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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| Indonesia: Jamkesmas |
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The Jamkesmas scheme is funded by the central government from general tax revenue. Beneficiaries are not responsible for premium payments nor are they charged a copayment at the time of visit. Read full sectionThe Jamkesmas scheme is funded by the central government from general tax revenue. Beneficiaries are not responsible for premium payments nor are they charged a copayment at the time of visit. A paramount question of importance in Indonesia is the solvency of the Jamkesmas program. Increasing utilization of health care will concurrently increase the cost of health insurance, particularly for the poorest populations covered by Jamkesmas as currently there is no co-payment provision within the program. While utilization of Puskesmas services has increased, the capacity of local service delivery may not be able to keep pace with increasing demands without further collaboration with private primary health care providers. Currently, it is the responsibility of the local government to finance the gap between the actual cost of insuring its population and what the central government provides via Jamkesmas reimbursements. Without further support for the poorest localities, this growing responsibility will become more problematic. The central government recognizes this problem, and in order to continue to strive towards universal coverage, it is considering how it might introduce strategies to develop further approaches to co-finance service delivery at the local level. The proposed funding requirements for the operational costs of preventive and promotive service delivery is under active consideration within the parliament at this time and known as the “BOK” fund. JamkesmasFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: None
Contributing Populations: All populations
Types of Contributions: Premiums, Co-payments The Jamkesmas scheme is funded by the central government from general tax revenue. Beneficiaries are not responsible for premium payments nor are they charged a copayment at the time of visit. A paramount question of importance in Indonesia is the solvency of the Jamkesmas program. Increasing utilization of health care will concurrently increase the cost of health insurance, particularly for the poorest populations covered by Jamkesmas as currently there is no co-payment provision within the program. While utilization of Puskesmas services has increased, the capacity of local service delivery may not be able to keep pace with increasing demands without further collaboration with private primary health care providers. Currently, it is the responsibility of the local government to finance the gap between the actual cost of insuring its population and what the central government provides via Jamkesmas reimbursements. Without further support for the poorest localities, this growing responsibility will become more problematic. The central government recognizes this problem, and in order to continue to strive towards universal coverage, it is considering how it might introduce strategies to develop further approaches to co-finance service delivery at the local level. The proposed funding requirements for the operational costs of preventive and promotive service delivery is under active consideration within the parliament at this time and known as the “BOK” fund. |
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| Rwanda: Mutuelles de Sante |
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Rwanda has developed a comprehensive financing framework for health care that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. In the Mutuelle system, funding is comprised of annual member premiums organized on a per household basis, with an annual payment of 1000 Rwandan francs (equivalent of approximately US$1.80) per family member, and a 10% service fee paid up-front for each visit to a health center or hospital. Read full sectionRwanda has developed a comprehensive financing framework for health care that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. In the Mutuelle system, funding is comprised of annual member premiums organized on a per household basis, with an annual payment of 1000 Rwandan francs (equivalent of approximately US$1.80) per family member, and a 10% service fee paid up-front for each visit to a health center or hospital. When a citizen cannot pay the premium up-front, microfinance institutions from community banks (Banques Populaires) provide individual loans to be repaid within a year of disbursement with 15% interest. Due to the high degree of poverty in Rwanda, the poorest individuals, as determined by community leaders, along with those infected with HIV/AIDs, are not required to pay the membership or service fees, rather their fees are subsidized by district and nationally organized solidarity funds financed primarily by the central government and external aid partners. A total of 1.5 million individuals enrolled in Mutuelles are subsidized by these funds.
