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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| Vietnam: Compulsory and Voluntary Health Insurance Schemes |
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The central Vietnamese government is responsible for financing the bulk of the cost. Provincial governments, however, also contribute a smaller percentage of funds to the program. Poor beneficiaries do not pay premiums and are exempt from copayments. The entire cost of the scheme, 4.5% of minimum wage, is covered by revenues from the state budget. Read full sectionThe central Vietnamese government is responsible for financing the bulk of the cost. Provincial governments, however, also contribute a smaller percentage of funds to the program. Poor beneficiaries do not pay premiums and are exempt from copayments. The entire cost of the scheme, 4.5% of minimum wage, is covered by revenues from the state budget. Funding for Vietnam’s various universal coverage schemes varies greatly by population segment. The following presents an overview of each program’s financing: Compulsory program (CHI)
Note that when the insurance program was initially introduced, there was no cost sharing. In 1998, cost sharing was introduced, with a 20 percent coinsurance rate but no deductible. In 2005, the 20 percent coinsurance rate was eliminated, only to be reintroduced again since January 1, 2010. Copayment is exempted for some groups, such as people of merit. Compulsory and Voluntary Health Insurance SchemesFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: None
Contributing Populations: Formal Sector
Types of Contributions: Premiums The central Vietnamese government is responsible for financing the bulk of the cost. Provincial governments, however, also contribute a smaller percentage of funds to the program. Poor beneficiaries do not pay premiums and are exempt from copayments. The entire cost of the scheme, 4.5% of minimum wage, is covered by revenues from the state budget. Funding for Vietnam’s various universal coverage schemes varies greatly by population segment. The following presents an overview of each program’s financing: Compulsory program (CHI)
Note that when the insurance program was initially introduced, there was no cost sharing. In 1998, cost sharing was introduced, with a 20 percent coinsurance rate but no deductible. In 2005, the 20 percent coinsurance rate was eliminated, only to be reintroduced again since January 1, 2010. Copayment is exempted for some groups, such as people of merit. |
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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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| : Taiwan: National Health Insurance |
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Revenue for the National Health Insurance (NHI) system comes primarily from individual payroll deductions and employer contributions, supplemented by governmental funds from general revenue. A small proportion of revenue also comes from a “sin tax” on cigarette sales. The working population pays premiums that are split with employers while non-working individuals pay a flat rate which is subsidized by the government. Read full sectionRevenue for the National Health Insurance (NHI) system comes primarily from individual payroll deductions and employer contributions, supplemented by governmental funds from general revenue. A small proportion of revenue also comes from a “sin tax” on cigarette sales. The working population pays premiums that are split with employers while non-working individuals pay a flat rate which is subsidized by the government. The share of premiums paid by the insured, employers, and government varies greatly within the different population subgroups and also varies based on how many dependents an individual has. For public or private employees the government pays 10%, the employer 60%, and the employee 30% through a payroll deduction. The non-poor self-employed pay 100% of their income-based premium without a government subsidy. For the poor who are unable to pay the premium and for military personnel, the government subsidizes 100% of the premium from general government revenues.
In 2002, the Supreme Court in Taiwan ruled that no one could be denied care because of lack of ability to pay. For those temporarily unable to pay, the Bureau of National Health Insurance (BNHI) has a fund from which such people may take out interest-free loans to pay premiums. Taiwan’s economy has advanced to a stage where most workers were employed in the formal sector, so a compulsory NHI can effectively collect premiums through employers. The government also has the revenue to subsidize the coverage of the poor, veterans, and farmers. Taiwan also has the organizational ability and human resources to manage national health insurance. The premiums are supplemented by out-of-pocket payments. Regular office visits have co-payments that are fixed and unvaried by the person’s income in the realm of about 10% of the cost of an inpatient visit—adjusted according to type of wards and length of stay—and 20% for an outpatient visit. Both co-payments and premiums are waived for the very poor and veterans. To help cope with NHI budget pressures, patient cost sharing increased in 2001 and again in 2002 for certain kinds of visits, drugs, inpatient care, lab tests and examinations. These copayments are unvaried by income to avoid the burden of administering a complex individual income-related-cost-sharing program. Though out-of-pocket payments fell from 48% of the total amount spent on health care in 1993 to 30% in 2000, critics still argue that the copayments are regressive, putting the burden primarily on the sick that are already disadvantaged and are often poor.
