CHAPTER 4
Addressing GSHIS Operational Challenges
Government-sponsored health insurance schemes (GSHISs) can serve as change agents for achieving universal coverage. Through pioneering new ways of doing business in terms of financing, managing, providing, and paying for care, the current crop of GSHISs can facilitate reform of the dominant fee-for-service private system as well as the budget-based, public direct delivery system. However, before spearheading any reforms in the broader health finance and delivery systems, GSHISs first need to address operational constraints emerging from both design and implementation. The future success and sustainability of GSHISs hinge on the development of strong governance arrangements, management systems, monitoring and purchasing mechanisms, cost-containment tools, and quality-improvement instruments. In this chapter, the first of a two-phased approach to universal coverage is presented. This first, short-term phase addresses the operational or “mechanical” challenges of the current crop of GSHISs that were outlined in the previous chapter. A series of corrective measures are proposed— often based on international best practice—to strengthen GSHISs’ institutional architecture and managerial practices. These operational improvements will encourage a more accountable institutional environment to utilize GSHIS funds effectively to improve access, utilization, and financial protection while containing costs. 127