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.
| Program | Types of benefits | 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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| Indonesia: Jamkesmas |
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Jamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited. Read full sectionJamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited. Overall, free access to many providers—both private and public—and a comprehensive benefits package make Jamkesmas more attractive to the majority of the population—even those covered under Askes and Jamsostek. A recent survey in early 2008 entitled “Study on Benefit Package Based on Community’s Preference” conducted by Center for Health Financing Policy and Health Insurance Management at the University of Gadjah Mada has shown that 79.8 % of people who were already enrolled with health insurance schemes, such as Askes and Jamsostek, preferred to be entitled with Jamkesmas benefits as they felt the coverage provided under Jamkesmas was superior to that provided under their existing plan. JamkesmasBenefits package Types of Benefits: Comprehensive Jamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited. Overall, free access to many providers—both private and public—and a comprehensive benefits package make Jamkesmas more attractive to the majority of the population—even those covered under Askes and Jamsostek. A recent survey in early 2008 entitled “Study on Benefit Package Based on Community’s Preference” conducted by Center for Health Financing Policy and Health Insurance Management at the University of Gadjah Mada has shown that 79.8 % of people who were already enrolled with health insurance schemes, such as Askes and Jamsostek, preferred to be entitled with Jamkesmas benefits as they felt the coverage provided under Jamkesmas was superior to that provided under their existing plan. |
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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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| 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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| 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. |