The Joint Learning Network for Universal Health Coverage systematically documents the reforms of its member countries and other countries that have expanded health coverage through demand-side financing. The case studies contained in these pages are brief, comparative and modular in nature, describing the key highlights and technical features of each program.
Compare various dimensions of country reform efforts using our interactive tool.
| Program | Types of benefits | Benefits package |
|---|---|---|
| Vietnam: Compulsory and Voluntary Health Insurance Schemes |
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HCFP offers a comprehensive benefits package that includes both inpatient and outpatient care. Excluded are interventions covered by vertical programs such as HIV/AIDS prevention and treatment, treatments not yet approved by the MoH, various “luxury” interventions such as cosmetic surgery, certain dental procedures, and treatment of self-inflicted injuries and drug addiction, among others. Read full sectionHCFP offers a comprehensive benefits package that includes both inpatient and outpatient care. Excluded are interventions covered by vertical programs such as HIV/AIDS prevention and treatment, treatments not yet approved by the MoH, various “luxury” interventions such as cosmetic surgery, certain dental procedures, and treatment of self-inflicted injuries and drug addiction, among others. The benefits package is essentially the same for everyone, except the poor, children under 6, pensioners, and meritorious persons who are exempted from copayment or have lower copayment rate. The following services are covered under all health programs: medical consultation, diagnosis and treatment, X-ray and laboratory tests, functional examination, imaging diagnosis, drugs listed by the MoH, blood and transfusion, surgery, antenatal examination and delivery. In addition to these items, the insurance also covers the cost (up to a certain limit) of a defined list of high-technology treatments (including magnetic resonance imaging (MRI), hemodialysis and laser surgery among a total of 177 specified high-tech procedures). The following exemptions, some of which are covered by the national target programs, are imposed: leprosy, tuberculosis, malaria, schizophrenia, epilepsy, STD, vaccination, convalescence, early-detected pregnancy, medical check-ups, family planning services and infertility treatments, prosthesis, aesthetic surgery, artificial arm, leg, tooth, glasses, hearing-aid machines, occupational diseases, war injuries, accidents at work place, treatment for suicide, self-inflicted injuries, drug addiction, medical appraisal, forensic appraisal, mental examination, home care, rehabilitation and delivery. Compulsory and Voluntary Health Insurance SchemesBenefits package Types of Benefits: Comprehensive HCFP offers a comprehensive benefits package that includes both inpatient and outpatient care. Excluded are interventions covered by vertical programs such as HIV/AIDS prevention and treatment, treatments not yet approved by the MoH, various “luxury” interventions such as cosmetic surgery, certain dental procedures, and treatment of self-inflicted injuries and drug addiction, among others. The benefits package is essentially the same for everyone, except the poor, children under 6, pensioners, and meritorious persons who are exempted from copayment or have lower copayment rate. The following services are covered under all health programs: medical consultation, diagnosis and treatment, X-ray and laboratory tests, functional examination, imaging diagnosis, drugs listed by the MoH, blood and transfusion, surgery, antenatal examination and delivery. In addition to these items, the insurance also covers the cost (up to a certain limit) of a defined list of high-technology treatments (including magnetic resonance imaging (MRI), hemodialysis and laser surgery among a total of 177 specified high-tech procedures). The following exemptions, some of which are covered by the national target programs, are imposed: leprosy, tuberculosis, malaria, schizophrenia, epilepsy, STD, vaccination, convalescence, early-detected pregnancy, medical check-ups, family planning services and infertility treatments, prosthesis, aesthetic surgery, artificial arm, leg, tooth, glasses, hearing-aid machines, occupational diseases, war injuries, accidents at work place, treatment for suicide, self-inflicted injuries, drug addiction, medical appraisal, forensic appraisal, mental examination, home care, rehabilitation and delivery. |
| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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Entitlements of coverage under the MHIF were introduced under the State Guarantee Benefits Package (SGBP). The specifications of the SGBP are the following:
Entitlements of coverage under the MHIF were introduced under the State Guarantee Benefits Package (SGBP). The specifications of the SGBP are the following:
The Additional Drug Package (ADP) was introduced in 2000 as a way of reinforcing the importance of primary care. It started in seven pharmacies and was slowly rolled out to the entire country by 2003. The ADP is an outpatient drug benefit for those insured with the MHIF, which initially included 37 generic drugs but has expanded since. To purchase drugs through the ADP, the patient pays a discounted price at the pharmacy and the MHIF reimburses the pharmacy for the difference. The subsidy amount is based on a reference price and is approximately 50% of the reference price. Mandatory Health Insurance Fund (MHIF)Benefits package Types of Benefits: Comprehensive Entitlements of coverage under the MHIF were introduced under the State Guarantee Benefits Package (SGBP). The specifications of the SGBP are the following:
