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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| 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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| 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. |
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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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