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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Colombia: General System of Social Security in Health |
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Indonesia: Jamkesmas |
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Chile: National Health Fund (FONASA) |
|
The Explicit Health Guarantee (GES) laws contain provisions for basic primary care, emergency care, and targeted health problems. Primary care coverage includes preventative and curative services provided by a physician and a family medicine team. Acute illnesses, preventative health care, health screenings, special programs for mental and cardiovascular health, specialist referrals, and home visits are all part of the primary care menu. Read full sectionThe Explicit Health Guarantee (GES) laws contain provisions for basic primary care, emergency care, and targeted health problems. Primary care coverage includes preventative and curative services provided by a physician and a family medicine team. Acute illnesses, preventative health care, health screenings, special programs for mental and cardiovascular health, specialist referrals, and home visits are all part of the primary care menu. Emergency care is guaranteed through a network of facilities covering the entire country. Emergency services provided include pre-hospital care, transportation, diagnostic care, stabilization, and treatment of life-threatening situations. ISAPREs must offer the same benefits covered under the GES. Beyond this, they are free to provide additional coverage to those who wish to purchase it. As of 2008, there were over 10,000 plans available. Coverage for targeted health problems is assured through the AUGE plan for both FONASA and ISAPRE enrollees. Table 2 outlines the health problems that are included in the plan. Table 2: AUGE health problems
Source: Bitran, R., Urcullo, G., 105 There are also special FONASA programs such as the Catastrophic Insurance program and the Seniors program. Catastrophic Insurance covers complex and high cost diseases such as cancer, cystic fibrosis, and brain tumors. Meanwhile, the Seniors program is designed to increase the coverage of pathologies that affect seniors over the age of 65 for the Institutional Modality and seniors over 55 for the Free Election Modality. This program is free to those enrolled. Among the benefits included are prosthetics, high-cost procedures, and expedited wait-listing for certain surgeries. National Health Fund (FONASA)Benefits package Types of Benefits: Comprehensive The Explicit Health Guarantee (GES) laws contain provisions for basic primary care, emergency care, and targeted health problems. Primary care coverage includes preventative and curative services provided by a physician and a family medicine team. Acute illnesses, preventative health care, health screenings, special programs for mental and cardiovascular health, specialist referrals, and home visits are all part of the primary care menu. Emergency care is guaranteed through a network of facilities covering the entire country. Emergency services provided include pre-hospital care, transportation, diagnostic care, stabilization, and treatment of life-threatening situations. ISAPREs must offer the same benefits covered under the GES. Beyond this, they are free to provide additional coverage to those who wish to purchase it. As of 2008, there were over 10,000 plans available. Coverage for targeted health problems is assured through the AUGE plan for both FONASA and ISAPRE enrollees. Table 2 outlines the health problems that are included in the plan. Table 2: AUGE health problems
Source: Bitran, R., Urcullo, G., 105 There are also special FONASA programs such as the Catastrophic Insurance program and the Seniors program. Catastrophic Insurance covers complex and high cost diseases such as cancer, cystic fibrosis, and brain tumors. Meanwhile, the Seniors program is designed to increase the coverage of pathologies that affect seniors over the age of 65 for the Institutional Modality and seniors over 55 for the Free Election Modality. This program is free to those enrolled. Among the benefits included are prosthetics, high-cost procedures, and expedited wait-listing for certain surgeries. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Mexico: Seguro Popular |
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Thailand: Universal Coverage Scheme |
|
UCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy. Read full sectionUCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy. The curative package covers ambulatory and hospitalization services with some exclusions, such as cosmetic surgery, infertility treatments, organ transplants, and the provision of private room and board. For high-cost care, the UCS has adopted a similar package to the one provided by the SSS in order to standardize the packages across the scheme to minimize inequities in health care services. Thus, substantial high-cost interventions are offered. All contracted public and private providers are bound to provide registered beneficiaries with these and other preventative services. ART treatment and renal replacement therapy coverage was extended beginning in October 2003 and January 2008 respectively, because of strong social movements pushing for these inclusions. In January 2008, based on a cost-benefit analysis, the NHS Board decided to provide the seasonal flu vaccination to high-risk groups. There was no increase to the budget because it was determined that it costs less to vaccinate for the flu than to treat it. Evidence from a cost-benefit analysis showing that the cost of treatment and care for flu patients in high-risk groups is higher than the cost of vaccination has resulted in the decision to provide seasonal flu vaccination to high-risk groups. The decision to expand benefits to include renal replacement therapy from January 2008 is forecasted to increase the burden on the health care system. The table below illustrates some high cost inclusions and exclusions in the UCS. Included services
Excluded services
Universal Coverage SchemeBenefits package Types of Benefits: Comprehensive UCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy. The curative package covers ambulatory and hospitalization services with some exclusions, such as cosmetic surgery, infertility treatments, organ transplants, and the provision of private room and board. For high-cost care, the UCS has adopted a similar package to the one provided by the SSS in order to standardize the packages across the scheme to minimize inequities in health care services. Thus, substantial high-cost interventions are offered. All contracted public and private providers are bound to provide registered beneficiaries with these and other preventative services. ART treatment and renal replacement therapy coverage was extended beginning in October 2003 and January 2008 respectively, because of strong social movements pushing for these inclusions. In January 2008, based on a cost-benefit analysis, the NHS Board decided to provide the seasonal flu vaccination to high-risk groups. There was no increase to the budget because it was determined that it costs less to vaccinate for the flu than to treat it. Evidence from a cost-benefit analysis showing that the cost of treatment and care for flu patients in high-risk groups is higher than the cost of vaccination has resulted in the decision to provide seasonal flu vaccination to high-risk groups. The decision to expand benefits to include renal replacement therapy from January 2008 is forecasted to increase the burden on the health care system. The table below illustrates some high cost inclusions and exclusions in the UCS. Included services
Excluded services
|