Palladium is a global leader in the design, development and delivery of Positive Impact - the intentional creation of enduring social and economic value. We work with foundations, investors, governments, corporations, communities and civil society to formulate strategies and implement solutions that generate lasting social, environmental and financial benefits.
For the past 50 years, we have been making Positive Impact possible. With a team of more than 2,500 employees operating in 90 plus countries and a global network of more than 35,000 technical experts, Palladium has improved - and is committed to continuing to improve - economies, societies and most importantly, people’s lives.
Palladium is a child-safe organisation, and screens applicants for suitability to work with children. We also provide equal employment to all participants and employees without regard to race, color, religion, gender, age, disability, sexual orientation, veteran or marital status. The Jordan Health Finance and Governance Activity (HFG) aims to improve health sector sustainability and resiliency in Jordan, including UHC. HFG’s goal supports Jordan’s commitment to UHC declared in its National Health Strategy 2016-2020 “…to provide health, financial, and social protection to the entire population on a fair basis.”
Jordan faces unique technical and operational challenges affecting the entire health sector and the health insurance system in particular. The GOJ is the principal financier of healthcare services. It operates two very separate pubic insurers which combined cover about 90% of the insured. The two insurers, MOH and RMS, also provide care through two distinct delivery systems. Classes of Jordanians receive qualitatively different care from the different delivery systems. Insurance participation is not mandatory for all eligible, leading to adverse selection problems, especially in the presence of generous charitable care. Enrollment is not carefully tracked or coordinated among insurers. Premiums are not actuarially based to obtain a targeted share of expected costs, not equitable with those more able to pay charged more, nor do the healthy subsidize the sick. There does not appear to be any risk management taking place at public insurers – questioning the meaning of the term insurance used in the public healthcare sector. This sample of current challenges demonstrates the need to understand how the regulatory underpinnings of the health insurance schemes in Jordan contribute to inefficiencies, inequities, and ineffectiveness in financing and care delivery. With such knowledge, regulations can be modified to strengthen the insurance system for UHC.
This scope of work (SOW) is for multiple tasks related to health insurance and efficient use of healthcare resources in support of Universal Health Coverage (UHC) in Jordan:
1. Support for Legal Review: Working with support from HFG experts in law and health care systems and in association with Jordanian legal researcher short-term consultant, undertake review of the regulations impacting both Ministry of Health (MOH) and Royal Medical Services (RMS), and private health insurance, including third party payers (TPAs) and self-insured entities in Jordan. In a system where there are several different types of health insurers and the largest are also health care deliverers, rules are required for holistic coordination and appropriate conduct. The purpose of this critical review is to identify existing regulations and gaps in regulations that contribute to the problems/weaknesses of the current health insurance system or restrict the ability to improve it. The goals of this work are to understand the ways in which the regulatory environment most significantly impedes a solvent and sustainable system of health insurance that could be supportive of UHC.
2. Priority areas for Grants and Public-Private Partnerships: Working closely with the HFG Private Sector expert and Grants manager review and identify 1-3 priority areas for HFG grants and provide a list of 1-3 potential opportunities for public-private partnerships that can support Jordan’ advance to UHC within each priority areas.
3. In agreement with HFG’s Senior Health Finance Advisor, prepare a short policy paper on an issue of health financing/insurance (up to 5 pages).
4. Provide critical review and feedback on a draft Political Economy Analysis of healthcare, insurance operations review, and insurance inventory fact sheets prepared by HFG staff.
5. Provide input to HFG workplanning for Fiscal Year 2018.
Task 1:
The work task is to critically review the regulatory environment around the MOH, RMS, University insurance, and private health insurance in Jordan. HFG is not interested in a comprehensive descriptive review of all health insurance related regulations but instead, seeks a very targeted review of the rules and regulations, or lack of rules and regulations, that significantly deter the current health insurance system from being coordinated, efficient and solvent.
The single most significant objective of health insurance regulation is the protection of consumers and providers. Health insurance regulation attempts to ensure
1) consumers are charged fair and reasonable insurance prices and receive quality health care,
2) providers receive contracted payments for healthcare services delivered, and
3) insurers operate in ways that are legal and fair to consumers and providers. Improper or missing regulations can adversely impact the consumers and providers insurance is designed to protect.
