The National Health Insurance system as one type of new typology: The case of South Korea and Taiwan

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1 Available online at Health Policy 85 (2008) The National Health Insurance system as one type of new typology: The case of South Korea and Taiwan Sang-Yi Lee a,b,, Chang-Bae Chun b, Yong-Gab Lee b, Nam Kyu Seo b a Department of Health Policy and Management, School of Medicine, Cheju National University, Jeju, South Korea b Institute for National Health Insurance, Korean National Health Insurance Corporation, Seoul, South Korea Abstract A typology is the useful way of understanding the key frameworks of health care system. With many different criteria of health care system, several typologies have been introduced and applied to each country s health care system. Among those, National Health Service (NHS), Social Health Insurance (SHI), and Private Health Insurance (PHI) are three most wellknown types of health care system in the 3-model typology. Differentiated from the existing 3-model typology of health care system, South Korea and Taiwan implemented new concept of National Health Insurance (NHI) system. Since none of previous typologies can be applied to these countries NHI to explain its unique features in a proper manner, a new typology needs to be introduced. Therefore, this paper introduces a new typology with two crucial variables that are state administration for health care financing and main body for health care provision. With these two variables, the world s national health care systems can be divided into four types of model: NHS, SHI, NHI, and PHI (Liberal model). This research outlines the rationale of developing new typology and introduces main features and frameworks of the NHI that South Korea and Taiwan implemented in the 1990s Elsevier Ireland Ltd. All rights reserved. Keywords: Health care system; Typology; National health insurance 1. Introduction A typology is the useful way of understanding the key frameworks of health care system. OECD has listed main principles that are required to be a good Corresponding author at: Department of Health Policy and Management, School of Medicine, Cheju National University, #1, Ara1-Dong, Jeju , South Korea. Tel.: ; fax: address: health21@cheju.ac.kr (S.-Y. Lee). typology. First, it should be based on characteristics of the health care system that can be identified objectively from the name given to the scheme in a certain country. Second, it should be applied to all countries consistently so that schemes featuring similar characteristics can be grouped in the same category [1]. Several typologies of health care systems have been introduced [2 10]. A well-known health care system typology among these is the 3-model typology that classifies health care system into National Health /$ see front matter 2007 Elsevier Ireland Ltd. All rights reserved. doi: /j.healthpol

2 106 S.-Y. Lee et al. / Health Policy 85 (2008) Services (NHS), Social Health Insurance (SHI), and Private Health Insurance (PHI). Although previous typologies delineate a country s the health care system in the world, any of those cannot appropriately explain the South Korea (referred to as Korea in this paper) and Taiwan health care system that were established through the integration reform since the 1990s. Health care reform in Korea has similarity to that in Taiwan in that considerable political pressure to put national health insurance structure in place was central to a stable democratic state in both countries. Korea and Taiwan have both been pluralist democracies only since the late 1980s. Korea was previously under military control; Taiwan was ruled by the Kuomintang [11]. In the process of implementing NHI, both countries passed through two major steps: extending coverage to the entire population and integrating previous social insurance programs. Before 2000 when NHI was implemented in Korea, multiple health insurers covered the segments of population. Health insurers for employees of corporation were established since A program for civil servants and private school teachers started in 1979, and health insurance societies for the self-employed were established in 1988 in rural areas and 1989 in urban areas. Therefore, the Korean corporatist SHI accomplished universal coverage in In 2000, the 139 insurance societies for enterprises and the National Medical Insurance Corporation into which 227 insurers for the self-employed and program for civil servants and private school teachers emerged were integrated into the National Health Insurance Corporation [11 13]. Prior to NHI implementation, Taiwan already had a limited social insurance program in place. The gradual introduction of various employment-based insurance programs beginning in the 1950s expanded the numbers of those covered by social insurance, though coverage remained less than 50% of the population by the early 1990s. Political pressure on the Kuomintang party-state prompted the ruling party to move in the direction of universalizing health care in order to protect against the legitimacy crisis. The existing health insurance programs were integrated to establish a National Health Insurance in 1995 [11,12,14,15]. Korea and Taiwan shared same goals in health care reform: equity in access to adequate care, social affordability, and improvement of efficiency [15,16]. Above-mentioned similarities in the history of health care reform and common goals shared may bring in the Korean and Taiwan NHI System s unique features including a single insurer system, the strong state intervention, relatively much amount of government subsidies, and patients freedom of choice of physician [12,17]. However, none of the existing typologies seem to succeed in capturing these unique characteristics. As a result, a call for new typology of health care system to describe Korean and Taiwan NHI is needed. 