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 | ||||||||||||
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| 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. |
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| 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. |
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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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| Brazil: Unified Health System (SUS) |
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Brazil’s health system offers free, universal coverage. Care under the SUS is divided into basic, specialized, and high complexity categories. Basic care is composed of health promotion and disease prevention. Care is deemed specialized if the intervention requires the use of a medical specialist. Finally, complex care is composed of interventions that require the use of advanced technology and equipment. Read full sectionBrazil’s health system offers free, universal coverage. Care under the SUS is divided into basic, specialized, and high complexity categories. Basic care is composed of health promotion and disease prevention. Care is deemed specialized if the intervention requires the use of a medical specialist. Finally, complex care is composed of interventions that require the use of advanced technology and equipment. The PSF’s original priority areas were: women’s health, child health, hypertension, diabetes, tuberculosis, leprosy, HIV, oral health, and health promotion. Unified Health System (SUS)Benefits package Types of Benefits: Comprehensive Brazil’s health system offers free, universal coverage. Care under the SUS is divided into basic, specialized, and high complexity categories. Basic care is composed of health promotion and disease prevention. Care is deemed specialized if the intervention requires the use of a medical specialist. Finally, complex care is composed of interventions that require the use of advanced technology and equipment. The PSF’s original priority areas were: women’s health, child health, hypertension, diabetes, tuberculosis, leprosy, HIV, oral health, and health promotion. |
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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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