The Additional Drug Package (ADP) was introduced in 2000 as a way of reinforcing the importance of primary care. It started in seven pharmacies and was slowly rolled out to the entire country by 2003. The ADP is an outpatient drug benefit for those insured with the MHIF, which initially included 37 generic drugs but has expanded since. To purchase drugs through the ADP, the patient pays a discounted price at the pharmacy and the MHIF reimburses the pharmacy for the difference. The subsidy amount is based on a reference price and is approximately 50% of the reference price. |
| Ghana: National Health Insurance Scheme (NHIS) |
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The basic benefits package is fairly extensive and purports to cover 95% of all health problems reported in Ghanaian health care facilities, though there is a noticeable emphasis on female reproductive health. Expensive, highly specialized care such as dialysis and organ transplants are not covered by the NHIS. ARVs for the treatment of HIV/AIDS are also not covered as these drugs are supplied by a separate government program. Read full sectionThe basic benefits package is fairly extensive and purports to cover 95% of all health problems reported in Ghanaian health care facilities, though there is a noticeable emphasis on female reproductive health. Expensive, highly specialized care such as dialysis and organ transplants are not covered by the NHIS. ARVs for the treatment of HIV/AIDS are also not covered as these drugs are supplied by a separate government program. The health services covered by the NHIS are laid out in the minimum basic benefits package. The list also delineates prescribed medicines. Benefits for maternity care include antenatal care, caesarean sections, and postnatal care for up to six months after birth. Treatment for breast and cervical cancer are included in the package, although treatment for other cancers is not. NHIS Benefits Package Outpatient services
Inpatient services
Oral health
Maternity care
Emergencies
Exclusions list
National Health Insurance Scheme (NHIS)Benefits package Types of Benefits: Comprehensive The basic benefits package is fairly extensive and purports to cover 95% of all health problems reported in Ghanaian health care facilities, though there is a noticeable emphasis on female reproductive health. Expensive, highly specialized care such as dialysis and organ transplants are not covered by the NHIS. ARVs for the treatment of HIV/AIDS are also not covered as these drugs are supplied by a separate government program. The health services covered by the NHIS are laid out in the minimum basic benefits package. The list also delineates prescribed medicines. Benefits for maternity care include antenatal care, caesarean sections, and postnatal care for up to six months after birth. Treatment for breast and cervical cancer are included in the package, although treatment for other cancers is not. NHIS Benefits Package Outpatient services
Inpatient services
Oral health
Maternity care
Emergencies
Exclusions list
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| Nigeria: National Health Insurance System |
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The benefits package for the National Health Insurance Scheme for workers in the formal sector is pre-determined and includes:
The benefits package for the National Health Insurance Scheme for workers in the formal sector is pre-determined and includes:
Exclusions for the package include:
The benefits packages for the informal program of the National Health Insurance Scheme (NHIS) are determined by the stakeholders through a process of consensus building. Members determine the benefits package according to local needs. National Health Insurance SystemBenefits package Types of Benefits: Comprehensive The benefits package for the National Health Insurance Scheme for workers in the formal sector is pre-determined and includes:
Exclusions for the package include:
The benefits packages for the informal program of the National Health Insurance Scheme (NHIS) are determined by the stakeholders through a process of consensus building. Members determine the benefits package according to local needs. |
| India: Rajiv Aarogyasri |
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The Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care. Read full sectionThe Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care. 30 groups of doctors from the Government and corporate hospital sectors were consulted to develop the benefits package for Aarogyasri. Through a series of these consultations, Aarogyasri benefits have been agreed upon to include 389 surgical procedures and 144 medical diseases. A list of all benefits and associated reimbursement to hospitals can be found on the Aarogyasri web site. There is no deductible or co-payment for seeking care, and because the system is entirely cashless patients are admitted, treated, and discharged without exchanging any money. Immediate pre- and post-operative expenditures are included in package rates to minimize the other financial expenses to the patient. Rajiv AarogyasriBenefits package Types of Benefits: Primarily Inpatient The Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care. 30 groups of doctors from the Government and corporate hospital sectors were consulted to develop the benefits package for Aarogyasri. Through a series of these consultations, Aarogyasri benefits have been agreed upon to include 389 surgical procedures and 144 medical diseases. A list of all benefits and associated reimbursement to hospitals can be found on the Aarogyasri web site. There is no deductible or co-payment for seeking care, and because the system is entirely cashless patients are admitted, treated, and discharged without exchanging any money. Immediate pre- and post-operative expenditures are included in package rates to minimize the other financial expenses to the patient. |
| India: RSBY |