Funding for the insurance scheme is coordinated at the central, district, and local levels. At the central level, two bodies exist to coordinate funding: the National Health Insurance Fund and the National Guarantee Fund of the Mutuelles. Financing for both these Funds comes primarily from external aid partners and the Central Government, though MMI, RAMA, and Mutuelle branches provide a small percentage of the financing as well. A substantial amount of funding for the National Funds comes from 16 bilateral and multi-lateral donors and external aid partners: approximately $700 million per year or a third of the central government’s total health spending. Though donor funds are generally funneled through the national Funds, some donors channel funds through NGOs. These funds are largely earmarked for specific purposed such as Tuberculosis, Malaria, and HIV/AIDS, rather than the national care system. The ear-marking of funds and diversion through third parties creates administrative challenges to the central government and often skews the focus of the health system, by placing an emphasis on disease-specific care. The National Funds allocate and disburse funds to the sector and district level Mutuelle solidarity funds through block transfers to the district and sector level Mutuelle bodies as well as separately providing other subsidies to sector level solidarity funds for coverage of indigent Mutuelle members. The National Funds also reimburse two national referral teaching hospitals and one psychiatric hospital for care of Mutuelle members who are referred by district hospitals. At the district level, a district Mutuelle acts as a risk-pooling mechanism for all Mutuelles in the district and acts to reimburse the costs of district hospital care for the Mutuelle members referred by local health centers. Several sources contribute to the district Mutuelle funds: the National Guarantee Fund of Mutuelles, the sector level Mutuelle organizations, the district, and external partners. At the sector level, the Mutuelles perform a risk-pooling function for high-risk events at the sector level. Sector level Mutuelles are financed primarily by user fees, while the rest of the fees are from NGOs and development partners, interest generated from their bank accounts, and the Government of Rwanda to co-finance and subsidize membership fees. The government sponsored program Rwanda Health Insurance Scheme (La Rwandaise d’Assurance Maladie or RAMA) is financed by monthly contributions of 15% of the member’s base salary with the employer paying 7.5% and the employee paying the difference. Members of the government sponsored Military Medical Insurance (MMI) contribute 5% of their base salary and the government adds 17.5% of the members’ base salary. Beneficiaries also contribute a 15% direct co-payment for services and pharmacies. The table below summarizes the recipients of donor aid for health in Rwanda:
Mutuelles de SanteFunding Primary Source of Funding: Member contributions
Secondary Source of Funding: General government revenues, Donor funding
Contributing Populations: Formal Sector, Informal Sector
Types of Contributions: Premiums, Co-payments Rwanda has developed a comprehensive financing framework for health care that includes risk pooling, cross-subsidies, and substantial support from donors, NGOs, and tax-generated funding from the formal sector. In the Mutuelle system, funding is comprised of annual member premiums organized on a per household basis, with an annual payment of 1000 Rwandan francs (equivalent of approximately US$1.80) per family member, and a 10% service fee paid up-front for each visit to a health center or hospital. When a citizen cannot pay the premium up-front, microfinance institutions from community banks (Banques Populaires) provide individual loans to be repaid within a year of disbursement with 15% interest. Due to the high degree of poverty in Rwanda, the poorest individuals, as determined by community leaders, along with those infected with HIV/AIDs, are not required to pay the membership or service fees, rather their fees are subsidized by district and nationally organized solidarity funds financed primarily by the central government and external aid partners. A total of 1.5 million individuals enrolled in Mutuelles are subsidized by these funds.
