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.
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| Estonia: Estonian Health Insurance Fund |
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The EHIF covers a broad range of services, including family physicians services, in- and out-patient care, long-term care, rehabilitation, and prescription drugs. Children through 19 years of age are also eligible for free dental care, including preventive and curative services. Meanwhile, adults receive partial reimbursement for dental care. Read full sectionThe EHIF covers a broad range of services, including family physicians services, in- and out-patient care, long-term care, rehabilitation, and prescription drugs. Children through 19 years of age are also eligible for free dental care, including preventive and curative services. Meanwhile, adults receive partial reimbursement for dental care. All Estonians register on a family doctor’s practice list. Doctors can refuse to add a patient if the patient lives outside the practice region or when the practice list is full. In 2005 only 13% of patients changed doctors and these cases were primarily due to a change in residence. Family doctors are required to hold a minimum of 20 visiting hours per week and the practice must remain open at least eight hours per day. Patients must get access to their doctor within one day for acute problems and within three days for chronic conditions. If certain services are not available in Estonia, patients can seek care abroad. In non-urgent situations, patients must seek approval from the EHIF. The service must be medically justifiable and must be proven efficacious with a probability of success of at least 50%. In order to add new benefits to be covered under EHIF, the managerial board conducts an evaluation process and recommends services to the supervisory board, which then proposes them to the Ministry of Social Affairs where they are reviewed and sent to the government for approval once per year. There are four criteria for including or excluding services from the benefits package:
Estonian Health Insurance FundBenefits package Types of Benefits: Comprehensive The EHIF covers a broad range of services, including family physicians services, in- and out-patient care, long-term care, rehabilitation, and prescription drugs. Children through 19 years of age are also eligible for free dental care, including preventive and curative services. Meanwhile, adults receive partial reimbursement for dental care. All Estonians register on a family doctor’s practice list. Doctors can refuse to add a patient if the patient lives outside the practice region or when the practice list is full. In 2005 only 13% of patients changed doctors and these cases were primarily due to a change in residence. Family doctors are required to hold a minimum of 20 visiting hours per week and the practice must remain open at least eight hours per day. Patients must get access to their doctor within one day for acute problems and within three days for chronic conditions. If certain services are not available in Estonia, patients can seek care abroad. In non-urgent situations, patients must seek approval from the EHIF. The service must be medically justifiable and must be proven efficacious with a probability of success of at least 50%. In order to add new benefits to be covered under EHIF, the managerial board conducts an evaluation process and recommends services to the supervisory board, which then proposes them to the Ministry of Social Affairs where they are reviewed and sent to the government for approval once per year. There are four criteria for including or excluding services from the benefits package:
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| Colombia: General System of Social Security in Health |
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One controversial component of the Colombian health system is that CR members—the wealthier—receive a richer benefits package than the poorer SR members. The CR benefits package covers all levels of care including inpatient, outpatient, maternity leave, and sick leave. The SR package covers all low-complexity care and catastrophic illnesses but provides only limited coverage for most hospital care and no short term disability coverage. Read full sectionOne controversial component of the Colombian health system is that CR members—the wealthier—receive a richer benefits package than the poorer SR members. The CR benefits package covers all levels of care including inpatient, outpatient, maternity leave, and sick leave. The SR package covers all low-complexity care and catastrophic illnesses but provides only limited coverage for most hospital care and no short term disability coverage. The SR is complemented by services provided by public hospitals, financed through direct payments to providers from the state, independent of what services they supply and of patients’ insurance status. General System of Social Security in HealthBenefits package Types of Benefits: Comprehensive One controversial component of the Colombian health system is that CR members—the wealthier—receive a richer benefits package than the poorer SR members. The CR benefits package covers all levels of care including inpatient, outpatient, maternity leave, and sick leave. The SR package covers all low-complexity care and catastrophic illnesses but provides only limited coverage for most hospital care and no short term disability coverage. The SR is complemented by services provided by public hospitals, financed through direct payments to providers from the state, independent of what services they supply and of patients’ insurance status. |
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| Mali: Mutuelles |
