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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| 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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| 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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| 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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| India: Rajiv Aarogyasri |
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The Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care. Read full sectionThe Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care. 30 groups of doctors from the Government and corporate hospital sectors were consulted to develop the benefits package for Aarogyasri. Through a series of these consultations, Aarogyasri benefits have been agreed upon to include 389 surgical procedures and 144 medical diseases. A list of all benefits and associated reimbursement to hospitals can be found on the Aarogyasri web site. There is no deductible or co-payment for seeking care, and because the system is entirely cashless patients are admitted, treated, and discharged without exchanging any money. Immediate pre- and post-operative expenditures are included in package rates to minimize the other financial expenses to the patient. Rajiv AarogyasriBenefits package Types of Benefits: Primarily Inpatient The Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care. 30 groups of doctors from the Government and corporate hospital sectors were consulted to develop the benefits package for Aarogyasri. Through a series of these consultations, Aarogyasri benefits have been agreed upon to include 389 surgical procedures and 144 medical diseases. A list of all benefits and associated reimbursement to hospitals can be found on the Aarogyasri web site. There is no deductible or co-payment for seeking care, and because the system is entirely cashless patients are admitted, treated, and discharged without exchanging any money. Immediate pre- and post-operative expenditures are included in package rates to minimize the other financial expenses to the patient. |
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| Mexico: Seguro Popular |
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The design of the Seguro Popular essential benefits package was informed by two key sets of analytical inputs. The first set of analytical tools was composed of estimates of the burden of disease used to assess the severity of different health problems. The second set was made up of cost-effectiveness analyses used to weigh the potential population-level benefits of distinct interventions against their financial costs. The first benefits package was selected in 2002 and consisted of 78 health interventions. These interventions included primarily preventive activities as well as the detection and treatment of degenerative diseases. Read full sectionThe design of the Seguro Popular essential benefits package was informed by two key sets of analytical inputs. The first set of analytical tools was composed of estimates of the burden of disease used to assess the severity of different health problems. The second set was made up of cost-effectiveness analyses used to weigh the potential population-level benefits of distinct interventions against their financial costs. The first benefits package was selected in 2002 and consisted of 78 health interventions. These interventions included primarily preventive activities as well as the detection and treatment of degenerative diseases. In 2004, the number of interventions increased to 91 and by 2005 the number increased to 155. In 2006-2007, the number of covered interventions increased significantly up to 255 interventions, covering most causes of primary care visits and nearly 95% of all causes of hospital admissions. As of 2009, there were 266 interventions that were covered under the Universal Catalog of Health Services (CAUSES). The benefits package can be divided into six distinct categories of services as follows:
There is also a distinct benefits package for protection against catastrophic expenditures. This centrally managed fund, known as the Protection Fund Against Catastrophic Expenditures (FPGC) covered 17 interventions in 2006. By 2010, the number of interventions grew to 49 and included treatment for HIV/AIDS, bone marrow transplant, and childhood cancer. Care for most of these catastrophic events (84%) is provided by private service providers. Seguro PopularBenefits package Types of Benefits: Comprehensive The design of the Seguro Popular essential benefits package was informed by two key sets of analytical inputs. The first set of analytical tools was composed of estimates of the burden of disease used to assess the severity of different health problems. The second set was made up of cost-effectiveness analyses used to weigh the potential population-level benefits of distinct interventions against their financial costs. The first benefits package was selected in 2002 and consisted of 78 health interventions. These interventions included primarily preventive activities as well as the detection and treatment of degenerative diseases. In 2004, the number of interventions increased to 91 and by 2005 the number increased to 155. In 2006-2007, the number of covered interventions increased significantly up to 255 interventions, covering most causes of primary care visits and nearly 95% of all causes of hospital admissions. As of 2009, there were 266 interventions that were covered under the Universal Catalog of Health Services (CAUSES). The benefits package can be divided into six distinct categories of services as follows:
There is also a distinct benefits package for protection against catastrophic expenditures. This centrally managed fund, known as the Protection Fund Against Catastrophic Expenditures (FPGC) covered 17 interventions in 2006. By 2010, the number of interventions grew to 49 and included treatment for HIV/AIDS, bone marrow transplant, and childhood cancer. Care for most of these catastrophic events (84%) is provided by private service providers. |
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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. |