Funding for the insurance scheme is coordinated at the central, district, and local levels. At the central level, two bodies exist to coordinate funding: the National Health Insurance Fund and the National Guarantee Fund of the Mutuelles. Financing for both these Funds comes primarily from external aid partners and the Central Government, though MMI, RAMA, and Mutuelle branches provide a small percentage of the financing as well. A substantial amount of funding for the National Funds comes from 16 bilateral and multi-lateral donors and external aid partners: approximately $700 million per year or a third of the central government’s total health spending. Though donor funds are generally funneled through the national Funds, some donors channel funds through NGOs. These funds are largely earmarked for specific purposed such as Tuberculosis, Malaria, and HIV/AIDS, rather than the national care system. The ear-marking of funds and diversion through third parties creates administrative challenges to the central government and often skews the focus of the health system, by placing an emphasis on disease-specific care. The National Funds allocate and disburse funds to the sector and district level Mutuelle solidarity funds through block transfers to the district and sector level Mutuelle bodies as well as separately providing other subsidies to sector level solidarity funds for coverage of indigent Mutuelle members. The National Funds also reimburse two national referral teaching hospitals and one psychiatric hospital for care of Mutuelle members who are referred by district hospitals. At the district level, a district Mutuelle acts as a risk-pooling mechanism for all Mutuelles in the district and acts to reimburse the costs of district hospital care for the Mutuelle members referred by local health centers. Several sources contribute to the district Mutuelle funds: the National Guarantee Fund of Mutuelles, the sector level Mutuelle organizations, the district, and external partners. At the sector level, the Mutuelles perform a risk-pooling function for high-risk events at the sector level. Sector level Mutuelles are financed primarily by user fees, while the rest of the fees are from NGOs and development partners, interest generated from their bank accounts, and the Government of Rwanda to co-finance and subsidize membership fees. The government sponsored program Rwanda Health Insurance Scheme (La Rwandaise d’Assurance Maladie or RAMA) is financed by monthly contributions of 15% of the member’s base salary with the employer paying 7.5% and the employee paying the difference. Members of the government sponsored Military Medical Insurance (MMI) contribute 5% of their base salary and the government adds 17.5% of the members’ base salary. Beneficiaries also contribute a 15% direct co-payment for services and pharmacies. The table below summarizes the recipients of donor aid for health in Rwanda:
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| Chile: National Health Fund (FONASA) |
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Monthly beneficiary contributions make up one third of FONASA funding, while half of FONASAs resources come from national coffers. The remainder is made up of operating income and copayments. FONASA is progressive in its funding mechanisms. Government subsidies are well targeted, with 90% directed to the indigent and 7.5% directed to low-income individuals. Furthermore, between 32% and 40% of high-income earner contributions cross-subsidize care for poorer beneficiaries. Read full sectionMonthly beneficiary contributions make up one third of FONASA funding, while half of FONASAs resources come from national coffers. The remainder is made up of operating income and copayments. FONASA is progressive in its funding mechanisms. Government subsidies are well targeted, with 90% directed to the indigent and 7.5% directed to low-income individuals. Furthermore, between 32% and 40% of high-income earner contributions cross-subsidize care for poorer beneficiaries. Primary health is free for all who enroll with FONASA. Hospital and ambulatory care under the Institutional Modality, however, require copayments that are determined by the income group in which the patient is classified. Group A (the indigent) and B (low income) receive free care, while group C pays 10% of the cost of the service and group D pays 20%. When enrollees undergo three family health events that require medical attention, those in groups D or C are transferred to groups C and B respectively. Catastrophic Insurance under FONASA is fully covered for patients who elect the Institutional Modality in accredited public hospitals. Furthermore, under the Free Election Modality, FONASA beneficiaries in groups B, C, and D can obtain a partial voucher from FONASA by making an out-of-packet payment for private health care from accredited providers. Resources for FONASA to cover the cost of the AUGE plan come from a temporary increase in the consumer tax from 18% to 19%, a tobacco tax, customs revenues, and the sale of the state’s minority shares in public health enterprises. The AUGE Plan only takes up 23% of the general budget set aside for service provision. AUGE services are free for those in categories A and B. Enrollees in categories C and D must in principle pay a copayment equal to 20% of the cost of the service. After a yearly copayment limit based on income is reached, 100% of services are covered for those in categories C and D. To date, however, copayments have seldom been collected. ISAPRE funding stems from the 7% monthly enrollee income contribution. Beneficiaries are also free to make additional contributions in order to purchase additional coverage. ISAPREs spend ten times more on per capita administration than FONASA, and despite the better health of its enrollees, they spend two times more on health care services per member. The average copayment under the ISAPREs was 35% in 2004. Although ISAPREs enrolled 22% of the population in 2004 they accounted for 43% of all health expenditures. Part of the reason for the higher expenditures is that ISAPREs rely almost exclusively on private providers that have higher cost and prices compared to public providers. These prices can be maintained because ISAPRE beneficiaries perceive the quality of private providers to be superior to the quality of public providers that are financed by FONASA. Figure 1 highlights the primary financial flows within the Chilean health system. The top half of the figure includes the resource flows for FONASA and the bottom half demonstrates resource flows for ISAPREs.
