Peru’s Health System
Angela Spencer, MBA
Portland State University
April 11, 2016
Peru has a decentralized system, with 5 entities administering health care. There is a public system, called Seguro Integral de Salud (SIS), for which all Peruvians are eligible, if they do not other options for health insurance. Managed by the Ministry of Health, SIS covers about 60% of insured Peruvians (World Health Organization [WHO], 2016). About 20-30% of the insured population has social security coverage, called EsSalud, connected to employment. Another 4-10% of insured Peruvians have health care via the armed services, national police, or private insurance (Franke, 2013; WHO, 2016).
Peru’s goal is universal health care. To that end, the Universal Health Insurance Law (AUS Law, uses Spanish initials) was passed in 2009, directing the Ministry of Health (MINSA) to create a basic health insurance plan for all Peruvians (Giedion, Bitrán, & Tristao, 2014). However universal coverage has not yet been achieved (Francke, 2013). Despite opportunities for insurance coverage, approximately 20-30% of the population are uninsured (Inter-American Development Bank, 2015; Seinfeld, Montañez, & Besich, 2013). Problems with enrolling people in SIS included difficulty with information systems connectivity at implementation, resulting in higher enrollments for people residing in urban areas and lower enrollments for rural Peruvians (Giedion, et al., 2014).
The passage of the AUS Law in 2009 guaranteed a minimum threshold of health coverage for all Peruvians. According to Seinfeld, et al.: “In the Essential Plan of Health Insurance (PEAS), the basic plan required to be offered by all public and private insurers includes 140 health conditions, organized in interventions and services according to stages of life and the health status of the population. It also includes 44 explicit guarantees of timeliness and quality for maternal and infant conditions (2013).” PEAS emphasizes maternal and child health, disease prevention and control across the lifespan. Only three catastrophic conditions are covered by PEAS (Giedion, et al., 2014). Supplemental coverage for catastrophic illness is provided by the national Intangible Solidarity Fund for Health (FISSAL). The Ministry of Health, following the criteria set forth in the AUS Law, created the initial list of PEAS-covered conditions in 2009. First, health conditions were ranked in order of highest to lowest burden of disease, and the top 45% of conditions were covered (Giedion et al., 2014). Then, conditions requiring hospital care with costs exceeding 30% of average annual spending for families living in extreme poverty (in 2010, that figure was $653.89 US), then conditions were excluded from the list if comprehensive care was not possible under the health system’s resources (Giedion et al., 2014). Finally, treatments that were covered by SIS and EsSalud were also included (Giedion et al., 2014). Ultimately, 65% of the total burden of disease was covered by PEAS as of 2014 (Giedion et al., 2014). Everyone who does not have social security or other options for health insurance (i.e. armed forces coverage) is eligible for SIS, however 30% Peruvians remain uninsured (Inter-American Development Bank, 2015).
EsSalud, the national social security health insurance, is financed by a 9% income-based contribution made by employers (Bitrán, Muñoz, & Prieto, 2010). Formal sector workers and retirees make up 75% and 17% of EsSalud beneficiaries, respectively (Bitrán, et al., 2010). EsSalud is a comprehensive plan, covering 752 diagnoses. EsSalud also administers its own network of clinics and hospitals (Bitrán, et al., 2010).
MINSA administers the largest network of providers, including hospitals that are available to all people, regardless of insurance coverage. MINSA also administers primary care health centers, which serve high density and medium density population areas, and health posts serving rural areas. Additionally, the SIS insurance system is managed by MINSA. SIS beneficiaries use MINSA facilities, which are paid an additional reimbursement for providing covered services (Giedion et al., 2014). SIS enrollees are categorized by income. People with the lowest incomes receive fully subsidized insurance and others are eligible for semi-contributory plans (Francke, 2013). The non-poor must also pay a fee at enrollment in a semi-contributory plan (Francke, 2013). Less than 2% of enrollees in SIS pay a contribution (Francke, 2013). Once enrolled in SIS, there are no out of pocket costs for patients for covered services.
The health system of Peru has a long way to go before all Peruvians have health insurance. The expansion of SIS resulted in reduced costs to poor people for out of pocket health care expenses, and has improved immunization and growth monitoring for children, and ambulatory care for people of all ages (Bitrán, 2010). However, up to 30% of Peruvians remain uninsured, and there are inequities in access between urban and rural populations. Hundreds of health conditions are not covered by the basic plans or the catastrophic plans, leaving a wide range of health problems untreated.
Bitrán, Muñoz, & Prieto, (2010). Health insurance and access to health service, health services use, and health status in Peru. In Escobar, M.-L., Griffin, C. C., Shaw, R. P., & Brookings Institution (Eds.). (2010). Impact of health insurance in low- and middle-income countries (pp. 106-121). Washington, D.C: Brookings Institution Press.