2. Overview of the typology on health care system Field s Typology in 1973 classified the health care system into pluralistic, insurance, health service, and socialized types [2]. Followed by Terris et al., the NHS and SHI types of health care system were introduced. These two types were classified in terms of the concept of the health care provision. While the health care providers were government employees and the places where health care was provided were at the government hospitals and health centers in NHS, the health care providers in SHI were independent entrepreneurs under contractual arrangements to deliver health services [3]. A year later, in 1978, Terris further developed his earlier typology by adding another type called the Public Assistance system, which relies on general tax revenue and public health care provision [18]. In the 1980s the study on typology of health care system continued at more various levels. Reviewing the path of the health care system in each country, Navarro found class coalition as an independent variable in determining the shaping of a country s health care system. With this notion he presupposed three types of health care system: NHS, SHI and the liberal model [4]. Frenk and Donabedian [5] proposed a typology of state intervention which is based on two dimensions: the form of state control over the production of health services and the basis for eligibility of the population. The former can be classified into four variables according to the degree of concentration and dispersion in public provision and financing criteria: concentrated ownership; dispersed ownership; concentrated financing; and dispersed financing. The latter, eligibility of the population, refers to the population

3 S.-Y. Lee et al. / Health Policy 85 (2008) which is protected from the health care system and can be classified into three forms: citizenship; contribution/privilege; and poverty. As a result the authors suggested a typology of modalities of state intervention in medical care by using four types of state control and three principle forms of eligibility, thus extracting 12 modalities. Efforts to develop good typologies were not abated in the 1990s and early 2000s. Roemer [6] suggested several types of health care systems based on comparing and classifying structures of existing health care system. Specifically two characteristics were captured in the analysis: market intervention in the health system and economic level represented by GNP level per capita. Based on these two dimensions, four types of health care system were introduced. The entrepreneurial and permissive type was while a company purchased private health insurance for its employees, the private sector owned the health care facilities. The welfare-oriented type was operated in the framework of a social health insurance system. Non-forprofit health insurance societies acted as the insurers, whereas private and public sectors occupied the medical facilities. The universal and comprehensive type was a health care system that provided health care services to all. Health care facilities were owned and controlled by the government. The socialist and centrally planned type was a system that all health care services were centrally provided with all population [6]. Hollingsworth et al. focused on the degree of state intervention in financing and in health care resources. They classified the UK as high centralization-control over public (degree of centralization: high, locus of control: public), Sweden as low centralizationcontrol over public (degree of centralization: low, locus of control: public), the US as low centralizationcontrol over private (degree of centralization: low, locus of control: private) [7]. In 1987, the OECD classified the health system on the basis of a dichotomy between patient sovereignty and social equity, and introduced three basic models: the National Health Service; the Social Insurance; the Private insurance [19]. In 1992, the OECD chose two variables to structuralize the health care system: the financing method and the principal actor in medical services provision. With these two variables, three types of health care systems were suggested: a mixed system of finance and private system of provision; financing by social health insurance scheme and mixed provision by public and private sectors; and financing by general taxation and provision by public providers [8]. From the 1992 OECD typology, the mixed-type was added on both finance and health care provision in the 1994 OECD typology [9]. While 12 models of health care system could be drawn in theory, only 7 models were suggested (Table 1). In 2004, the OECD removed the mixed mode from both financing and health care provision to simplify typology. Final model, therefore, consisted of the three types: the public integrated; the public contract; and the private insurance-provider model. Viewing these three types of health care system in detail [1], the public-integrated model is based on public financing and public provision. This is common in the northern European countries. In the public-contract model, the public insurer makes contracts with private Table 1 Typology of OECD health care systems, 1994 Financing Health care provision Public Contribution Taxation Public provider Mixed (public + private) Private provider Ireland, Italy, Spain, Sweden, Denmark, UK, Finland, Greece, Portugal, Norway Belgium, Japan, France, Germany, Austria, Luxemburg Australia, New Zealand Canada Mixed Turkey, Korea Netherlands, Mexico Private US, Swiss Source: OECD, The reform of health care systems, 1994 [9].

