DESK REVIEWS | 02.01.01. The public health system

DESK REVIEW | 02.01.01. The public health system

The SUS was implemented in 1990. It is state-funded, it provides health services free of charge to the entire population, and it is one of the largest and most complex health systems in the world (Paim et al., 2011). In 2017, it accounted for 8.3% of national revenue, meaning 1.8% of the Brazilian Gross Domestic Product (GDP) in that year  (Brazilian National Treasure, 2018). The SUS provides a range of health services and interventions spanning the whole life-course (from the gestational period to the end of life). These include the primary, secondary, and tertiary levels of care; urgency and emergency systems; hospital care; health and environmental surveillance; and a pharmaceutical assistance program (Brazilian Ministry of Health, 2019k). The system is the major source of healthcare for low-income groups and those without access to private health insurance (Castro et al., 2019). According to the latest published version of the National Health Survey – 2013 (Pesquisa Nacional de Saúde – PNS), around 70% of the Brazilian population do not have private health insurance and therefore benefit from services provided by SUS or pay directly for private health services (Brazilian Ministry of Health, 2013a). The SUS is informed by local, municipal, state, and federal councils that aim to embed the population’s voices and needs into policy.


Brazilian Ministry of Health. (2013a). Pesquisa Nacional de Saúde 2013: Acesso e Uitlização dos Serviços de Saúde, Acidentes e Violências.

Brazilian Ministry of Health. (2019k). Sistema Único de Saúde (SUS): Estrutura, principios e como funciona.

Brazilian National Treasure. (2018). Aspectos Fiscais da Saúde no Brasil.

Castro, M. C., Massuda, A., Almeida, G., Menezes-Filho, N. A., Andrade, M. V., Noronha, K. V. M. de S., Rocha, R., Macinko, J., Hone, T., Tasca, R., Giovanella, L., Malik, A. M., Werneck, H., Fachine, L. A., & Rifat, A. (2019). Brazil’s unified health system: The first 30 years and prospects for the future. Lancet Health Public.

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797.


The public health services are financed by the Government and regulated by the Food and Health Bureau (FHB), Department of Health (DH), and Hospital Authority (HA) (HKSAR Government, 2019b).

  • Food and Health Bureau (FHB)

It is one of the policy bureaus of the Government responsible for forming policies and allocating resources for health services. It ensures that these policies are carried out effectively to protect and promote public health, and provide lifelong holistic health care to every resident (HKSAR Government, 2019b).

  • Department of Health (DH)

Under the FHB, the Department of Health serves as health adviser and agency to execute healthcare policies and statutory functions. It safeguards the community’s health through a range of promotional, preventive, curative, and rehabilitative services. It also provides subsidised healthcare services through health centres and clinics in each district (HKSAR Government, 2019b).

  • The Hospital Authority (HA)

The Hospital Authority is a statutory body established under the Hospital Authority Ordinance in 1990. It is accountable to the Government through the Secretary of FHB and provides public hospital services for the whole Hong Kong territory. Every Hong Kong resident is eligible for subsidised healthcare services through 43 public hospitals, 73 general out-patient clinics and 49 specialist out-patient clinics operated by HA (HKSAR Government, 2019b; Hospital Authority, 2019a).

The public sector provides most of the secondary and tertiary care services in Hong Kong. Public hospitals under HA manage approximately 80% of all hospital admissions and the share of total bed-days reaches almost 90%. As of 31 March 2019, a total of 28,929 hospital beds were provided in public hospitals. Nearly all critical emergencies are tackled by the accident and emergency departments of public hospitals (Food and Health Bureau, 2017b).

Regarding the proportion of population using public healthcare, the Census and Statistics Department conducted a household survey on the population’s use of doctor consultation, hospitalisation, and dental consultation in 2016/17. While only 29.2% of doctor consultations took place in the public sector, 70.9% of the hospital admissions in Hong Kong were handled by public hospitals under Hospital Authority. Further breakdown of these findings by age and gender can be found from the survey report (Census and Statistics Department, 2017, December).


Census and Statistics Department. (2017, December). Thematic Household Survey Report No. 63. Retrieved from

Food and Health Bureau. (2017b). Report of the Strategic Review on Healthcare Manpower Planning and Professional Development.

HKSAR Government. (2019b, March). Overview of the Health Care System in Hong Kong. Retrieved from

Hospital Authority. (2019a). Clusters, Hospitals & Institutions. Retrieved from

Hospital Authority. (2019b). Hospital Authority Statistical Report 2018-2019.  Retrieved from

The provision of health care to the public is enlisted as State subject in the constitution of India. Furthermore, there are references to health in the Union as well as Concurrent Lists (Government of India, n.d.). This means that the States have the opportunity for unique customization of the Union public health initiatives and introduction of state-specific services. The public health network is monitored by the Indian Public Health Standards (Ministry of Health and Family Welfare (MoHFW), 2012).