Francke, P. (2013). Universal Health Coverage Study Series (UNICO) 11: Peru’s comprehensive health insurance and new challenges for universal coverage.
Giedion, U., Bitran, R. A., & Tristao, I. (2014). Health benefit plans in Latin America: a regional comparison.
Inter-American Development Bank. (2015, November 19). Peru modernizes management to improve universal coverage of health services with IDB support. Retrieved from http://www.iadb.org/en/news/news-releases/2015-11-19/universal-health-coverage-peru,11325.html
Seinfeld, J., Montañez, V., & Besich, N. (2013). The health insurance system in Peru: Towards a universal health insurance. Global Development Network. Retrieved from http://coopami.org/en/countries/countries/Peru/social_protection/pdf/social_protection02.pdf
World Health Organization. (2016). Global health workforce alliance: Peru. Retrieved from http://www.who.int/workforcealliance/countries/per/en/
Romania’s Health System
Angela Spencer, MBA
Portland State University
April 11, 2016
Romania has a universal healthcare system, with mandatory social health insurance. Romania raked 32nd out of 35 countries (Bosnia and Herzegovina was not ranked) in the European Health Consumer Index (Health Consumer Powerhouse, 2016), due to “severe problems with the management of its entire public sector.” The 1989 revolution in Romania ushered in dramatic changes in every sector of public life as the country shifted from a communist system to a democratic republic. Since 1989, the population has declined due to emigration, decreased birth rate, and increased mortality (Vlădescu, Scîntee, Olsavszky, Allin, & Mladovsky, 2008). Health care was decentralized between 1989 and 1998. Pre-revolution, Romania had a Shemasko model of health care, which was highly centralized and regulated (Ianole, Druică, & Cornescu, 2014). The current system is a national social insurance system with “contractual relationships between purchasers, the health insurance funds, and providers (Vlădescu, et al., 2008).”
The Ministry of Public Health serves a regulatory and policy function, as well as responsibility for public health campaigns. The National Health Insurance Fund (NHIF) receives funds collected from the Ministry of Finance to administer and regulate the health insurance system, and pay for contracted health services from private and public providers via 42 District Health Insurance Funds (DHIFs) (Vlădescu, et al., 2008). DHIFs are financed primarily via tax contributions from employers and employees. Members of the military, people in penitentiaries, people on maternity leave, children, people with disabilities, and students aged 18-26, and a few other special groups are exempt from having to contribute to the health insurance fund (Vlădescu, et al., 2008). External funds from sources such as the World Bank, United States Agency for International Development, and United Nations Children’s Fund also finance health services in Romania.
According to Vlădescu, et al., NHIF health insurance covers, “preventive health care services, ambulatory health care, hospital care, dentistry services, medical emergency services, complementary, medical rehabilitation services, pre-, intra- and post-birth medical assistance, home care nursing, drugs, health care materials, and orthopaedic devices (2008).” The National Insurance Fund for Work Accidents and Occupational Diseases provides additional coverage for certain groups (Vlădescu, et al., 2008). Private supplemental and/or complementary coverage is also available and private facilities exist for those who can pay out of pocket. DHIFs contract with primary and secondary health services providers acting under contract as independent practitioners. Prior to health care reforms in the late 1990s, the majority of health care providers were publicly employed. Today, only hospitals remain public institutions (Vlădescu, et al., 2008). Informal payments have a long history in Romanian culture, and are estimated to account for a significant proportion of out-of-pocket expenditures (Vlădescu, et al., 2008). In 2010, a copayment system was introduced in an attempt to infuse funds into the ailing healthcare sector, and to reduce the prevalence of bribes being taken by providers (Holt, 2010).
The global financial crisis stymied financial growth and increased Romania’s deficit (World Bank, 2014). The country is plagued with lack of modern equipment and medical facilities. Health outcomes are among the poorest in the European Union. In 2010, Romania had more than twice the EU average infant mortality rate (World Bank, 2014). Life expectancy has declined over the last 50 years, and Romania is lagging behind other EU countries on multiple health outcomes, including infant mortality, cardiovascular disease death rates, and smoking-related death rates (World Bank, 2014). Preventative services are under-utilized, hospital services are over-utilized, and access to quality health care is highly variable (World Bank, 2014).
Romania is also suffering from an exodus of health care providers. According to the president of the Romanian College of Physicians, the number of doctors working in Romanian hospitals dropped from 21,400 in 2011 to 14,400 in 2013 (Gillet & Taylor, 2014). Doctors, nurses, and specialists can make higher wages in other countries. Despite the promise of universal health coverage, Romania’s health care system is lagging behind in a number of key indicators, and there are regional shortages in health care providers and facilities (World Health Organization, 2012).