4 108 S.-Y. Lee et al. / Health Policy 85 (2008) providers on pre-payment system basis. The public insurer can be either the government or social security organizations, such as medical insurance societies. Japan, Korea, and European countries that are not belonging to the public-integrated model are included in this model. The private insurance-provider model is based on private financing and predominantly private providers. The private insurance can be either compulsory as in Switzerland or voluntary as in the United States. Meanwhile, Moran [20] constructed three different type of health care states (i.e., the entrenched command and control; the corporatist; the supply health care state [10]) based on the distinction between institutions related to the governance of health care consumption, provision and technology. 3. Limitation of previous typologies As shown the history of typology development in health care system above, 3-model typology has been used in the world since late 1970s. The 2004 OECD typology also corresponds typically to 3-model typology in that the public-integrated model is equivalent to NHS, the public-contract model to SHI, and the private insurance-provider model to PHI. Among the several typologies, 3-model typology has been relatively wellknown and popularly used. The health care system of the UK and Sweden is NHS system, which is characterized by universal coverage, tax financing, and public provision. The Germany case is paradigmatic SHI system, which is characterized by compulsory universal coverage, financing by employer and employee contribution through multiple non-profit insurance funds, and public and private providers. The United States is the prototype of PHI (Liberal) system, which is characterized by private funding such as individuals and employer s premium and predominant private health care delivery. Being popularly used, however, the financing source (i.e., public versus private) of this 3-model typology does not properly reflect state intervention. Further, it cannot properly explain the range and characteristics of financing administration (i.e., single versus multiple insurer). Other typologies also have limitations as follows. First, Frenk and Donabedian [5] pointed out that a country s health care system consists of various programs that are supported and managed by diverse institutions. Adopting the state intervention theory, in this typology, the health care system was classified as modality. A drawback of this typology is the limited capability of depicting entire features of countries health care systems. That is, a typology on the health care system should not be based on a specific modality such as various and fragmented public health programs, but on a nation in general. From the strict point of view, Frenk and Donabedian s view is difficult to be classified as typology, because modality represents an intermediate level of analysis that falls between the macro-level of total health system and the micro-level of specific programs. Second, Roemer s typology on health care systems [6] concentrates on two variables: market intervention in the health system policies and GNP level per capita. Although Roemer s typology considers government intervention as an important variable and relates it to a country s economic level, it fails to clarify the dimension of state intervention. According to Burau et al. [10], the common typology should consider the variation of funding and corresponding differences in organization of health care provision. Since Roemer s typology does not provide enough description of funding variation and provision, it cannot be considered as a typology, but rather a sort of classification that differentiated health care system. For structuring health care systems intensively, Wessen [21] introduced 11 structural parameters including the degree of medical dominance, role of insurer, role of government, degree of centralization, financing source, etc. The previous typologies failed to explain each country s features of health care system in these 11 parameters. Further, none of those typologies suggested what type of health care system can capture the new features of Korean and Taiwan health care system after the integration reform. 4. NHI as a model of new typology on health care system Variables used in previous typologies are the main financing source and the provision of health care service which need to be explained by the degree of state intervention. State intervention, however, should not just be viewed as a variable that classified financing

