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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| 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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| 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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| 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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| 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. |