Gillet, K., & Taylor, M. (2014, February 7). Romanian health service in crisis as doctors leave for UK and other states. The Guardian. Retrieved from http://www.theguardian.com/world/2014/feb/07/romanian-health-service-crisis-doctors-uk
Health Consumer Powerhouse. (2016). Euro consumer health index 2015 report. Retrieved from http://www.healthpowerhouse.com/files/EHCI_2015/EHCI_2015_report.pdf
Holt, E. (2010). Romania's health system lurches into new crisis. The Lancet, 376 (9748), 1211-1212.
Ianole, R., Druică, E., & Cornescu, V. (2014). Health knowledge and health consumption in the Romanian society. Procedia Economics and Finance, 8, 388-396.
World Bank. (2014). Project appraisal document on a proposed loan in the amount of 250 million Euro to Romania for a health sector reform – Improving health system quality and efficiency project (P145174).
World Health Organization. (2012). Evaluation of structure and provision of primary care in Romania: A survey based project.
Vlădescu C, Scîntee G, Olsavszky V, Allin S and Mladovsky P. (2008). Romania: Health system review. Health systems in transition. Retrieved from http://old.hpi.sk/cdata/Documents/HIT/Romania_2008.pdf
Rwanda’s Health System
Angela Spencer, MBA
Portland State University
April 11, 2016
The 1994 Rwandan genocide disrupted every aspect of social structure. Since then, the country has made enormous strides in rebuilding their health system and economy. In 1996, the Vision 2020 plan was adopted by the government of Rwanda. The plan focused on decentralized health services, primary care, community participation, human resources development, and information systems infrastructure (World Health Organization [WHO], 2015). Rwanda has made dramatic improvements in heath outcomes over the last 15 years (Rosenburg, 2012). Life expectancy is increasing and childhood deaths are decreasing (Farmer et al., 2013). The country’s national health insurance, Mutuelle de Santé (Mutelle) covers approximately 90-96% of Rwandans (Farmer, et al., 2013; Rosenburg, 2012), and another 7% are covered by military, civil service, military, private plans (Farmer, et al. 2013). Rwandans are required by law to have some type of health insurance (WHO, 2008).
Preventative services, including vaccines and bed nets, are fully covered, along with HIV and AIDS treatment, tuberculosis treatment, and treatment for some cancers (Farmer et al., 2013). Mutelle enrollees pay annual premiums and 10% copayments for other services. External sources of funding from entities such as the Global Fund Against AIDS, Tuberculosis, and Malaria (GFATM) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) were used to boost salaries and train health sector workers, and to subsidize premiums and copayments for the poor (Kalk, Groos, Karasi, & Girrbach, 2009). The system is also financed by state funds and individual contributions (Republic of Rwanda, 2016). The health system is made up of 18 primary care, outpatient, or referral dispensaries, 16 prison dispensaries, 34 health posts, over 430 health centers, and 4 national hospitals (Republic of Rwanda, 2016).
Rwanda has achieved near universal health coverage for its citizens, but it remains to be determined if the system is sustainable. The current reliance on outside sources for funding, combined with high levels of poverty that hinder people from being able to afford premiums and copays, presents significant challenges to the long term success of Rwanda’s health system.
Farmer, P. E., Nutt, C. T., Wagner, C. M., Sekabaraga, C., Nuthulaganti, T., Weigel, J. L., … Drobac, P. C. (2013). Reduced premature mortality in Rwanda: lessons from success. BMJ, 346(jan18 1), f65–f65. http://doi.org/10.1136/bmj.f65
Kalk, A., Groos, N., Karasi, J.-C., & Girrbach, E. (2009). Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda. Tropical Medicine & International Health. http://doi.org/10.1111/j.1365-3156.2009.02424.x
Republic of Rwanda. (2016). Services: Health system. Retrieved from http://www.gov.rw/services/health-system/
Rosenburg, T. (2012, July 3). Rwanda, health care coverage that eludes the US. The New York Times. Retrieved from http://opinionator.blogs.nytimes.com/2012/07/03/rwandas-health-care-miracle/?_r=0
World Health Organizatio. (2008). Sharing the burden of sickness: Mutual health insurance in Rwanda. Bulletin of the World Health Organization, 86(11), 817-908. Retrieved from http://www.who.int/bulletin/volumes/86/11/08-021108/en/
World Health Organization. (2015). Rwanda country health profile. Retrieved from http://www.afro.who.int/en/rwanda/country-health-profile/health-and-development.html
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