Elsevier

Health Policy

Volume 123, Issue 7, July 2019, Pages 621-629
Health Policy

National Health Insurance: A conceptual framework from conflicting typologies

https://doi.org/10.1016/j.healthpol.2019.05.013Get rights and content

Highlights

  • Different definitions for NHI had been proposed in the literature.

  • Two main areas of controversy exist: revenue sources and providers ownership.

  • Neither revenue from social security or private provision define NHI schemes.

  • We present a definition by access, financing, governance and insurance-providers relationship.

  • NHI is characterized by universal coverage, public funding, single-fund and single-payer.

Abstract

In the path to universal health coverage, policymakers discuss different alternative health system’s financing schemes. Classical typologies have been posited, including models such as National Health Service, Social Health Insurance and Private Health Insurance. More recently, National Health Insurance (NHI) has been suggested as a separate model. Nevertheless, there are discrepancies regarding what defines an NHI model. The purpose of this article is to propose a comprehensive definition of an NHI model, aimed to disentangle the current discrepancies in the conceptualization and the scope of this type of arrangement. Based on the previous literature we identified some common characteristics across NHI definitions, namely universal coverage, pooling in a single fund and a purchasing function based on a single-payer financing mechanism. Areas of controversy were also identified. While some authors emphasized the importance of an effective separation between the purchaser and provider functions, others highlighted the relative importance of privately-owned provision to define a system like NHI-type. Based on empirical data, we suggest that the ownership is not a critical variable to distinguish an NHI from other models, and instead, suggest that a pivotal characteristic of the NHI is the single payer mechanism that is not integrated with the health providers.

Introduction

Countries are continuously striving to implement effective health policies and reforms to improve population’s health and wellbeing. There is a growing global consensus on the need to accomplish universal health coverage and equitable access to health services. The Pan American Health Organization (PAHO) defines universal health coverage (UHC) in its strategy for universal access to health and UHC as a situation “where all people and communities have equitable access to the comprehensive and guaranteed quality services that they need, throughout the life course, without financial hardship” [1]. This definition emphasizes the importance of guaranteeing an equitable access and providing financial protection and broad benefits to the population as crucial elements to reach UHC.

Effective health insurance, understood as the pooling financing function, is a key instrument to achieve financial protection. Health insurance is defined as “a way to distribute financial risk associated with the variation of individuals’ health care expenditures by pooling costs over time through pre-payment and over people by risk pooling” [2].Therefore, health insurance should generate a broad effective resource pooling, ideally incorporating the whole population in a single risk fund, delinking financial contributions from health needs. This can be achieved through different institutional designs including such as the National Health Service (NHS), National Health Insurance (NHI) or Social Health Insurance (SHI) schemes.

The NHI emerges within the range of possible health financing models to head towards UHC, ensure equitable access to healthcare, reinforce stewardship and improve systems’ efficiency. This article aims to understand the key features and characteristics of the NHI model, which has emerged more recently and received comparatively less attention in the specialized literature than NHS and SHI schemes. Moreover, a substantial inconsistency remains in the use of the concept “National Health Insurance” to describe very different health systems [[3], [4], [5]]. For example, while in some countries the term NHI is referred to a public insurer among multiple health insurances, in others is used to refer to an institution acting as a single-payer or a vertical program with a narrow scope for specific diseases at a national level. Additionally, even when NHI is conceptualized as a single-payer, further discrepancies emerge on key characteristics such as revenue collection and providers ownership.

In this context, we attempt to contribute with greater clarity about the crucial features of a NHI to further inform policy-makers and reformers searching for new organizational schemes to improve health systems performance, especially in the Americas. For this purpose, in the next section we provide a brief overview of the health system’s and health financing functions as a background for further discussion. In the third section, we review typologies for the health systems’ organization that incorporate the NHI-type within their scope of analysis. In the fourth section, we provide a critical assessment of current definitions, using data from selected countries to characterize their limitations. In the fifth section, we propose an extended and more accurate definition of the NHI-type model, guided by the characteristics of countries frequently presented in the literature as typical NHI systems. Finally, we present an overview of those countries in order to exemplify some common characteristics across them.

Section snippets

Health system and financing functions

A health system could be broadly defined as “all the activities whose primary purpose is to promote, restore or maintain health” [6]. The main functions of a health system are often defined as: stewardship, resource generation, service provision and financing [6]. Stewardship refers to the governance and administration of the health system - overseeing all the other functions-, in order to reach national health policy objectives, which relies largely on the government. It is a political process

Typologies of health financing schemes

A wide variety of taxonomies for health system’s organization have been proposed in the last decades. Taxonomies are useful to learn from other health system experiences as an input for future reforms. While no single taxonomy could be sufficiently complex to account for all the elements that define a health financing arrangement, they are useful as long as they identify relevant elements that help to understand the functioning and, to a certain degree, the level of success of each arrangement.

Single-payer or National Health Insurance?

To refer to NHI literature requires a review of the concept of single-payer system, a phrase sometimes used interchangeably with NHI system. Probably the most accepted definition of a single payer is a “single purchaser for the main service package on behalf of the entire population living in a defined geographic area” [21]. Other authors refer to further dimensions, for example Tuohy describes single-payer as a system financed by the government and delivered by privately owned providers [28].

Proposal of a common definition

It is important to clarify the characteristics that describe and distinguish the NHI from other financial schemes. We suggest an extension of previous classifications based on the purchasing function, in particular regarding the relationship between the payer and providers. Whereas the NHI celebrates contractual agreements with both public and private (non-for-profit and for-profit) providers as a single-payer, there is no vertical integration between the NHI and these providers. This is a

Examples in context

The path to implementing NHI models has been diverse worldwide. Countries’ specific epidemiological, economic, cultural and political context determine different trajectories to achieve their actual health system arrangements. In this section, some case-countries experiences of NHI implementation are presented, trying to capture both the particularities of the implementation process of a NHI and if their current health system arrangement is in line with the proposed definition of a NHI.

Conclusion

In the ongoing challenge of reforming health systems in order to achieve Universal Health Coverage, the organization of the health systems’ financing is crucial. In order to learn from countries experience, classification of health systems regarding their financing functions has been identified as a useful tool.

The growing complexity of health systems arrangements have left the standard tripartite classification of the health systems insufficient to account for real-world country experiences.

Funding

This work was supported by the Pan American Health Organization [grant 67378 Contribution for Activities for Promotion of Universal Health Coverage, 2018]

Conflict of interest statement

The authors declare no competing interests regarding the topic covered in this article.

Acknowledgement

Lorena Prieto for insightful commentaries on an earlier version of this manuscript.

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