This work focuses on identifying the existing or missing regulations that most weaken the insurance system by contributing to inappropriate isolation, lack of coordination and cooperation, inefficiency, inequity, lack of transparency and accountability. It will be important to consider rules and assumed rules (when there is common thinking a rule exists, yet it does not) and any administration of a law that may be a misinterpretation of the law as well as lack of proper enforcement and compliance mechanisms. For each significant law or gap in regulation, the consultant should make recommendations for revisions or additions.
The consultant should consider the illustrative health insurance regulation topics below and propose any additional they feel should also be included. Some topics are more applicable to public than private insurance schemes, or vice versa. Since Jordan has both insurer types, all could be relevant. The consultant should investigate the most significant barriers to a high functioning health insurance system. It is not expected that s/he address them in equal detail.
The consultant will review laws and regulations available in English and will rely for review and input on laws and regulations unavailable in English on a team of Jordanian lawyers (HFG staff and short-term legal researcher) which s/he will guide.
* Health Insurance Oversight-Is there an independent oversight body empowered to monitor and enforce rules? The overseer typically examines health insurer conduct on a routine basis, but exams also can be triggered by complaints against an insurer. These exams review licensing issues, complaints, types of products sold and sales practices, rating methods and premiums, handling of claims/provider payments, finances and other aspects of an insurer’s operation. When violations are found, the insurance overseer makes recommendations to improve the health insurer’s operations and to bring the company into compliance with the law.
* Penalties- Is there a system of civil penalties or license suspension or revocation for health insurers out of legal compliance? And an impartial and fair process for appeal?
* Licensing- Must health insurers be licensed specifically for health insurance which is a very different product than other types of insurance? Are TPAs (third party administrators) and self-insured entities considered health insurers and regulated similarly? Is there a limit to the number of insurers in Jordan’s very small market or must health insurers have a minimum enrollment? Are there different rules for different sized insurance pools?
* Sales and Advertising- Must those who sell insurance be licensed? Is continuing education required? Are there rules about advertising?
* Finances- Are health insurer finances monitored regularly, through quarterly filings and yearly audits, for example? Are there profit limits? Are there reserve requirements? Are there rules about arrears or debt levels? Is there guidance about what to do when an insurer is failing to protect consumers and providers?
* Accreditation - Are health insurers required to be accredited? Are there gaps and issues with the accreditation process?
* Data and Record Keeping - Are there any requirements about data collection and transfer, of sales transactions, or health care delivery, for example? Must insurers report any data? Are there common forms and specifications for reporting?
* Eligibility- Who can participate in insurance schemes? Is there clarity and consistency of definitions-the poor, for example, are defined the same way for all.
* Ineligibility- How might a participant become ineligible? What happens if premium is not paid or if s/he loses their position and their insurance is employment based? What happens when a woman is covered because she is pregnant and she delivers her baby? Is there any legal guidance on how eligibility or ineligibility should be monitored by insurers?
* Enrollment Processes and Periods- Are processes to enroll straightforward for all or is enrollment more complex and difficult for some? Are there limited, defined enrollment periods or is enrollment possible at any time? Is medical underwriting allowed?
* Benefits- How are benefits determined? Are there any rules about health care services that must be covered or must not? Is there a benefit maximum or minimum? Are subtle gaps in coverage allowed to exist? How are benefits communicated to consumers and providers?
* Consumer Out of Pocket Payments- What are rules for copayments, coinsurance, deductibles, out of pocket limits, etc.?
* Insured and Provider Rights- Are insurers required to inform insureds and providers about their rights? Are rights communicated in a way that is easy for the average person to understand?
* Preexisting Conditions- Are there rules about what insurers can and cannot do about preexisting conditions? For example, can insurers ask about preexisting conditions or impose waiting periods?
* Premiums-Who sets premiums and how? Are there rules about different rating methods? Are health insurance products and rates reviewed, made public? Any rules about how premiums are collected such as automatic deductions from social security payments?
* Coordination of Benefits- Are there rules about how to administer insurance when an insured has multiple insurers?
* Denying Service- Are there rules about what happens when a person presents for health care and does not have health insurance? Are providers required to deliver care? Who pays?
* Charity Care- Are there rules to make sure charity care is delivered to those who truly need it and not to those who could have purchased insurance but did not.
* Public/Private Collaboration-Are there rules limiting the ways in which public and private insurers and providers can interact?
Task 2
Working closely with the HFG Private Sector expert and Grants manager the consultant will conduct meetings with private and public participants in the health sector and review relevant documents with objective to identify 1-3 priority areas for HFG grants and provide a list of 1-3 potential opportunities for public-private partnerships that can support Jordan’ advance to UHC within each priority areas. This work will inform the preparation of HFG workplan for FY 2018.