National Health Fund (FONASA)Funding Primary Source of Funding: General government revenues
Secondary Source of Funding: Payroll Tax, Member contributions
Contributing Populations: Formal Sector, Government Employees, Informal Sector
Types of Contributions: Premiums, Co-payments Monthly beneficiary contributions make up one third of FONASA funding, while half of FONASAs resources come from national coffers. The remainder is made up of operating income and copayments. FONASA is progressive in its funding mechanisms. Government subsidies are well targeted, with 90% directed to the indigent and 7.5% directed to low-income individuals. Furthermore, between 32% and 40% of high-income earner contributions cross-subsidize care for poorer beneficiaries. Primary health is free for all who enroll with FONASA. Hospital and ambulatory care under the Institutional Modality, however, require copayments that are determined by the income group in which the patient is classified. Group A (the indigent) and B (low income) receive free care, while group C pays 10% of the cost of the service and group D pays 20%. When enrollees undergo three family health events that require medical attention, those in groups D or C are transferred to groups C and B respectively. Catastrophic Insurance under FONASA is fully covered for patients who elect the Institutional Modality in accredited public hospitals. Furthermore, under the Free Election Modality, FONASA beneficiaries in groups B, C, and D can obtain a partial voucher from FONASA by making an out-of-packet payment for private health care from accredited providers. Resources for FONASA to cover the cost of the AUGE plan come from a temporary increase in the consumer tax from 18% to 19%, a tobacco tax, customs revenues, and the sale of the state’s minority shares in public health enterprises. The AUGE Plan only takes up 23% of the general budget set aside for service provision. AUGE services are free for those in categories A and B. Enrollees in categories C and D must in principle pay a copayment equal to 20% of the cost of the service. After a yearly copayment limit based on income is reached, 100% of services are covered for those in categories C and D. To date, however, copayments have seldom been collected. ISAPRE funding stems from the 7% monthly enrollee income contribution. Beneficiaries are also free to make additional contributions in order to purchase additional coverage. ISAPREs spend ten times more on per capita administration than FONASA, and despite the better health of its enrollees, they spend two times more on health care services per member. The average copayment under the ISAPREs was 35% in 2004. Although ISAPREs enrolled 22% of the population in 2004 they accounted for 43% of all health expenditures. Part of the reason for the higher expenditures is that ISAPREs rely almost exclusively on private providers that have higher cost and prices compared to public providers. These prices can be maintained because ISAPRE beneficiaries perceive the quality of private providers to be superior to the quality of public providers that are financed by FONASA. Figure 1 highlights the primary financial flows within the Chilean health system. The top half of the figure includes the resource flows for FONASA and the bottom half demonstrates resource flows for ISAPREs.
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| Ghana: National Health Insurance Scheme (NHIS) |
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The NHIF is financed from several different sources. Approximately 70% of total funding comes from a health insurance levy added to VAT, 23% comes from contributions made by formal sector workers to the Social Security and National Trust (SSNIT), and 5% comes from Premium payments. Members do not pay deductibles or copayments when accessing health care. Read full sectionThe NHIF is financed from several different sources. Approximately 70% of total funding comes from a health insurance levy added to VAT, 23% comes from contributions made by formal sector workers to the Social Security and National Trust (SSNIT), and 5% comes from Premium payments. Members do not pay deductibles or copayments when accessing health care. Each funding source is described in further detail below:
The NHIS is a hybrid of social and community based health insurance models. The basic structure of the NHIS is described as a “hub-satellite” model. The “hub” of the system, which is essentially based on the SHI model of pooled public tax resources, is the National Health Insurance Fund (NHIF) which is administered by the National Health Insurance Authority (NHIA). The “satellites” are a country wide network of CBHI schemes known as District Wide Mutual Health Insurance (DWMHI) schemes which are monitored, subsidized and re-insured by the “hub.” The table below presents estimates and projections for the composition of NHIS income from 2008 to 2018.