5 S.-Y. Lee et al. / Health Policy 85 (2008) Table 2 A new typology on health care system Financing administration Provision of health care Public Private Single/concentrated NHS NHI Multiple/dispersed SHI Liberal model and provision for structuring and functioning of health care system, but rather be considered as value embedded in the society. State intervention structuralizes the dominant social values prevailed in the society in which the health care system is embedded. Social solidarity is the core value that the health care system tries to protect. The range of solidarity was attempted to be explained with general taxation and contribution: while tax-financing foster a general solidarity, contributory approach is regressive [22]. However, this should be examined more in depth in the heath care system. If the multiple insurance societies merged toward single insurance society, the range of social solidarity is to be entire population like in NHS system. The range of solidarity can be decided depending on the organization s level of responsibility for financing. That is, whether the concentrated financing administration or the dispersed financing administration decides the range of social solidarity. In a single insurer system, health care system centralizes financing, which means that one organization collects and pools revenues and provides health care to all population. In contrast, in a multiple insurer system, several organizations are responsible for financing and administration with the specified group based on a certain criteria [23]. While the single insurer system (single pipe) includes all population within a single risk pool, multiple insurer system (multiple pipes) has many pools at different levels of potential health risks [14]. To take into account of financing organization as the structural and functional variable that contains societal value, main source for health care financing should be changed to state administration for health care financing. From this perspective, two variables: state administration for health care financing and main body for health care provision can be suggested as the crucial variables in the new typology. With the application of those crucial variables, the new typology classifies the world s national health care systems into NHS, SHI, NHI, and Liberal model as shown in Table 2. Brief description of each health care system classified by new typology is as follows. The NHS model characterizes a government provision of health care services and public finance for all citizens. In the SHI model, service provision limits only to the insured, whereas the government indirectly administers health care financing through dispersed multiple health insurance societies. In the NHI model, private sectors dominantly provide health care services whereas the state centrally administers health care financing and covers all citizens. In the Liberal model, the private providers mainly provide health care services and the role of state in health care provision is limited to the marginal segment of population. Those four types of health care system clearly explain each country s health care system in terms of social value, main body of health care provision, and state intervention into health care financing and provision (Table 3). The social value for constitution of the health care system can be classified into universalism, corporatism, and liberalism. From the view of the health care provision to all citizens, the NHS and NHI are rooted in universalism. In contrast, health care are provided to the specific population in SHI and liberal model, which are rooted in corporatism and liberalism, respectively. Specifically, health care services are offered only to the insured in the SHI model, whereas those are offered only to the vulnerable people in the Liberal model. The social solidarity in NHS and NHI is ranged across the nation regardless of the sex, age, income, and health status. For this reason, the range of risk dispersion is to be the entire nation. Under the SHI model where health care services are provided to the insured, however, the range of social solidarity is limited only to the insured of a certain group based on the region, occupation, and economic activity. Another way of classification of health care system is based on the main body of health care provision. Depending on the proportion of the public to private provision, the descending order of health care system is to be NHS SHI Liberal system. The ratio of public bed to all hospitals bed is good example of this. The ratio of public bed to all hospitals bed is 96.0% in UK (NHS); 53.1% in Germany (SHI) [24,25]; 33.7% in US (PHI) [24]. In case of Korea and Taiwan (NHI), however, this ratio is relatively low as 17.5 and 33.0% [26,27]. This is close proportion with that of US.

