Table 3.

Examples of health care systems and their financing

Country	Health care system and financing details
Colombia	Until the early 1990s, the Colombian health system was made up of 3 subsectors: (i) Social Security scheme offered to formal sector workers; (ii) private health insurance for those able to afford it; and (iii) a tax-based financing system for those without health care insurance. In 1994, the system changed to the current 2 major health insurance schemes: (i) a contributory regime, which is mandatory for formal workers and those with the capacity to pay; (ii) a subsidized regime for the unemployed, informal sector workers, and the poor.10 The contributory regime is financed by an income-based payroll tax paid partly by employees and partly by employers, whereas the subsidized regime is financed mainly by taxation. People are free to buy additional private health insurance on top of the contributory one. Teachers in public schools and universities, the military and police officers, and workers of the national oil company still have special health care schemes. The Fondo de Solidaridad y Garantía pools all payroll-based contributions for health as well as other public sources earmarked for the health sector. In 2007, the government established a high-cost subaccount, managed by a nongovernmental organization (CAC), to pool and redistribute risk retrospectively for catastrophic conditions such as ESKD, HIV, hemophilia, and some other diseases across the entire population.20 The main health care purchasers are EPSs, which are similar to health maintenance organizations. EPSs manage a package of a mandatory health plan, which includes dialysis and kidney transplantation, and public health activities such as screening for certain diseases such as hypertension, diabetes, and chronic kidney disease. Although EPSs can either provide services directly or contract private or public providers, the private sector dominates health care provision in Colombia, accounting for two-thirds of health expenditure by EPS in 2012. Under both the contributory and subsidized regimes, members are allowed to choose the EPS of their preference, which results in EPSs competing for enrollees and providers competing for inclusion in EPS networks. This is more evident in the more densely populated urban areas where competition exists between different EPSs, but not in rural and underserved areas where it is less profitable for EPSs to set up.10 Access to KRT in Colombia is universal, and with the implementation of CAC, the prevalence of treated ESKD increased from 445.3 pmp in 2007 to 671.5 pmp in 2016.21 However, some disparities are evident between the contributory and the subsidized regimes. In 2016, there were 32,786 patients on KRT, with 61% being in the contributory regime. The patients in the subsided scheme were underrepresented in all types of KRT and especially in kidney transplantation (only 18.6%).20 In spite of its success, CAC has been criticized by its lack of transparency of reporting the financing of KRT, the equal access to treatment and the assessment of health outcomes, and its strong emphasis on KRT rather than prevention.22
Mexico	Health services in Mexico are provided through a variety of subsystems. The largest of these is the IMSS, which provides health care services for formal workers in the private sector. The ISSSTE provides similar services for federal government employees. The military and the national oil company have their own health care schemes. Other key institutions include the network of SHS, for those without employment-linked insurance. After the introduction of the SP in 2004, publicly-funded health insurance extended to 50 million Mexicans who were previously uninsured. Prior to the SP, these individuals only had access to SHS for a fee.23 Health insurance in the social security schemes is funded through payroll contributions by the employer and the employee, with an additional federal allocation from general taxation. Financing of the SP is based on a tripartite structure that includes contributions from 3 sources: the federal government, state governments, and the beneficiary. The social contribution is a fixed allocation per family, which is funded entirely by the federal government. The second element is the coresponsible contribution between the federal and state governments to redress the differences in the level of development among states. The third component is the family contribution, which is progressive and redistributes family income.24 The SP divides personal health services into an essential package of primary- and secondary-level interventions, which are provided in ambulatory settings and general hospitals, and a package of high-cost tertiary-level interventions financed through the Fondo de Proteccion contra Gastos Catastroficos.24,25 Patients and families belonging to IMSS or ISSSTE and those with private insurance have universal access to KRT. SP does not cover ESKD treatment, except for kidney transplantation in children <18 years of age. Patients without social security must pay from their own resources for KRT, which limits their access. As a consequence, many patients refuse dialysis, eventually abandon their treatment, or lose their kidney grafts because sustaining KRT becomes unaffordable.26 This results in marked disparities between the insured and uninsured population, and in 2015, KRT incidence and prevalence rates in the population with vs. without social security were 281 and 1357 vs. 130 and 200 pmp, respectively.21 In spite of the success of the SP in expanding health insurance coverage to close to 84% of the Mexican population, its existence has been questioned by the new federal authorities and so has the access to KRT coverage for more than one-half of the Mexican population.
