UHC Forward: Towards Universal Health Coverage

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.
Patients are free to choose the doctors and hospitals they prefer, since the EHIF contracts with most providers. The primary constraint in the system is the waiting list that a highly preferred doctor or facility may have.

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:

• Medical efficacy
• Cost effectiveness
• Appropriateness and compliance with national health policy
• Availability of financial resources

Entitlements of coverage under the MHIF were introduced under the State Guarantee Benefits Package (SGBP). The specifications of the SGBP are the following:

• Primary care is provided free of charge for the entire population with certain lab and diagnostic tests against copayment.
• Hospital care is provided against formal copayment. Copayment is a flat fee payable upon admission.
• Exemption categories were designed based on categorical targeting and disease types to protect populations with high expected health care use. Providers receive a higher payment for treating exempt patients to prevent selection bias.
• An additional outpatient drug benefit was also introduced to subsidize the price of medicines for primary care sensitive conditions in order to reduce unnecessary hospitalizations (e.g., anemia, ulcers, pneumonia, and hypertension).

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.

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

• General and specialist consultation services
• General and specialist diagnostic testing, including laboratory investigation, X-rays, ultrasound scanning
• Medicines on the NHIS medicines list
• Surgical operations such as hernia repair
• Physiotherapy

Inpatient services

• General and specialist inpatient care
• Diagnostic tests
• Medication - prescribed medicines on the NHIS medicines list, blood and blood products
• Surgical operations
• Inpatient physiotherapy
• Accommodation in the general ward
• Feeding (where available)

Oral health

• Pain relief (tooth extraction, temporary incision and drainage)
• Dental restoration (simple amalgam filling, temporary dressing)

Maternity care

• Antenatal care
• Deliveries (normal and assisted)
• Caesarean section
• Postnatal care

Emergencies

• Medical emergencies
• Surgical emergencies
• Pediatric emergencies
• Obstetric and gynecological emergencies
• Road traffic accident

Exclusions list

• Appliance and prostheses including optical aids, heart aids, orthopedic aids, dentures, etc.
• Cosmetic surgeries and aesthetic treatment
• HIV retroviral drugs
• Assisted reproduction (e.g., artificial insemination) and gynecological hormone replacement therapy
• Echocardiography
• Photography and angiography
• Dialysis for chronic renal failure
• Organ transplantation
• All drugs not listed on the NHIS list
• Heart and brain surgery other than those resulting from accidents
• Cancer treatment other than breast and cervical
• Mortuary services
• Diagnosis and treatment abroad
• Medical examinations for purposes other than treatment in accredited health facilities
• VIP ward accommodation

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:

• OPD expenses, or expenses in hospitals which do not lead to hospitalization
• Congenital external diseases
• Drug and alcohol induced illness
• Sterilization and fertility-related procedures