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The social protection policy aims to have the three systems cover the same services. The laws and decrees assured consistency in the services between the AMO and RAMED when the two organizations were founded. Read full sectionThe social protection policy aims to have the three systems cover the same services. The laws and decrees assured consistency in the services between the AMO and RAMED when the two organizations were founded. For the Mutuelles, payment for services is not yet consistent. The risks that the Mutuelles cover as they exist today in Mali are paid for partially or completely for the following:
Most Mutuelles limit themselves to the services provided at the first level of contact, which is the community health center (CSCOM), where patients receive the first level of care, but not for the more costly risks. The national Mutuelle extension strategy seeks to bridge this gap through the Mutuelle Support Fund by paying for care at the secondary and tertiary levels. With regard to standardizing the services that are covered, the starting point is the package of services covered by the AMO and RAMED, with certain modifications possible for more comprehensive coverage of preventive care, in particular for reproductive health. Table 3: Package of services covered, 2010
Source: Ministry of Social Protection MutuellesBenefits package Types of Benefits: Comprehensive The social protection policy aims to have the three systems cover the same services. The laws and decrees assured consistency in the services between the AMO and RAMED when the two organizations were founded. For the Mutuelles, payment for services is not yet consistent. The risks that the Mutuelles cover as they exist today in Mali are paid for partially or completely for the following:
Most Mutuelles limit themselves to the services provided at the first level of contact, which is the community health center (CSCOM), where patients receive the first level of care, but not for the more costly risks. The national Mutuelle extension strategy seeks to bridge this gap through the Mutuelle Support Fund by paying for care at the secondary and tertiary levels. With regard to standardizing the services that are covered, the starting point is the package of services covered by the AMO and RAMED, with certain modifications possible for more comprehensive coverage of preventive care, in particular for reproductive health. Table 3: Package of services covered, 2010
Source: Ministry of Social Protection |
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| Korea, Rep.: National Health Insurance Program |
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The benefit package for the National Health Insurance Program began small and was extended incrementally, because extension of population coverage was prioritized over expansion of benefits. Currently, benefits are the same for all insured individuals, regardless of whether they are self-employed or not. Both preventative and curative services are included in the benefits package. Preventative services include biannual check-ups and vaccination. For curative services, the insured are entitled to in-patient and outpatient care, dental services, traditional oriental medicines, and prescription medication. Procedures excluded from coverage include treatment for simple fatigue, superficial dermatology problems, cosmetic surgery, urogenic and gynecological diseases which cause no problems in everyday life, treatment of addiction to narcotics, and orthodontics. Read full sectionThe benefit package for the National Health Insurance Program began small and was extended incrementally, because extension of population coverage was prioritized over expansion of benefits. Currently, benefits are the same for all insured individuals, regardless of whether they are self-employed or not. Both preventative and curative services are included in the benefits package. Preventative services include biannual check-ups and vaccination. For curative services, the insured are entitled to in-patient and outpatient care, dental services, traditional oriental medicines, and prescription medication. Procedures excluded from coverage include treatment for simple fatigue, superficial dermatology problems, cosmetic surgery, urogenic and gynecological diseases which cause no problems in everyday life, treatment of addiction to narcotics, and orthodontics. Services are provided without a referral in all non-specialized health centers. To visit a specialized general hospital the patient must have a referral. Co-payments are required for all medical procedures. The amount of co-payment depends on the level of medical care received and whether the procedure was in-patient or out-patient. When an insured individual pays more than the co-payment ceiling—about 3 million Won or $2,400 USD—within 6 consecutive months, he or she is exempted from further co-payments. The co-payments are higher for hospitals than for physician clinics in order to encourage people to visit physician clinics before hospitals. Table 1: Co-payment system