South Africa	Private insurance, the so-called medical schemes, is a key element of the financing system. Initially, there were few schemes restricted to formal workers. Over time, many open schemes have developed, allowing anyone to join provided they can pay. Most care for private insurees is provided by the private supplier sector. Private general practitioners are widespread in urban areas, and private for-profit hospitals are available in the major cities and provincial capitals. Prices in the private sector are prohibitive for the majority of the population, resulting in major inequities in the health care resources used by different population groups.13 To promote financial access to public-sector health care services for vulnerable groups, user fees have been removed for all public-sector primary care services. However, outside these services, patients face substantial fees at public-sector hospitals. An analysis of the South African public–private mix demonstrated substantial inequities in health financing. Sixteen percent of the population is covered for all health care in the private sector, and a further 21% of the population uses the private sector with out-of-pocket basis mainly for primary care but are likely to be entirely dependent on the public sector for tertiary care such as KRT. The remaining 64.2% of the population is entirely dependent on the public sector for all types of health care services, including KRT.13 Between 2013 and 2015, the prevalence of treated ESKD increased from 167 pmp to 189 pmp, mainly due to the increased numbers of patients accessing dialysis in the private sector. In the public sector, the prevalence of KRT remained stable around 72 pmp over the last 25 years, so the disparity in access to KRT continued to increase.27 Initially, rationing of patients for dialysis was based on informal criteria concerning eligibility for kidney transplantation. In 1997, the National Department of Health consolidated the criteria in use to develop a formal national policy. However, of all patients with ESKD assessed over a 15-year period, only 47% were actually accepted for KRT. The likelihood of acceptance into the program was significantly biased in favor of patients who were employed, married, white, and younger. Almost 60% of patients were denied KRT because of social factors related to poverty.28 Recently the Accountability for Reasonableness guidelines have been adopted by the health authorities of the Western Cape government. They include a novel 3-tiered hierarchy of priorities, based on the likelihood of best outcomes. Although the model’s success ensured that all ideal candidates received treatment, it failed to completely eliminate inequity, and only 25% of all ESKD patients assessed were accepted for KRT.29 Patients in rural areas are underserved as a result of the lack of facilities and geographical barriers. The expenses attributable to the HIV/AIDS epidemic at least partially contribute to the low level of provision of KRT compared with the level of KRT provision in similar upper-middle-income countries.
Thailand	Extension of health insurance coverage has been pursued in Thailand since 1975. In 1975, low-income households were covered under the publicly funded LIC scheme. Government employees and their dependents were covered with the establishment of the CSMBS in 1978. In 1981, a publicly subsidized VHC scheme was initiated by the Ministry of Public Health to cover the nonpoor informal sector. Later in 1990, the SSS was established to provide mandatory coverage for formal-sector private employees. The major sources of funds are from general taxation, followed by direct out-of-pocket payment, social health insurance, and private insurance premiums.30 In 2001, UHC was implemented. The UHC scheme incorporated the existing LIC and VHC schemes and extended coverage to the 30% previously uninsured population. All 3 groups are covered under a single fund financed by general taxation, whereas the CSMBS and the SSS still operate their own schemes.30 The initial UHC did not include KRT because of budget impact reasons and only beneficiaries of the CSMBS and the SSS, representing 25% of the Thai population, had access to KRT. Advocacy by nephrologists and civil society seeking equity in access to dialysis led to the development of the “PD First” policy and marked a turning point in ESKD care in Thailand. Initially, full reimbursement for PD was provided. However, if there was any contraindication to PD, HD costs could also be fully reimbursed. If a patient started with PD, but because of any medical or social problems with the therapy required shifting to HD, the costs would continue to be fully reimbursed. The indications for shifting to HD were set up by the Nephrology Society of Thailand and regional committees are authorized to make the decisions. Over time, the policy has been revised and patients who started HD before launching the policy are now also fully reimbursed. However, those who elect to start HD since the launch of the policy must pay the cost of the treatment.31 The PD First policy has been successfully implemented, with an increase of the incidence and prevalence of treated ESKD from 68.34 pmp and 419.9 pmp in 2007 to 249.06 pmp and 1072.9 pmp in 2013, respectively. By 2015, the percentage of UHC patients on PD was 60%. The budget of the PD First policy has increased gradually to more than 220 million USD in 2017.31
India	All forms of KRT are available in India but are largely restricted to big cities and private-sector hospitals. Public-sector hospitals are overburdened with the dialysis requirement of patients with acute kidney injury and do not have the infrastructure to support chronic outpatient dialysis.32 Few people have access to health insurance, and discontinuation of dialysis is high due to excessive out-of-pocket costs, which are often substantially higher than monthly income, resulting in catastrophic health expenditure.33,34 As part of its agenda to achieve UHC by 2022, the Indian government has committed to establishing at least one 8-station dialysis unit in each of its 688 districts and is offering free HD to people living below the poverty threshold. To realistically meet this demand, care models with low-cost dialysis machines and nonphysician health workers will need to be developed.33

CAC, Cuenta de Alto Costo; CSMBS, Civil Servant Medical Benefit Scheme; EPS, Entidades Promotoras de Salud; ESKD, end-stage kidney disease; HD, hemodialysis; IMSS, Instituto Mexicano del Seguro Social; ISSSTE, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado; KRT, kidney replacement therapy; LIC, Low-Income Card; PD, peritoneal dialysis; pmp, per million population; SHS, Servicios Estatales de Salud; SP, Seguro Popular; SSS, Social Security Scheme; UHC, universal health care coverage; VHC, Voluntary Health Card.