6 110 S.-Y. Lee et al. / Health Policy 85 (2008) Table 3 Comparison of NHS, SHI, NHI and Liberal type on health care system NHS model SHI model NHI model Liberal model 1. Social value for constitution of health care system 1.1 Basic principle Universalism Corporatism Universalism Liberalism 1.2 Principle of population coverage Citizen The insured Citizen The vulnerable 1.3 Boundary of social National solidarity 2. Main body of health care services provision 2.1 Existence of private health care resources (*Percentage means the proportion of public beds) 2.2 Strength of state regulation on private health care resources 2.3 Availability of citizen to providers Limited, GB: 96.0% (1998) Extensive, strong, detail Among individual groups of the insured Germany: relatively limited, Japan: extensive Germany: 53.1% (2003) Japan: 35.8% (1998) Germany: limited, medium, general, Japan: extensive, strong, detail National Extensive, Korea: 17.5% (2004) Taiwan: 33.0% Extensive, strong, detail Between the vulnerable and the others Extensive, US: 33.7% (1995) Limited Limited Limited Unlimited Unlimited 3. State intervention into health care financing 3.1 Proportion of public financing in total health care expenditure UK: 83.0% (2001) Germany: 78.6% (2001) Japan: 81.7% (2001) 3.2 Source of health care financing 3.3 State administration of health care financing 4. Characteristics of state intervention Tax Germany: social insurance contribution Japan: social insurance contribution and tax Korea: 54.4% (2001) Taiwan: 64.4% (2001) Social insurance contribution and Tax Single Multiple Single Multiple US: 44.9%(2001) Tax and premium Provider Regulator Conductor Regulator at low level The NHI model keeps a higher degree of government intervention in management, whereas private sector overwhelms public sector in health care resources such as hospitals. Although the size of private health care resources in NHS and NHI system is different, these two models share much in common. Both systems adopt broad, intensive and detailed state intervention over the private sector to offer equitable health care to all citizens. In contrast, state intervention in private health care provision in the Liberal system is considerably restrictive. No matter Japanese and German health care system are classified into same in SHI model, these two systems take on different aspects. While Germany maintains a general level of state intervention, Japan implemented broad and strong state intervention over the private sector like NHI system. To explain the degree of state intervention into health care financing, two indicators are available ratio of public expenditure to total health care expenditure and mode of state s roles in health care financing administration. Looking at the ratio of public expenditure to total health care expenditure in 2001, the UK is 83.0%. Korea and Taiwan are 54.4, 64.4%, respectively. Germany and Japan are 78.6, 81.7%, while the US in the Liberal model is 44.9% [24,28]. The most important aspect in financing is whether a state collects and administers revenues centrally and directly, or whether a state administers financing system downwardly and indirectly to different organizations. In a typical case, the state administers health care financing directly in the NHS system and a specialized public corporate is assumed to be responsible for administering and controlling health care financing in the NHI system. In the SHI system, multiple public insurers administer financing, while in the Liberal system the state and

7 S.-Y. Lee et al. / Health Policy 85 (2008) Fig. 1. Typology by public financing and public health care provision. many private health insurers control the health care financing. Comparing characteristics of state intervention among different systems of new typology, several important matters should be considered: state s directorship for providing health care services, the degree of the state s role as regulator, and the extent of state s direct control. While state in the NHS system is a practical provider, it is both conductor and regulator in the NHI system. Further, although the states act as a regulator in both the SHI and Liberal systems, the degree of the state s role in the SHI type is higher than that in the Liberal system. To summarize, the new typology of a country s health care system can be classified by the following criteria. First, what group of people does the national health care system aim to protect all citizens, the specific insured, or the vulnerable? Second, which sector is the main provider in health care provision is it public or private? Third, is state intervention in health care financing administration concentrated or dispersed? Based on these criteria, a new typology divides the existing health care systems into four types NHS, SHI, NHI and Liberal system. With this typology, the SHI system has multiple insurers that provide health care services for the insured and their dependants by contracts, while the state is indirectly involved in administrating the dispersed health care financing organizations. In contrast, in the NHI system, the private sector plays a dominant role in providing health resources, whereas the state is responsible for administrating centrally health care financing, covering the total population directly. Depending on the ratio of public expenditure to total health care expenditure and the ratio of public hospital beds to total hospital beds, which were used for classification of health care system into NHS, SHI, PHI based on the OECD typology, countries are clustered in one of four sections in Fig. 1. The UK and Sweden are classified as NHS, Germany and France as SHI, Korea and