Task 3
Following guidelines from the HFG’s Senior Health Finance Advisor, prepare a short policy paper on an issue of health insurance. The policy paper will support a small discussion under the HFG rubric “From Talk to Action” in September.
Task 4
Provide critical review and practical feedback on: draft Political Economy Analysis of healthcare; public insurance operations review documents; and insurance inventory fact sheets prepared by HFG staff.
Task 5
Provide input to HFG workplanning for Fiscal Year 2018.
Deliverables
Task 1:
HFG expects a deliverable analytical document describing the most problematic regulations and regulation gaps affecting health insurance and in need to change. The regulations/gaps should be listed in order of importance with those causing the most critical problems first. For each regulation/rule identified as significantly problematic, the document should present/refer to the legal title of the law/regulation quoting the language of used in the regulation itself, an explanation about why the regulation or specific sections/articles of it is/are an important problem including for whom (MOH, RMS, University, private sector) it is a problem, and recommendations about how to fix it. Other, less important obstructive rules can be listed with minimal elaboration.
All findings should be summarized in a Findings Table. All laws, bylaws and other regulations examined for the preparation of the document should also be presented in a table.
Task 2:
HFG expects the delivery of document presenting findings from interviews/meetings and analysis of options and opportunities in a way that would enable a group of high-level policy makers to receive sufficient but not excessive detail that would allow them to make a selection from among presented choices.
Task 3:
HFG expects the delivery of a professionally written, high quality, relevant for the situation in Jordan policy paper on issue of health insurance relevant for the advance of UHC. The policy paper (brief) will not exceed 5 pages.
Tasks 4 and 5:
HFG expects the delivery of detailed written feedback/critical review of documents produced by HFG staff. The feedback should be practical helping improve the quality of HFG deliverables including by making them more actionable and implementable.
The level of effort (LOE) for this consultancy is 69 days including time in travel for up to two trips to Jordan. Minimum LOE in Jordan is expected to be at least 65% of total. Work is expected to begin in July and be completed by September 2017.
The consultant will provide weekly progress reports and update meetings to ensure the assignment is progressing well and on time. Products and communication associated with the task will be in English.
DeliverableDue dateLOE
TASK 1
1.1 Review background documents and laws in English. Outline of the deliverable health insurance legal review / sample product40 days after singing of consulting agreement9
1.2 First draft insurance / health insurance legal reviewNo later than 60 calendar days after signing of consulting agreement15
1.3 Final draft insurance/health insurance legal reviewNo later than 80 calendar days after signing the consulting agreement10
TASK 2: Document identifying priority areas and opportunities for public-private partnerships and grants in support of UHCNo later than 45 days from the signing of the consulting agreement15
TASK 3: Policy Paper on Issue of Health FinanceTBD5
TASK 4: Review and feedback on Political Economy Analysis of healthcare; public insurance operations review documentation; and insurance inventory fact sheets prepared by HFG staff.TBD8
TASK 5: Feedback to HFG FY 2018 workplanBy August 283
Time in Travel 4
The consultant must have a solid understanding of best regulatory practices in insurance and health insurance and should have reviewed insurance laws and regulations in the past as well as knowledge about the principles and traits of robust health insurance systems and the regulations that support such systems. The consultant should have practical work experience in health insurance, health finance, and private sector internationally.
* Minimum 10 years of work experience in insurance and health insurance
* Experience working directly with, reviewing, analyzing insurance laws, regulations, and policies
* Strong analytical and report writing skills
* Work experience in Jordan and internationally in the area of health insurance and private sector required
* Experience with public-private partnerships strongly preferred
* Fluent in English
* International consulting experience on issues of insurance is a plus
* Knowledge of Arabic is an advantage
Palladium is a global leader in the design, development and delivery of Positive Impact – the intentional creation of enduring social and economic value. We work with foundations, investors, governments, corporations, communities and civil society to formulate strategies and implement solutions that generate lasting social, environmental and financial benefits.
For the past 50 years, we have been making Positive Impact possible. With a team of more than 2,500 employees operating in 90 plus countries and a global network of more than 35,000 technical experts, Palladium has improved – and is committed to continuing to improve – economies, societies and most importantly, people's lives.
Palladium is a child-safe organisation, and screens applicants for suitability to work with children. We also provide equal employment to all participants and employees without regard to race, colour, religion, gender, age, disability, sexual orientation, veteran or marital status.