National Health InsuranceFunding Primary Source of Funding: Member contributions
Secondary Source of Funding: General government revenues, Employer contributions
Contributing Populations: Formal Sector, Government Employees, Informal Sector
Types of Contributions: Premiums, Co-payments Revenue for the National Health Insurance (NHI) system comes primarily from individual payroll deductions and employer contributions, supplemented by governmental funds from general revenue. A small proportion of revenue also comes from a “sin tax” on cigarette sales. The working population pays premiums that are split with employers while non-working individuals pay a flat rate which is subsidized by the government. The share of premiums paid by the insured, employers, and government varies greatly within the different population subgroups and also varies based on how many dependents an individual has. For public or private employees the government pays 10%, the employer 60%, and the employee 30% through a payroll deduction. The non-poor self-employed pay 100% of their income-based premium without a government subsidy. For the poor who are unable to pay the premium and for military personnel, the government subsidizes 100% of the premium from general government revenues.
In 2002, the Supreme Court in Taiwan ruled that no one could be denied care because of lack of ability to pay. For those temporarily unable to pay, the Bureau of National Health Insurance (BNHI) has a fund from which such people may take out interest-free loans to pay premiums. Taiwan’s economy has advanced to a stage where most workers were employed in the formal sector, so a compulsory NHI can effectively collect premiums through employers. The government also has the revenue to subsidize the coverage of the poor, veterans, and farmers. Taiwan also has the organizational ability and human resources to manage national health insurance. The premiums are supplemented by out-of-pocket payments. Regular office visits have co-payments that are fixed and unvaried by the person’s income in the realm of about 10% of the cost of an inpatient visit—adjusted according to type of wards and length of stay—and 20% for an outpatient visit. Both co-payments and premiums are waived for the very poor and veterans. To help cope with NHI budget pressures, patient cost sharing increased in 2001 and again in 2002 for certain kinds of visits, drugs, inpatient care, lab tests and examinations. These copayments are unvaried by income to avoid the burden of administering a complex individual income-related-cost-sharing program. Though out-of-pocket payments fell from 48% of the total amount spent on health care in 1993 to 30% in 2000, critics still argue that the copayments are regressive, putting the burden primarily on the sick that are already disadvantaged and are often poor.
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| Kenya: National Hospital Insurance Fund |
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The National Hospital Insurance Fund (NHIF) requires compulsory membership for all salaried employees with premium contributions automatically deducted through payroll. Contributions are calculated on a graduated scale based on income, with a majority contributing between KES 30 to KES 320 per month. For the self-employed and others in the informal sector, membership is contributory and is available for a fixed premium of 160 KES per month. Read full sectionThe National Hospital Insurance Fund (NHIF) requires compulsory membership for all salaried employees with premium contributions automatically deducted through payroll. Contributions are calculated on a graduated scale based on income, with a majority contributing between KES 30 to KES 320 per month. For the self-employed and others in the informal sector, membership is contributory and is available for a fixed premium of 160 KES per month. A new proposed measure has been gazetted in June 2010 that will see the first increase in premiums to the NHIF in almost two decades. This to between KES 150 to KES 2,000 per month, depending on income, with approximately 46,000 of the highest paid formal sector employees paying the maximum amount. Under this proposed change, premium payments for those in the informal sector would rise from KES 160 to KES 500 per month. Finally, under the proposed changes, other sectors of the government, development agencies, philanthropic organizations and other well-wishers would be able to purchase NHIF cover for indigent populations for a rate of KES 300 per person per month. Proposed changes are currently under judicial review and have not yet been implemented. NHIF funding and payments to providers exist alongside supply-side payments from the government directly to public sector providers. In essence, the salaries of most physicians and other health workers are still paid via supply-side payments, with NHIF payments typically going toward facility charges, drugs, supplies and consumables, and other types of overhead. Total health expenditure in Kenya, 2000 and 2006