Source: Song, Young Joo. “The South Korean Health Care System” JMAJ, Vol. 52, No. 3: 207. 2009. Out of pocket (OOP) expenditures have been reduced drastically since the expansion of health insurance coverage, from 63% of total health expenditure in 1983 to 38% of total health expenditure in 2008. However, despite this improvement, the share of OOP payments is still greater than the OECD average, and some scholars suggest that this is still a substantial barrier to medical care utilization across different socio-economic groups. National Health Insurance ProgramBenefits package Types of Benefits: Comprehensive The benefit package for the National Health Insurance Program began small and was extended incrementally, because extension of population coverage was prioritized over expansion of benefits. Currently, benefits are the same for all insured individuals, regardless of whether they are self-employed or not. Both preventative and curative services are included in the benefits package. Preventative services include biannual check-ups and vaccination. For curative services, the insured are entitled to in-patient and outpatient care, dental services, traditional oriental medicines, and prescription medication. Procedures excluded from coverage include treatment for simple fatigue, superficial dermatology problems, cosmetic surgery, urogenic and gynecological diseases which cause no problems in everyday life, treatment of addiction to narcotics, and orthodontics. Services are provided without a referral in all non-specialized health centers. To visit a specialized general hospital the patient must have a referral. Co-payments are required for all medical procedures. The amount of co-payment depends on the level of medical care received and whether the procedure was in-patient or out-patient. When an insured individual pays more than the co-payment ceiling—about 3 million Won or $2,400 USD—within 6 consecutive months, he or she is exempted from further co-payments. The co-payments are higher for hospitals than for physician clinics in order to encourage people to visit physician clinics before hospitals. Table 1: Co-payment system
Source: Song, Young Joo. “The South Korean Health Care System” JMAJ, Vol. 52, No. 3: 207. 2009. Out of pocket (OOP) expenditures have been reduced drastically since the expansion of health insurance coverage, from 63% of total health expenditure in 1983 to 38% of total health expenditure in 2008. However, despite this improvement, the share of OOP payments is still greater than the OECD average, and some scholars suggest that this is still a substantial barrier to medical care utilization across different socio-economic groups. |
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| 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. |
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| Thailand: Universal Coverage Scheme |
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UCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy. Read full sectionUCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy. The curative package covers ambulatory and hospitalization services with some exclusions, such as cosmetic surgery, infertility treatments, organ transplants, and the provision of private room and board. For high-cost care, the UCS has adopted a similar package to the one provided by the SSS in order to standardize the packages across the scheme to minimize inequities in health care services. Thus, substantial high-cost interventions are offered. All contracted public and private providers are bound to provide registered beneficiaries with these and other preventative services. ART treatment and renal replacement therapy coverage was extended beginning in October 2003 and January 2008 respectively, because of strong social movements pushing for these inclusions. In January 2008, based on a cost-benefit analysis, the NHS Board decided to provide the seasonal flu vaccination to high-risk groups. There was no increase to the budget because it was determined that it costs less to vaccinate for the flu than to treat it. Evidence from a cost-benefit analysis showing that the cost of treatment and care for flu patients in high-risk groups is higher than the cost of vaccination has resulted in the decision to provide seasonal flu vaccination to high-risk groups. The decision to expand benefits to include renal replacement therapy from January 2008 is forecasted to increase the burden on the health care system. The table below illustrates some high cost inclusions and exclusions in the UCS. Included services
Excluded services
Universal Coverage SchemeBenefits package Types of Benefits: Comprehensive UCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy. The curative package covers ambulatory and hospitalization services with some exclusions, such as cosmetic surgery, infertility treatments, organ transplants, and the provision of private room and board. For high-cost care, the UCS has adopted a similar package to the one provided by the SSS in order to standardize the packages across the scheme to minimize inequities in health care services. Thus, substantial high-cost interventions are offered. All contracted public and private providers are bound to provide registered beneficiaries with these and other preventative services. ART treatment and renal replacement therapy coverage was extended beginning in October 2003 and January 2008 respectively, because of strong social movements pushing for these inclusions. In January 2008, based on a cost-benefit analysis, the NHS Board decided to provide the seasonal flu vaccination to high-risk groups. There was no increase to the budget because it was determined that it costs less to vaccinate for the flu than to treat it. Evidence from a cost-benefit analysis showing that the cost of treatment and care for flu patients in high-risk groups is higher than the cost of vaccination has resulted in the decision to provide seasonal flu vaccination to high-risk groups. The decision to expand benefits to include renal replacement therapy from January 2008 is forecasted to increase the burden on the health care system. The table below illustrates some high cost inclusions and exclusions in the UCS. Included services
Excluded services
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