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 |
|---|---|---|
| Indonesia: Jamkesmas |
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Jamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited. Read full sectionJamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited. Overall, free access to many providers—both private and public—and a comprehensive benefits package make Jamkesmas more attractive to the majority of the population—even those covered under Askes and Jamsostek. A recent survey in early 2008 entitled “Study on Benefit Package Based on Community’s Preference” conducted by Center for Health Financing Policy and Health Insurance Management at the University of Gadjah Mada has shown that 79.8 % of people who were already enrolled with health insurance schemes, such as Askes and Jamsostek, preferred to be entitled with Jamkesmas benefits as they felt the coverage provided under Jamkesmas was superior to that provided under their existing plan. JamkesmasBenefits package Types of Benefits: Comprehensive Jamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited. Overall, free access to many providers—both private and public—and a comprehensive benefits package make Jamkesmas more attractive to the majority of the population—even those covered under Askes and Jamsostek. A recent survey in early 2008 entitled “Study on Benefit Package Based on Community’s Preference” conducted by Center for Health Financing Policy and Health Insurance Management at the University of Gadjah Mada has shown that 79.8 % of people who were already enrolled with health insurance schemes, such as Askes and Jamsostek, preferred to be entitled with Jamkesmas benefits as they felt the coverage provided under Jamkesmas was superior to that provided under their existing plan. |
| 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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| Philippines: PhilHealth |
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PhilHealth beneficiaries have access to a nearly comprehensive package of services, including inpatient care, catastrophic coverage, ambulatory surgeries, deliveries, and outpatient treatment for malaria and tuberculosis. Those identified as indigent and OFW are also entitled to outpatient primary care. Read full sectionPhilHealth beneficiaries have access to a nearly comprehensive package of services, including inpatient care, catastrophic coverage, ambulatory surgeries, deliveries, and outpatient treatment for malaria and tuberculosis. Those identified as indigent and OFW are also entitled to outpatient primary care. More specifically, services included range from:
Except for the outpatient primary care that the poor and OFW are entitled to via public providers, there is free choice of providers for beneficiaries, both public and private. Annual or lifetime coverage limits do exist. These limits are expressed in terms of volumes of services (e.g., days) rather than a peso coverage limit. For example, member households are eligible for 45 days of inpatient admission, sharing 45 days among all household members. Each day of ambulatory surgery counts as a day of admission. While there is no formal system that sets fixed deductibles or co-payments, health care providers are allowed to charge the patient the balance between the total cost of care and what PhilHealth pay (i.e., balance billing). There are some waiting periods before beneficiaries can access care; waiting periods differ by population category:
PhilHealthBenefits package Types of Benefits: Comprehensive PhilHealth beneficiaries have access to a nearly comprehensive package of services, including inpatient care, catastrophic coverage, ambulatory surgeries, deliveries, and outpatient treatment for malaria and tuberculosis. Those identified as indigent and OFW are also entitled to outpatient primary care. More specifically, services included range from:
Except for the outpatient primary care that the poor and OFW are entitled to via public providers, there is free choice of providers for beneficiaries, both public and private. Annual or lifetime coverage limits do exist. These limits are expressed in terms of volumes of services (e.g., days) rather than a peso coverage limit. For example, member households are eligible for 45 days of inpatient admission, sharing 45 days among all household members. Each day of ambulatory surgery counts as a day of admission. While there is no formal system that sets fixed deductibles or co-payments, health care providers are allowed to charge the patient the balance between the total cost of care and what PhilHealth pay (i.e., balance billing). There are some waiting periods before beneficiaries can access care; waiting periods differ by population category:
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| 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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