Traditionally, the public health care system in India has been rural-centric. A three-tiered network of health facilities consisting of sub centres, primary health care centres, and community health centres caters to the primary and secondary health care needs of the population, mostly in rural areas where about 2/3rd of India’s population live.

  1. A Sub Centre (SC) is the first point of contact between the community and the primary health care system, and it is staffed by nurses and health workers. The minimum requirement of the SC is to have at least one auxiliary nurse midwife (ANM)/female health worker and one male health worker (Ministry of Health and Family Welfare (MoHFW), n.d.-b). SCs provide services in relation to family welfare, maternal and child health (MCH), nutrition, immunization, diarrhoea control, and control of communicable diseases programs (MoHFW, n.d.-b). Existing SCs are being converted to Health and Wellness Centres to provide an expanded range of services at a primary care level as part of the Ayushman Bharat programme (MoHFW, n.d.-b)
  2. A Primary Health Centre (PHC) is the first point of contact between the village community and a medical officer (MO) — an appointed graduate physician trained in allopathic system of medicine (MBBS; Bachelor of Medicine and Bachelor of Surgery) (MoHFW, n.d.-b). Each PHC is recommended to have at least one MO along with 14 paramedical and other staff. PHCs consist of 4 to 6 beds for in-patients and act as referral units for 6 SCs (MoHFW, n.d.-b). Existing PHCs are being converted to Health and Wellness Centres to provide an expanded range of services at a primary care level as part of the Ayushman Bharat programme (MoHFW, n.d.-b)
  3. Community Health Centres (CHCs) function as community hospitals. CHCs are required to staff a surgeon, physician, gynaecologist/obstetrician, and paediatrician (4 medical specialists) supported by additional team of 21 paramedical and other staff (MoHFW, n.d.-b). The CHC works as referrals for PHCs within a block (a group of villages), which is the planning and development unit of a district. The CHC also provides specialist obstetric care and specialist consultations facilities across other disciplines (MoHFW, n.d.-b). CHCs are equipped to provide round the clock emergency obstetric care services and thus, they serve as the First Referral Units (FRU) for reproductive health (MoHFW, n.d.-b).

Sub-divisional hospitals, District hospitals, and Government Medical colleges provide comprehensive speciality and super speciality care to referrals, as these may also serve as FRUs (MoHFW, n.d.-b).

Table 2.1. Size of Rural Public Health Network in India (as of March 2020) (Ministry of Health and Family Welfare, n.d.-b).

Sl. No. Type Level of care Number of centres Denominator Function
1 Sub centre (SC)


* SCs are being converted to HWCs under Ayushman Bharat

Primary 155404 in rural areas 1 SC for every 5000 population in the plains, 3000 in Hilly terrains



(Approx. population of 1 village = 1000)

1st point of contact for the community with the formal health care system. Led by an Auxiliary Nurse Midwife (ANM)/ Multi-purpose Health Worker
2 Primary Health Centre (PHC)


*PHCs are being converted to HWCs under Ayushman Bharat.

Primary 24918 in rural areas 1 PHC per 20000 (tribal)-30000 (plains) population Each PHC is headed by a graduate physician trained in allopathic medicine. The PHCs provide primary outpatient

services, preventive, curative and emergency care services and implementation of national health programmes.


They have 4-6 beds for in-patient care and provide referral support to 6 sub-centres.

3 Community Health Centre (CHC) Primary/ Secondary 5183 in rural areas 1 CHC per 80000-100000 population


(1/ block)

30 bed hospitals.

Staff a surgeon, physician, gynaecologist/ obstetrician, and paediatrician.

Serves as referral centre for 4 PHCs.

4 Sub-Divisional Hospital Secondary 1193 in the country. 821 as First Referral Units (FRUs) Caters to usually 5-6 lakh population Usually 31-100 bed hospitals. Provide specialized services and may serve as the First Referral Unit (FRU) for obstetric emergencies (hold blood storage facilities, essential laboratory services and provide new-born health services).
5 District Hospitals Secondary 810 in the country. 668 as First Referral Units (FRUs) At the district level. Provide comprehensive specialist care at the district level.
6 Government Medical Colleges Tertiary 274 in the country. 118 as First Referral Units (FRUs) Usually located in urban areas. A district may have no, one or several medical colleges. Provide speciality and super speciality (provides care and services in one specialism such as neurology/cardiology etc.) care to all referrals