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RSBY covers all hospitalization expenses of up to Rs. 30,000/- (USD 600) per family per year and has established package rates for 727 inpatient surgical procedures, including maternity and newborn care. Benefits packages also provide beneficiaries with transportation assistance of up to Rs. 100/- (USD 2) per visit, though not exceeding Rs. 1,000/- (USD 20) per year. Read full sectionRSBY covers all hospitalization expenses of up to Rs. 30,000/- (USD 600) per family per year and has established package rates for 727 inpatient surgical procedures, including maternity and newborn care. Benefits packages also provide beneficiaries with transportation assistance of up to Rs. 100/- (USD 2) per visit, though not exceeding Rs. 1,000/- (USD 20) per year. A family covered by RSBY can include up to five members (including a husband, a wife, and three dependents). Most of the surgical and medical conditions for which hospitalization is necessary are covered in the scheme. In addition, beneficiaries are covered for outpatient surgeries which can be done on an outpatient basis. The benefit also includes one day pre- and five day post-hospitalization expenses. All pre-existing diseases are covered from the first day of enrollment with some exclusions. RSBY does not cover:
RSBYBenefits package Types of Benefits: Primarily Inpatient RSBY covers all hospitalization expenses of up to Rs. 30,000/- (USD 600) per family per year and has established package rates for 727 inpatient surgical procedures, including maternity and newborn care. Benefits packages also provide beneficiaries with transportation assistance of up to Rs. 100/- (USD 2) per visit, though not exceeding Rs. 1,000/- (USD 20) per year. A family covered by RSBY can include up to five members (including a husband, a wife, and three dependents). Most of the surgical and medical conditions for which hospitalization is necessary are covered in the scheme. In addition, beneficiaries are covered for outpatient surgeries which can be done on an outpatient basis. The benefit also includes one day pre- and five day post-hospitalization expenses. All pre-existing diseases are covered from the first day of enrollment with some exclusions. RSBY does not cover:
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| Mexico: Seguro Popular |
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The design of the Seguro Popular essential benefits package was informed by two key sets of analytical inputs. The first set of analytical tools was composed of estimates of the burden of disease used to assess the severity of different health problems. The second set was made up of cost-effectiveness analyses used to weigh the potential population-level benefits of distinct interventions against their financial costs. The first benefits package was selected in 2002 and consisted of 78 health interventions. These interventions included primarily preventive activities as well as the detection and treatment of degenerative diseases. Read full sectionThe design of the Seguro Popular essential benefits package was informed by two key sets of analytical inputs. The first set of analytical tools was composed of estimates of the burden of disease used to assess the severity of different health problems. The second set was made up of cost-effectiveness analyses used to weigh the potential population-level benefits of distinct interventions against their financial costs. The first benefits package was selected in 2002 and consisted of 78 health interventions. These interventions included primarily preventive activities as well as the detection and treatment of degenerative diseases. In 2004, the number of interventions increased to 91 and by 2005 the number increased to 155. In 2006-2007, the number of covered interventions increased significantly up to 255 interventions, covering most causes of primary care visits and nearly 95% of all causes of hospital admissions. As of 2009, there were 266 interventions that were covered under the Universal Catalog of Health Services (CAUSES). The benefits package can be divided into six distinct categories of services as follows:
There is also a distinct benefits package for protection against catastrophic expenditures. This centrally managed fund, known as the Protection Fund Against Catastrophic Expenditures (FPGC) covered 17 interventions in 2006. By 2010, the number of interventions grew to 49 and included treatment for HIV/AIDS, bone marrow transplant, and childhood cancer. Care for most of these catastrophic events (84%) is provided by private service providers. Seguro PopularBenefits package Types of Benefits: Comprehensive The design of the Seguro Popular essential benefits package was informed by two key sets of analytical inputs. The first set of analytical tools was composed of estimates of the burden of disease used to assess the severity of different health problems. The second set was made up of cost-effectiveness analyses used to weigh the potential population-level benefits of distinct interventions against their financial costs. The first benefits package was selected in 2002 and consisted of 78 health interventions. These interventions included primarily preventive activities as well as the detection and treatment of degenerative diseases. In 2004, the number of interventions increased to 91 and by 2005 the number increased to 155. In 2006-2007, the number of covered interventions increased significantly up to 255 interventions, covering most causes of primary care visits and nearly 95% of all causes of hospital admissions. As of 2009, there were 266 interventions that were covered under the Universal Catalog of Health Services (CAUSES). The benefits package can be divided into six distinct categories of services as follows:
There is also a distinct benefits package for protection against catastrophic expenditures. This centrally managed fund, known as the Protection Fund Against Catastrophic Expenditures (FPGC) covered 17 interventions in 2006. By 2010, the number of interventions grew to 49 and included treatment for HIV/AIDS, bone marrow transplant, and childhood cancer. Care for most of these catastrophic events (84%) is provided by private service providers. |