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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| 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. |
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| Chile: National Health Fund (FONASA) |
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The Explicit Health Guarantee (GES) laws contain provisions for basic primary care, emergency care, and targeted health problems. Primary care coverage includes preventative and curative services provided by a physician and a family medicine team. Acute illnesses, preventative health care, health screenings, special programs for mental and cardiovascular health, specialist referrals, and home visits are all part of the primary care menu. Read full sectionThe Explicit Health Guarantee (GES) laws contain provisions for basic primary care, emergency care, and targeted health problems. Primary care coverage includes preventative and curative services provided by a physician and a family medicine team. Acute illnesses, preventative health care, health screenings, special programs for mental and cardiovascular health, specialist referrals, and home visits are all part of the primary care menu. Emergency care is guaranteed through a network of facilities covering the entire country. Emergency services provided include pre-hospital care, transportation, diagnostic care, stabilization, and treatment of life-threatening situations. ISAPREs must offer the same benefits covered under the GES. Beyond this, they are free to provide additional coverage to those who wish to purchase it. As of 2008, there were over 10,000 plans available. Coverage for targeted health problems is assured through the AUGE plan for both FONASA and ISAPRE enrollees. Table 2 outlines the health problems that are included in the plan. Table 2: AUGE health problems
Source: Bitran, R., Urcullo, G., 105 There are also special FONASA programs such as the Catastrophic Insurance program and the Seniors program. Catastrophic Insurance covers complex and high cost diseases such as cancer, cystic fibrosis, and brain tumors. Meanwhile, the Seniors program is designed to increase the coverage of pathologies that affect seniors over the age of 65 for the Institutional Modality and seniors over 55 for the Free Election Modality. This program is free to those enrolled. Among the benefits included are prosthetics, high-cost procedures, and expedited wait-listing for certain surgeries. National Health Fund (FONASA)Benefits package Types of Benefits: Comprehensive The Explicit Health Guarantee (GES) laws contain provisions for basic primary care, emergency care, and targeted health problems. Primary care coverage includes preventative and curative services provided by a physician and a family medicine team. Acute illnesses, preventative health care, health screenings, special programs for mental and cardiovascular health, specialist referrals, and home visits are all part of the primary care menu. Emergency care is guaranteed through a network of facilities covering the entire country. Emergency services provided include pre-hospital care, transportation, diagnostic care, stabilization, and treatment of life-threatening situations. ISAPREs must offer the same benefits covered under the GES. Beyond this, they are free to provide additional coverage to those who wish to purchase it. As of 2008, there were over 10,000 plans available. Coverage for targeted health problems is assured through the AUGE plan for both FONASA and ISAPRE enrollees. Table 2 outlines the health problems that are included in the plan. Table 2: AUGE health problems
Source: Bitran, R., Urcullo, G., 105 There are also special FONASA programs such as the Catastrophic Insurance program and the Seniors program. Catastrophic Insurance covers complex and high cost diseases such as cancer, cystic fibrosis, and brain tumors. Meanwhile, the Seniors program is designed to increase the coverage of pathologies that affect seniors over the age of 65 for the Institutional Modality and seniors over 55 for the Free Election Modality. This program is free to those enrolled. Among the benefits included are prosthetics, high-cost procedures, and expedited wait-listing for certain surgeries. |
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| 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. |
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| Kenya: National Hospital Insurance Fund |