Source: MoHFW (n.d.-b); Directorate General of Health Services (2012)

Priority health challenges are addressed through an expansive set of health care programs. Traditionally, the focus has been on maternal and child health (MCH) issues and family welfare. In 2005, the National Rural Health Mission (NRHM) brought a paradigm change in the country’s approach (focused attention to ‘weaker’ in terms of infrastructure and/or public health indicators) states, brought programs, and resources under a common banner, decentralised decision making, undertook ‘communitisation’ through a new cadre of community-based health mobilisers (called Accredited Social Health Activists (ASHAs)). Given the success of the NRHM, the approach was extended to both rural and urban areas under the banner of the National Health Mission (NHM) in 2012 with two sub-missions i.e., the NRHM and the National Urban Health Mission (NUHM). Over the years, the focus has expanded beyond MCH to non-communicable diseases, mental health and geriatric care, and a series of state sponsored health insurance schemes (MohFW, n.d.-a)

The NUHM and respective municipal corporations share primary responsibility for providing health services for the urban population. The proposed urban public health infrastructure consists of UPHCs and UCHCs that each cater to approximately 50,000 and 2.5 to 5 lakh population respectively in urban areas to provide equitable and quality care to the urban poor (MoHFW, 2013; MoHFW, n.d.-b).

Table 2.2. Frontline workers in the Public Health System in India

Sl. No. Type Number of Frontline workers
1 Accredited Social Health Activists (ASHAs) in Rural Areas 905047 (NHSRC, 2019)
2 Accredited Social Health Activists (ASHAs) in Urban Areas 64272 (NHSRC, 2019)
3 Auxiliary Nurse Midwives (positioned at both SCs and PHCs) 212593 in position

(March 2020)

In 2018, considerable changes were initiated to improve the existing primary health infrastructure as per recommendations of the National Health Policy of 2017 (National Health Portal, 2019). The Ayushman Bharat was introduced to aid in achieving the goal of Universal Health Coverage (UHC). Under Ayushman Bharat, the concept of Health and Wellness Centres (HWCs) was initiated with the aim of providing comprehensive primary care by transforming existing SCs and PHCs (National Health Portal, 2019). Subsequently, a network of HWCs has been rapidly expanded across Indian under the Ayushman Bharat Yojana. By 17th March 2022, 76,633 HWCs had been operationalised across India (MoHFW, 2022). The 13th Common Review Mission (2019) reports that about 1.5 lakh Sub-Centres and PHCs would be transformed to HWCs by 2022 to provide comprehensive and quality primary health care in both urban and rural areas (MoHFW, 2019). A mid-level health officer (Community Health Officer; CHO) manages the HWCs and is supported by two multipurpose workers (one male and one female) and ASHAs. To strengthen HWCs, staff vacancies are being filled-in, and multi-skilling and capacity building efforts are underway. Infrastructure and logistics are being upgraded along with expansion in the range of medicines and diagnostics, adoption of Information Technology (IT) equipment and applications, telemedicine platforms (MoHFW, 2019). Community outreach and information-education-communication (IEC) efforts are being scaled-up through the HWCs with a focus on promotion of health and wellness (MoHFW, 2019).

Proportion that makes use of public sector services:

The percentage of households that use health care in the public sector has increased from 34% to 45% in 2005-2006 and 2015-2016 respectively (International Institute for Population Sciences (IIPS) and ICF, 2017).


Directorate General of Health Services (2012). Indian Public Health Standards. Guidelines for Sub-District/Sub-Divisional Hospitals. Ministry of Health and Family Welfare. Government of India. Available from:

Government of India (n.d.). Seventh schedule., 1970(5). Retrieved from:

International Institute for Population Sciences (IIPS) and ICF (2017). NATIONAL FAMILY HEALTH SURVEY (NFHS-4) 2015-16 INDIA. Mumbai.

Ministry of Health and Family Welfare (2013). National Urban Health Mission. Government of India. Available from:

Ministry of Health and Family Welfare (2019). 13th Common Review Mission. National Health Mission, Goverment of India. Available from:

Ministry of Health and Family Welfare (2022). Ayushman Bharat-Health and Wellness Centres. Ministry of Health and Family Welfare, Government of India. Retrieved from:

Ministry of Health and Family Welfare (n.d.-a). National Rural Health Mission-Meeting people’s health needs in rural areas: framework for implementation 2005-2012. Government of India. Available from:

Ministry of Health and Family Welfare (n.d.-b). Rural Health Statistics 2019-2020. Statistics Division, Ministry of Health and Family Welfare. Government of India.

