The experiences of merging health insurance funds in South Korea, Turkey, Thailand, and Indonesia: a cross-country comparative study

Abstract

Background Fragmentation in health insurance system may lead to inequity in financial access to and utilization of health care services. One possible option to overcome this challenge is merging the existing health insurance funds together. This article aims to review and compare the experience of South Korea, Turkey, Thailand and Indonesia regarding merging their health insurance funds. Methods This was a cross-country comparative study. The countries of the study were selected purposefully based on the availability of data to review their experience regarding merging health insurance funds. To find the most relevant documents about the subject, different sources of information including books, scientific papers, dissertations, reports, and policy documents were studied. Research databases including PubMed, Scopus, Google Scholar, Science Direct and ProQuest were used to find relevant articles. Documents released by international organizations such as WHO and World Bank were analyzed as well. The content of documents was analyzed using a data-driven conventional content analysis approach and all details regarding the subject were extracted. The extracted information was reviewed by all authors several times and nine themes emerged. Results The findings show that improving equity in health financing and access to health care services among different groups of population was one of the main triggers to merge health insurance funds. Resistance by groups enjoying better benefit package and concerns of workers and employers about increasing the contribution rates were among challenges ahead of merging health insurance funds. Improving equity in the health care financing; reducing inequity in access to and utilization of health care services; boosting risk pooling; reducing administrative costs; higher chance to control total health care expenditures; and enhancing strategic purchasing were the main advantages of merging health insurance funds. The experience of these countries also emphasizes that political commitment and experiencing a reliable economic growth to enhance benefit package and support the single national insurance scheme financially after merging are required to facilitate implementation of merging health insurance funds. Conclusions Other contributing health reforms should be implemented simultaneously or sequentially in both supply side and demand side of the health system if merging is going to pave the way reaching universal health coverage.

Identifying priorities for research on financial risk protection to achieve universal health coverage: a scoping overview of reviews

“…Risk pooling involves delinking health-related financial contributions from health risk by enabling lower-need (and by extension, healthier and/or wealthier) individuals to subsidise higher-need (and by extension, sicker and/or poorer) individuals 37 42 50 53 54 63 68–71. Consequently, health-related financial risk is spread to a pool of individuals, rather than being borne by a single person experiencing ill health 68 70 71.…”

“…Risk pooling involves delinking health-related financial contributions from health risk by enabling lower-need (and by extension, healthier and/or wealthier) individuals to subsidise higher-need (and by extension, sicker and/or poorer) individuals 37 42 50 53 54 63 68–71. Consequently, health-related financial risk is spread to a pool of individuals, rather than being borne by a single person experiencing ill health 68 70 71. The design of pooling arrangements, including the source of funds and extent of government subsidisation; whether contributions are compulsory or voluntary; and the size, number and competitiveness of pools, affects the extent to which risk pooling is achieved 37 42 47 50 53 66 68 70 71.…”

“…Consequently, health-related financial risk is spread to a pool of individuals, rather than being borne by a single person experiencing ill health 68 70 71. The design of pooling arrangements, including the source of funds and extent of government subsidisation; whether contributions are compulsory or voluntary; and the size, number and competitiveness of pools, affects the extent to which risk pooling is achieved 37 42 47 50 53 66 68 70 71. The pooling arrangements examined by the included studies comprised national or social health insurance (SHI; compulsory schemes operated by the state, which are publicly financed through taxation or social security schemes)37 46 51 56 66 69–74; community-based health insurance (CBHI; voluntary schemes operated by non-profit and non-governmental insurers, in which insurers apply community-rated premiums)37 41 47 50 51 73 75 76; and private health insurance (PHI; voluntary schemes operated by private for-profit insurers with little to no state involvement, in which insurers apply risk-rated premiums) 37 51 53 66 67 72 73.…”

“…The design of pooling arrangements, including the source of funds and extent of government subsidisation; whether contributions are compulsory or voluntary; and the size, number and competitiveness of pools, affects the extent to which risk pooling is achieved 37 42 47 50 53 66 68 70 71. The pooling arrangements examined by the included studies comprised national or social health insurance (SHI; compulsory schemes operated by the state, which are publicly financed through taxation or social security schemes)37 46 51 56 66 69–74; community-based health insurance (CBHI; voluntary schemes operated by non-profit and non-governmental insurers, in which insurers apply community-rated premiums)37 41 47 50 51 73 75 76; and private health insurance (PHI; voluntary schemes operated by private for-profit insurers with little to no state involvement, in which insurers apply risk-rated premiums) 37 51 53 66 67 72 73. PHI schemes can be further classified as complementary (covering residual OOPE, such as copayments, or additional health services, excluded from the state benefit package), supplementary (providing enhanced provider choice and access) or substitutional (providing coverage to those unable to receive state benefits) 53 66–68…”

Equity of health care financing in South Korea: 1990–2016

“…Indeed, in several other countries where the health insurance funds (HIFs) were merged to create a single-payer health insurance system or reduce the number of HIFs, the equity in health care financing has been reported to be improved as well. Specifically, the share of the OOP health care payment, which is usually the most regressive form of health care financing, was reduced to 19% in Turkey and 12% in Thailand several years after the merger of their HIFs, from nearly 30% before the merger [ 15 ].…”