UHC Forward: Towards Universal Health Coverage

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.

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.

National Health Insurance (NHI) offers a comprehensive benefit package that covers some preventative medical services (pediatric immunizations, adult health exams, prenatal care, etc), prescription drugs, dental service, Chinese medicine, home nurse visits, inpatient care, and ambulatory care, among others. More expensive treatments, such as medication for HIV/AIDS and organ transplants are also covered. Abortion services are covered in the case of sexual assault and 60 days of end-of-life care is included either in a hospice or hospital. Out-of-pocket expenditures are for services not covered by the NHI such as orthodontics and lab tests that are not medically necessary.

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.