Ministry of Health and Family Welfare. (2012). Indian Public Health Standards. Available from

National Health Portal (2019). Ayushman Bharat Yojana. Government of India. Available from:

National Health Systems Resource Centre (2019). Update on ASHA Programme: July 2019. Ministry of Health and Family Welfare. Available from:

Indonesia introduced universal health care through the National Health Insurance System (Jaminan Kesehatan Nasional (NHIS)) in 2014. Services covered under the NHIS can be provided by the government-owned health facilities and registered private providers (Agustina et al., 2019, pp.75,89).

The system was created by bringing together a number of existing, but still fragmented, health insurance and social assistance schemes under the umbrella of a single payer, the Social Security Agency for Health (Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS)) and covers a range of services from simple procedures to ‘open heart surgery […] and cancer therapies’ (Agustina et al., 2019, pp.76,89). Furthermore, reproductive, maternal, neonatal, child health as well as emergency services are fully covered, and medicines and medical supplies can be received without co-payment if the patient adheres to procedures. The system does not cover cosmetic procedures, self-inflicted injuries, and services provided outside pre-approved providers, unless they are emergencies (Agustina et al., 2019, p.89).

The system covers civil servants, private sector employees and provides for socio-economically vulnerable members of the community. Government subsidises for 109.5 million socio-economically vulnerable account for 61 per cent of those with insurance coverage. Civil servants, private sector employees and others providing independent contributions make up 39 per cent of those insured. (TNP2K, 2018, p.83).

By October 2018, the systems served 203 million members, representing the ‘largest single-payer scheme in the world’. In 2017, 223.4 million consultations were recorded, amounting to US$20.15 billion (US$ PPP) (Agustina et al., 2019, p.75).

As over half of members of the BPJS receive government subsidies and among those contributing independently, members often only pay during periods of illness, which poses challenges for the financial sustainability of the programme. It was reported that claims exceeded contributions by 600 per cent in 2014 (TNP2K, 2018, p.84).

The system in Indonesia consists of three main service tiers, these are:

Community health centres (Puskesmas)

The Puskesmas programme was introduced under president Suharto in 1968. By 1970, community health centres were established in all subdistricts (Agustina et al., 2019, p.77). The Puskesmas provide frontline primary health care. From there, patients with more complex needs can be referred to hospitals or other services. In 2015, 9,754 Puskesmas were in operation, covering 92% of subdistricts. However, particularly in the eastern part of the country, some subdistricts did not have Puskesmas. There are also concerns regarding quality. According to Agustina and colleagues (2019, pp.84-95), ‘only 74% of community health centres met preparedness requirements’. Quality standards were found to be better in urban than in rural areas (Agustina et al., 2019, pp.84-85).

Integrated community health service post (Posyandu)

The Posyandu were introduced shortly after the Puskesmas (1980), with a focus on preventive health services (Agustina et al., 2019, p.77). The Posyandu are staffed by a midwife, a nurse assistant, and a vaccinator and are facilitated by health volunteers (kaders) in each community. These teams visit hamlets or village subdivisions on a monthly basis and provide ‘basic reproductive, maternal, neonatal, and child health services’, although later on several Posyandu Lansia focusing on older people’s health have been set up. It is estimated that almost 300,000 Posyandu are held every month (Agustina et al., 2019, p.84).


The number of hospitals almost doubled between 2005 and 2015, from 1,268 to 2,488 (Agustina et al., 2019, pp.84-85). As outlined above, subsidised members can access third-class hospital rooms without co-payments, while self-employed members can access first to third-class rooms in accordance with their insurance plan. Those earning more than $300 a month are entitled to first-class rooms. BPJS members can upgrade their hospital room through payments or private insurance (Agustina et al., 2019, p.89). In the end of 2021, the government has announced the plan to erase this classing system in BPJS, and will only offer a standardised class, following the health equity principle. It will be implemented gradually starting in 2023 (Hasibuan, 2022).

The Ministry of Health further regulates geriatric services in Indonesia’s public hospitals (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014). By 2015, six hospitals on Java Island and one hospital in Bali, Sumatra, and Sulawesi islands provided older people with ‘integrated geriatric services’ (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014, 2016b).

Data from the Ministry of Health shows that the number of private hospitals has grown more rapidly than that of public hospitals. However, private hospitals remain mostly concentrated on the Java islands where there are larger urban and peri-urban centres.


Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102.

Hasibuan L. (2022). Siap-siap! Kelas 1,2,3, BPJS Kesehatan Dihapus, Ini Gantinya. CNBC Indonesia.

Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS), (2014) (testimony of Ministry of Health Republic of Indonesia).

