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Reforming China’s Rural Health System
Box 5.5 (Continued)
Several characteristics of the Estonian social health insurance system contribute to its success. The combination of EHIF’s legal status as an autonomous entity and solid regulations fosters an environment conducive for purchasing services. While the Supervisory Board has a very narrowly defined role, its existence buffers EHIF from government and provider actions. Strong government commitment to EHIF and to conservative fiscal policy has helped Estonia steer clear of health insurance deficits. Negotiated contracts are the most effective means for EHIF to reach its targets and contain costs. The development of EHIF’s transparent reporting and management system was supported by public pressure and hard budget constraints. Costa Rica has a single mandatory health insurance fund known as the Caja Costarricense de Seguro Social (CCSS) that supports universal coverage in health care provision. The fund has a board of directors, with representatives from government, employers, workers, and physicians. Beneficiaries are not represented. The CEO of CCSS is appointed by the country’s President. The Costa Rican system does not have a separate supervisory body for oversight. The CCSS board of directors has the power to change fees paid to providers and exclusive power to define user protection regulations. The CCSS determines its internal regulations based on government objectives and has some power to carry out sanctions against offending providers. Because providers are a part of CCSS, the fund’s capacity to regulate providers is somewhat weak; although a Management Agreement is in place, costs have still escalated. The lack of a purchaserprovider split is highlighted by a case of corruption between the CEO of the CCSS and a CFO of a major medical supplier.51 CCSS appears to have limited domain over any code of ethics or anticorruption regulations and essentially has no authority over setting benefit packages, which are under the auspices of Costa Rica’s Constitutional Court. Source: Savedoff and Gottret 2008.
Especially in view of the management challenges discussed above, China might want to consider a dedicated autonomous government health insurance agency to run both NRCMS and BMI (and eventually a unified scheme), rather than have one of the existing program administrators (NRCMS or BMI) do so. A question that arises in China’s decentralized governmental system is at what level this agency should operate. Internationally, the trend seems to be toward centralization of insurance agencies. Estonia, for example, started with several separate