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Health insurance system in Mongolia

Ch. Oyun, MD, MPH

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Context

• Introduction of the health insurance system

•Health insurance fund - revenue for health sector financing

•The current situation and concerns

•Payment methods•Challenges and potential areas

of improvement

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Health insurance system introduced

• 1990-transition from a centrally planned economy to a market economy

• The underlying reasons were the need - to increase revenue- to introduce market incentives- to raise public responsibility

• Citizen’s health insurance law passed on July 8, 1993 and enforced on Jan 1, 1994

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Cont..

•Social health insurance system- solidarity

•One of the five social insurance schemes

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The health insurance fund

•Employers•Employees•Those in the informal sector

•State subsidized groups

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Health insurance coverage

•Compulsory for the total population (75%)

•Voluntary for foreigners

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Percentage and amount of insurance premium as well as

collection procedures

• Employers - not exceed 6 percent of their salary and other similar income

• Those in the informal sector pay approx 5USD per year

• The state shall be responsible for the insurance premiums of vulnerable groups & pay approx 3USD per year

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Revenue of HIF, 2006

12% - State subsidized

groups

83.9% - Employers & employees

4.1% -unemployed, herders & students

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HEALTH INSURANCE FUND EXPENDITURE, 2006

4%2%2%

9.0% for private

sector's care

13.0% for out-patient

care 70% for in-patient

care

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Benefit packages of HI

• In-patient care services

• Out-patient care services

• Pharmaceutical drugs prescribed by FGP from the list of essential drugs are discounted by 50-75%

• Sanatoriums

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Benefit packages of HI

Health insurance care services are provided by licensed and accredited health facilities under all forms of ownership

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Health insurance care services

–Therapeutic –Neurological –Eye, ear, skin and muscles–Non-emergency injuries–Surgical

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Copayment

• 10% at the aimag/district hospitals as well as regional diagnostic and treatment centers

• 15% at the tertiary level hospitals respective of the variable inpatient costs

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Policy framework of health insurance

• Health insurance policy is the responsibility of the MOSWL and MOH

• Legislation and programs are enforced by the SSIGO, the governmental implementation agency under the MOSWL

• Social Insurance National Council reports to the Parliament & authorizes revenue & expenditures from the HI fund

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State Social Insurance general Office (SSIGO)

•Vertical management system•31 branches in total •1065 employees,100 of which deal w/health insurance

•Social insurance inspectors in every soum (365)

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What HI has brought?

• One of the key financial sources of health care and services

• 25% of the total health care expenditure

• Prospective payment with adjustment at the end

• Insurers contract with health agencies

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Challenges and potential areas of

improvementCOVERAGE:

• Informal sector’s enrollment• Reaching out to those who are in

the informal sector is cumbersome• Gaps in contribution rates• Participation of the State and

individuals

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Cont..

THE PROVIDER’S PAYMENT SYSTEM:

• Moral hazard towards more inpatient care

• The poor quality of health care and services

• No systematic data for evaluation

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Conclusion

• To introduce performance based incentives

• To incorporate provider’s payment methods with the quality of services

• To strengthen health insurance w/universal coverage

• To enhance organizational capacity

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Thank you for your attention