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The benefits package includes coverage of inpatient expenses with the share of expenses covered determined largely by the type of hospital. The NHIF’s hospital network is broken into three tiers of hospitals. At “Contract A” hospitals, which include primarily government hospitals, NHIF beneficiaries receive comprehensive cover with no overall limit on the amount of benefits received. Read full sectionThe benefits package includes coverage of inpatient expenses with the share of expenses covered determined largely by the type of hospital. The NHIF’s hospital network is broken into three tiers of hospitals. At “Contract A” hospitals, which include primarily government hospitals, NHIF beneficiaries receive comprehensive cover with no overall limit on the amount of benefits received. At “Contract B” hospitals, which include certain non-state providers (e.g., non-profit private hospitals, mission hospitals, and private hospitals in rural areas or areas not sufficiently served by the public sector), coverage remains comprehensive, but an annual limit of 432,000 KES per member (including the member and all dependents) applies. At “Contract B” hospitals, certain high cost surgeries may also carry a co-pay, which can be as high as 80% of the professional portion of the cost (with facility and hospitalization charges still covered with no co-pay). Finally, at “Contract C” hospitals, which include many higher cost private hospitals, the NHIF provides a rebate only, which generally ranges from KES 400 to KES 2,000 per day of hospitalization. Stays over 5 days in “Contract C” hospitals require prior authorization, and the total number of days covered in this type of hospital cannot exceed 180 days per beneficiary annually. The benefits package includes comprehensive medical coverage for maternity cases. NHIF works with a wide network of over 600 accredited Government, private and mission health providers spread across the country and reimburses hospital claims as per agreed contracts. In 2010, changes were gazetted that call for an increase in contributions from members. The increase in charges would include an expansion of services to outpatient care, including unlimited general consultation with doctors, unlimited prescribed laboratory tests, medicines, as well as coverage of all costs related to diseases that require specialists, and the unlimited management of chronic illnesses and ailments such as HIV/AIDs, diabetes, and hypertension. These changes in member contributions and services are under judicial review and have not yet been fully implemented. Preventative care currently falls outside of the NHIF and under the purview of the Ministry of Health. Preventative care available to all Kenyans includes a number of services that were originally defined under the NHSSP 2. The benefits extended to the population depend on cohort life stage, and are provided primarily by the Ministry of Health (MOH), local governments, and parastatal organizations. National Hospital Insurance FundBenefits package Types of Benefits: Primarily Inpatient The benefits package includes coverage of inpatient expenses with the share of expenses covered determined largely by the type of hospital. The NHIF’s hospital network is broken into three tiers of hospitals. At “Contract A” hospitals, which include primarily government hospitals, NHIF beneficiaries receive comprehensive cover with no overall limit on the amount of benefits received. At “Contract B” hospitals, which include certain non-state providers (e.g., non-profit private hospitals, mission hospitals, and private hospitals in rural areas or areas not sufficiently served by the public sector), coverage remains comprehensive, but an annual limit of 432,000 KES per member (including the member and all dependents) applies. At “Contract B” hospitals, certain high cost surgeries may also carry a co-pay, which can be as high as 80% of the professional portion of the cost (with facility and hospitalization charges still covered with no co-pay). Finally, at “Contract C” hospitals, which include many higher cost private hospitals, the NHIF provides a rebate only, which generally ranges from KES 400 to KES 2,000 per day of hospitalization. Stays over 5 days in “Contract C” hospitals require prior authorization, and the total number of days covered in this type of hospital cannot exceed 180 days per beneficiary annually. The benefits package includes comprehensive medical coverage for maternity cases. NHIF works with a wide network of over 600 accredited Government, private and mission health providers spread across the country and reimburses hospital claims as per agreed contracts. In 2010, changes were gazetted that call for an increase in contributions from members. The increase in charges would include an expansion of services to outpatient care, including unlimited general consultation with doctors, unlimited prescribed laboratory tests, medicines, as well as coverage of all costs related to diseases that require specialists, and the unlimited management of chronic illnesses and ailments such as HIV/AIDs, diabetes, and hypertension. These changes in member contributions and services are under judicial review and have not yet been fully implemented. Preventative care currently falls outside of the NHIF and under the purview of the Ministry of Health. Preventative care available to all Kenyans includes a number of services that were originally defined under the NHSSP 2. The benefits extended to the population depend on cohort life stage, and are provided primarily by the Ministry of Health (MOH), local governments, and parastatal organizations. |
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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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| 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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