At present, employers are not held to anything in terms of contributions other than ensuring the necessary SSNIT deductions are made from the payrolls of formal sector employees. However, the NHIC has apparently made it known that it would prefer employers to contribute a sum equal to that of the employee’s contribution. The NHIA has set the DWMHI annual premium levels at a minimum of 7.20 Ghana cedis and a maximum of 48.00 Ghana cedis (approximately $5-$34 in 2009) per adult member, to be determined by income status. The NHIA website states that this can be paid as a lump sum, or in 12 monthly installments (www.nhis.gov.gh). In practice, varying flat premiums are paid by districts across the country, with rich districts paying higher than poor districts. The recent return to power of the NDC in the 2008/2009 elections may signal a significant change in the premium structure, however. The new government is considering the possibility of instituting a one-time premium that would guarantee access to the NHIS for life. Although no definite figures have been given as yet, rumor has it that the life time premium may be in the range of 150 Ghana cedis (just over $100), although the figure of $10-12 is also heard. National Health Insurance Scheme (NHIS)Funding Primary Source of Funding: General government revenues
Secondary Source of Funding: Payroll Tax, Member contributions, Donor funding
Contributing Populations: Formal Sector, Government Employees, Informal Sector
Types of Contributions: Premiums The NHIF is financed from several different sources. Approximately 70% of total funding comes from a health insurance levy added to VAT, 23% comes from contributions made by formal sector workers to the Social Security and National Trust (SSNIT), and 5% comes from Premium payments. Members do not pay deductibles or copayments when accessing health care. Each funding source is described in further detail below:
The NHIS is a hybrid of social and community based health insurance models. The basic structure of the NHIS is described as a “hub-satellite” model. The “hub” of the system, which is essentially based on the SHI model of pooled public tax resources, is the National Health Insurance Fund (NHIF) which is administered by the National Health Insurance Authority (NHIA). The “satellites” are a country wide network of CBHI schemes known as District Wide Mutual Health Insurance (DWMHI) schemes which are monitored, subsidized and re-insured by the “hub.” The table below presents estimates and projections for the composition of NHIS income from 2008 to 2018.
At present, employers are not held to anything in terms of contributions other than ensuring the necessary SSNIT deductions are made from the payrolls of formal sector employees. However, the NHIC has apparently made it known that it would prefer employers to contribute a sum equal to that of the employee’s contribution. The NHIA has set the DWMHI annual premium levels at a minimum of 7.20 Ghana cedis and a maximum of 48.00 Ghana cedis (approximately $5-$34 in 2009) per adult member, to be determined by income status. The NHIA website states that this can be paid as a lump sum, or in 12 monthly installments (www.nhis.gov.gh). In practice, varying flat premiums are paid by districts across the country, with rich districts paying higher than poor districts. The recent return to power of the NDC in the 2008/2009 elections may signal a significant change in the premium structure, however. The new government is considering the possibility of instituting a one-time premium that would guarantee access to the NHIS for life. Although no definite figures have been given as yet, rumor has it that the life time premium may be in the range of 150 Ghana cedis (just over $100), although the figure of $10-12 is also heard. |
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| India: Rajiv Aarogyasri |
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Aarogyasri is funded through general tax revenues generated by the state of Andhra Pradesh and the cost of premiums is fully subsidized for each beneficiary. Read full sectionAarogyasri is funded through general tax revenues generated by the state of Andhra Pradesh and the cost of premiums is fully subsidized for each beneficiary. The state chose to fully cover the cost of insurance premiums as the administrative costs of collecting the premium would outweigh the total cost of the premium itself. In addition, the state wanted to ensure that the benefits of the scheme reached the poorest, who might otherwise be deterred from enrolling even if the premium to be paid out-of-pocket was nominal. Rajiv AarogyasriFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: None
Contributing Populations: None
Types of Contributions: None Aarogyasri is funded through general tax revenues generated by the state of Andhra Pradesh and the cost of premiums is fully subsidized for each beneficiary. The state chose to fully cover the cost of insurance premiums as the administrative costs of collecting the premium would outweigh the total cost of the premium itself. In addition, the state wanted to ensure that the benefits of the scheme reached the poorest, who might otherwise be deterred from enrolling even if the premium to be paid out-of-pocket was nominal. |
