Joint Learning Network for Universal Health Coverage

The Joint Learning Network 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.

Use the compare reforms feature below to view comparable technical information across multiple programs at once. Select a reform element to the right, and filter the selection of countries and programs using the selection list.



Program Key Actors in Insurance Administration Organizational Structure Collections Responsibility Operations Responsibility Oversight Responsibility Institutional structures
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.

Read full section

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

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.

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
Rwanda: Mutuelles de Sante
  • Central Government
  • District/Local Government
  • Decentralized to district/local level
  • Mutuelles
  • District/Local Government
  • Mutuelles
  • Central Government
  • District/Local Government

The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

Read full section

The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels.

The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers.

In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.

Reformed Rwandan Health System

Mutuelles de Sante

Institutional structures

Central Government, District/Local Government
Decentralized to district/local level
Mutuelles
District/Local Government, Mutuelles
Central Government, District/Local Government

The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals.

The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels.

The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers.

In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.

Reformed Rwandan Health System
India: Rajiv Aarogyasri
  • Centralized
  • State Government
  • State Government
  • Commercial insurers
  • State Government

Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme.

Read full section

Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme.

The administrative structure of Aarogyasri is comprised of four main organizations:

  • Aarogyasri Healthcare Trust: The Trust is responsible for oversight of the entire insurance program as well as some important administrative functions such as setting benefits and pricing, managing contracts with insurer(s) and in-network providers, approving claims, and monitoring.
  • Insurer: The insurer is selected based on a competitive bidding process to bear risk and manage all back-end insurance administration, including claims processing, reimbursements to providers, oversight of hospitals. The Insurer is also responsible for holding health camps in villages to screen, diagnose, treat, and make beneficiaries aware of any health problems they might have; health camps are also used to enroll eligible beneficiaries.
  • Network hospitals: Network hospitals provide care to Aarogyasri beneficiaries.
  • Aarogya Mithras: Aarogya Mithras are patient advocates and assist Aarogyasri beneficiaries to navigate through the system and ensure beneficiaries receive quality care. Aarogya Mithras are also responsible for community outreach.

The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:

Aarogyasri TrustInsurerNetwork HospitalsAarogya Mithras
Oversight of schemeX
Financing schemeX
Setting parameters (benefits package, empanelment criteria, etc.)XX
Hardware specifications (e.g, systems, card, etc.)XX
Contract management with InsurerX
Accreditation/Empanelment of providersXX
EnrollmentXXX
Financial management/planningX
Actuarial analysisXX
Setting rate schedules for services/reimbursement rates X
Claims processing and paymentXX
Outreach, Marketing to beneficiariesXXX
Service deliveryX
Developing clinical information system for monitoring/evalX X
Monitoring utilization and other patient informationXX
Customer serviceXXX

Rajiv Aarogyasri

Institutional structures

Centralized
State Government
State Government, Commercial insurers
State Government

Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme.

The administrative structure of Aarogyasri is comprised of four main organizations:

  • Aarogyasri Healthcare Trust: The Trust is responsible for oversight of the entire insurance program as well as some important administrative functions such as setting benefits and pricing, managing contracts with insurer(s) and in-network providers, approving claims, and monitoring.
  • Insurer: The insurer is selected based on a competitive bidding process to bear risk and manage all back-end insurance administration, including claims processing, reimbursements to providers, oversight of hospitals. The Insurer is also responsible for holding health camps in villages to screen, diagnose, treat, and make beneficiaries aware of any health problems they might have; health camps are also used to enroll eligible beneficiaries.
  • Network hospitals: Network hospitals provide care to Aarogyasri beneficiaries.
  • Aarogya Mithras: Aarogya Mithras are patient advocates and assist Aarogyasri beneficiaries to navigate through the system and ensure beneficiaries receive quality care. Aarogya Mithras are also responsible for community outreach.

The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:

Aarogyasri TrustInsurerNetwork HospitalsAarogya Mithras
Oversight of schemeX
Financing schemeX
Setting parameters (benefits package, empanelment criteria, etc.)XX
Hardware specifications (e.g, systems, card, etc.)XX
Contract management with InsurerX
Accreditation/Empanelment of providersXX
EnrollmentXXX
Financial management/planningX
Actuarial analysisXX
Setting rate schedules for services/reimbursement rates X
Claims processing and paymentXX
Outreach, Marketing to beneficiariesXXX
Service deliveryX
Developing clinical information system for monitoring/evalX X
Monitoring utilization and other patient informationXX
Customer serviceXXX
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.

Read full section

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

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.

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.

Read full section

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

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.

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.