health care delivery. Moreover, it can lead to a better monitoring of the system, providing public health authorities with key performance information. However, this also underlines the importance of data governance and data privacy.

In Turkey, a web-based integrated system (Medula) between the social security institution and contracted healthcare providers has proven essential for ensuring and improving service quality and also allows for data storage for monitoring and projection of health expenditures.  

In the Republic of Korea, data governance and the use of ICT is paramount for the health-care system. The advanced ICT-based information management system, set up in the NHIS, is interconnected with 42 public organizations. It provides personalized health information, holding each citizen’s eligibility, contribution, medical records, treatment and health-care providers’ information. This data is being used in the development of personalized health services, to support research and policy, and is shared with other institutions.

Conclusions

Adequate and appropriate financing mechanisms and health services infrastructures are vital to ensure progress towards universal health care globally.

Social and national health insurance systems, whether implemented through multiple or single payers, play a key role in improving the quality of health care and in guaranteeing the citizens’ equal access. However, implementing them involves several challenges and requires ongoing adaptations to a rapidly evolving context.

Reaching all population groups through insurance-based mechanisms, an aging population, addressing the increased demand for medical care and securing sustainable financial resources are the main common challenges. The weight of different challenges and the response strategies vary by country.

In all countries, however, the needs of the people must be the essential yardstick for the design of appropriate health-care systems.

References and further reading