Taiwan as NHI (according to new typology), and the United States as PHI (Liberal system). While Japanese SHI is similar to German SHI system in that both countries have multiple insurers, it is rather viewed as a hybrid model between SHI and NHI because of higher proportion of the insured belonged to government as insurer in Japan. That is, the state in Japan covers about 68% of the insured as an insurer and remaining 31.8% belongs to classical SHI system (24.1% of corporate insured with 1674 societies and 7.7% of public servants and private school employees with 78 societies) [29]. The ratio of public beds is less than a third of all hospital beds in the NHI system. Nevertheless, the NHI system secures health care with relatively high quality for all population through the efficient financing administration and effective control of the predominantly private health resources. As a result, the state s role in the NHI system over the private sector has to be stronger than that in the corporatist SHI system. An

8 112 S.-Y. Lee et al. / Health Policy 85 (2008) insurer in the NHI system typically a specialized public corporation is an agent of health care security not only for the whole population but also for the state. This characteristic shows the foremost role of the state in the NHI system. A high government subsidy (30% of total revenue in Korea [16], 27% in Taiwan [28]) shows a good example of state s interventionist role in NHI system. The ratio of public beds in corporatist SHI system is relatively high. So the state s role over the private sector as a regulator is generally limited in the SHI system. Also, the state in principle is not directly responsible for financing health care. Japanese health care system is peculiar even though it is practically classified as the SHI system. The ratio of public beds is around one third of the total hospital beds, and the role of government over the private sector is strong as a powerful regulator. This means that the level of state intervention is higher than that of classical SHI model. In Japan s SHI system, the state controls and negotiates with providers, while the state is the direct insurers for specific types of social groups. Moreover, the state s role in financing is relatively strong. Japanese government as the insurer subsidizes a certain proportion of the insurance contribution and covers administrative costs. Government subsidy for the total health insurance programs in 2003 accounted for 27.1% of total revenue [29]. 5. Conclusions Previous studies related to the traditional 3-model typology explained the degree of state intervention into the health care system with two main variables: the main financing source and the provision of health care service. The financing source variable (i.e., public versus private) of the 3-model typology, however, has limitations: it is not only hard to explain the difference between the basic principles of financing sector in health care systems but also hard to make clear the degree and ways of state intervention into health care system. Furthermore, public financing itself is hard to make an answer for the question what group of people does the national health care system aim to protect all citizens or the specific insured?. For this reason, the present study employs state administration for health care financing as a substitute variable for the source of finance. While both NHS and SHI operate the public financing as the source of finance, each is distinctive with respect to the social value and basic principle. While the core principle of the NHS is universalism, which includes all nations as one financial system, the core principle of the SHI is corporatism, which includes a large number of specific eligible funds for participants based on health welfare in business perspectives. The characteristics variable of state intervention into the health finance system that our new typology proposed enables us to classify clearly NHS as single pipe and SHI as multiple pipes. In other words, with two variables, state administration for health care financing and main body for health care provision we successfully classified the world s national health care systems into NHS, SHI, NHI, and Liberal model. In our new typology presented in Table 2, all the countries that have single/concentrated health financing administration are mainly public financed compulsorily without exception, which already includes the notion of the variable the source of finance of previous OECD typology. However, of countries with multiple/dispersed health financing system, if there may exist a country with a mix of mainly social health insurance and almost dominantly private health care providers 1, the health care system of the country exceptionally will be classified not into liberal model but into SHI. The Korean and Taiwan health care systems are classified into NHI based on our new typology, which well explain the characteristics of both countries health care system. Social solidarity, equity, and efficiency in financing system were greatly enhanced after the transition to NHI system through the integration reform in both Korea and Taiwan [12,16,28,30,31]. The reason of those improvements in the two countries health care system may have been due to the integration of multiple insurers into a single pipe. Health system typology that can capture the characteristics and ways of state intervention in health care system well and represent itself concisely is likely to increase its global utilizations. 1 The authors would like to thank the anonymous reviewer who made a comment about this during the review process.

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