Ministry of Health. 2012–2017. Ministry of Health Annual Health Sector Profile 2011–2016. Jakarta, Indonesia: Ministry of Health.

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Pusat Data dan Informasi Kementerian Kesehatan RI. (2016b). Situasi Lanjut Usia (Lansia di Indonesia).

Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (2018) The Future of the social protection system in Indonesia, Jakarta Pusat: Office of the Vice President of the Republic of Indonesia.

63% of the Kenyan population access public health services within a distance of 1 hour walk on foot (Mugo et al., 2018). The public sector in Kenya is composed of the national government, county government, development partners and public corporations. Their main mandate is to strengthen performance and management systems including the capability of public service leadership and to enhance quality and efficiency of public service delivery while transforming the culture and attitude of its employees (Fortune of Africa, 2019).

The public health system is overseen by the Ministry of Health and parastatal organizations. It includes a total of 4,616 health facilities, and consists of different levels of care, including national referral hospitals (level 6 – highest level of care – only four in Kenya (Kenyatta National Hospital, Moi Referral and Teaching Hospital, Mathari Hospital and National Spinal Injury Hospital), county hospitals (level 5), sub-county hospitals (level 4), health centres (level 3), dispensaries (level 2) and communities (level 1). Any higher level facility acts as a referral centre for the lower level facility (see table 2 below). The different levels of care are outlined below (Noor et al., 2006).

Table 2:  Description of health services provided by the Kenyan public sector
Level of service Purpose Services offered % of individuals accessing outpatient public services Expected catchment population
National Referral services (level 6) Serve all Kenyans and act as referral centre for County hospitals Surgical services, internal medicine, and specialty services such as emergency obstetric care (EmOC) and anesthesiology Referral services accessed 5,000,000
County Referral Services (level 5) The intermediary between national referral hospitals and sub-County hospitals.  Their role is to coordinate Sub-County activities while providing some form of specialized care Less extensive surgical services, internal medicine, and specialty services as compared to the National Referral Hospitals
Sub-County (Primary care services) (level 4) These serve as the referral centres for health centres and offer outpatient, inpatient and maternity services, emergency surgery, blood transfusion and laboratory services Antenatal care (ANC) and routine birthing services, formal immunization programs, HIV/ AIDS care, paediatric and Emergency Obstetric Care (EmOC) services   100,000
Health centres (primary health care services) (level 3) Identification of cases that need to be further managed at higher levels of care Preventive and curative services with a focus on primary care services
Dispensaries – primary care health services (level 2) This is the intermediary between the community and health centres. The role is to receive cases directly from the community level for provision of primary health care services. Preventive and curative services with a focus on primary care services   10,000
Community-based services (level 1) Health promotion and demand creation: To prevent affliction and promote good health to avert the need for facility-based care Some of the interventions provided focus on sleeping under insecticide treated mosquito nets to avert malaria. However, when affliction arises, the system expects the first port of call to be the dispensary (Level 2) Prevention services and based on home visits 5,000 per unit

Source: (Kenya Healthcare Federation and Task Force Health Care, 2016; Ministry of Health, 2014e; Mugo et al., 2018)


Fortune of Africa. (2019). Public Sector Profile of Kenya.

Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya

Ministry of Health. (2014e). Towards Universal Health Coverage: The Kenya Health Strategic and Investment Plan, 2014 – 2018 – Human Resources for Health Norms and Standards Guidelines for the Health Sector.

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya.

Noor, A. M., Amin, A. A., Gething, P. W., Atkinson, P. M., Hay, S. I., & Snow, R. W. (2006). Modelling distances travelled to government health services in Kenya. Tropical Medicine & International Health, 11(2), 188–196.

23.1% of the population used private sector services, 40.1% public services provided by the Ministry of Health, and 36.8% used services provided by social security institutions (OECD, 2017a). Health services in the public (MoH) and social security sectors (i.e. IMSS, ISSSTE, Armed Forces, etc.) are similarly organised.


OECD. (2017a). Estudios Económicos de la OCDE México (OCDE Publishing, Ed.). OCDE Publishing.

About 82 of every 100 South Africans (i.e., 45 million) are largely dependent on public healthcare  (StatsSA, 2017a), which provides healthcare to 84% of the population (Mahlathi & Dlamini, 2015). This sector is governed by the National Department of Health which is responsible for the development of policies and overall coordination (Mahlathi & Dlamini, 2015). Provincial departments are responsible for providing primary, secondary and tertiary care services through public clinics and hospitals (Mahlathi & Dlamini, 2015).


Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from:

StatsSA. (2017a). Public healthcare: How much per person? Statistics South Africa: Statistical Release.