Source: Kenya Ministry of Health, 2009 Overall, Kenya spends approximately 5% of its GDP on health. There are 3 major sources of financing for the health care system: the government (both central and local); private contributions; and donors. Donor contributions to the health sector have been steadily increasing from 8% of the health budget in 2000 to 36% in 2008. Traditionally, donor funding has been allocated directly to specific programs, limiting the flexibility of the MOH to reallocate donor assistance to fit government priorities. Public funding comes primarily from taxation, and allocations from the Ministry of Health (MOH), local governments, and parastatal organizations. Funding flows from the Ministry of Health (MOH) to the district level District Health Management Boards (DHMBs) and District Health Management Teams (DHMTs) and supplemented by local government, revolving funds, and user fees. Since the 1970s, the real financing allocations to the public sector have declined, and in 2008 the MOH only spent approximately USD $11.80 per capita, well below the WHO recommended spending level of USD $34 per capita. This lack of funding is largely because tax revenues have proven to be an unreliable source of health finance. To fill the funding gap, MOH has pursued a policy of cost sharing, which places a higher burden for financing on out-of-pocket expenditures in both absolute terms and as a percentage of the health budget. This poses a serious financing issue for the 56% of the population who are considered poor. In 2004, the government attempted to minimize cost sharing through the institution of a “10/20” policy, in which local health facilities only charge 10 or 20 KES for curative care; this has decreased out-of-pocket expenditures from 54% of THE in 2000 to about 36% in 2009. National Hospital Insurance FundFunding Primary Source of Funding: Payroll Tax
Secondary Source of Funding: Member contributions, Employer contributions
Contributing Populations: Formal Sector, Government Employees, Informal Sector
Types of Contributions: Premiums, Co-payments The National Hospital Insurance Fund (NHIF) requires compulsory membership for all salaried employees with premium contributions automatically deducted through payroll. Contributions are calculated on a graduated scale based on income, with a majority contributing between KES 30 to KES 320 per month. For the self-employed and others in the informal sector, membership is contributory and is available for a fixed premium of 160 KES per month. A new proposed measure has been gazetted in June 2010 that will see the first increase in premiums to the NHIF in almost two decades. This to between KES 150 to KES 2,000 per month, depending on income, with approximately 46,000 of the highest paid formal sector employees paying the maximum amount. Under this proposed change, premium payments for those in the informal sector would rise from KES 160 to KES 500 per month. Finally, under the proposed changes, other sectors of the government, development agencies, philanthropic organizations and other well-wishers would be able to purchase NHIF cover for indigent populations for a rate of KES 300 per person per month. Proposed changes are currently under judicial review and have not yet been implemented. NHIF funding and payments to providers exist alongside supply-side payments from the government directly to public sector providers. In essence, the salaries of most physicians and other health workers are still paid via supply-side payments, with NHIF payments typically going toward facility charges, drugs, supplies and consumables, and other types of overhead. Total health expenditure in Kenya, 2000 and 2006
Source: Kenya Ministry of Health, 2009 Overall, Kenya spends approximately 5% of its GDP on health. There are 3 major sources of financing for the health care system: the government (both central and local); private contributions; and donors. Donor contributions to the health sector have been steadily increasing from 8% of the health budget in 2000 to 36% in 2008. Traditionally, donor funding has been allocated directly to specific programs, limiting the flexibility of the MOH to reallocate donor assistance to fit government priorities. Public funding comes primarily from taxation, and allocations from the Ministry of Health (MOH), local governments, and parastatal organizations. Funding flows from the Ministry of Health (MOH) to the district level District Health Management Boards (DHMBs) and District Health Management Teams (DHMTs) and supplemented by local government, revolving funds, and user fees. Since the 1970s, the real financing allocations to the public sector have declined, and in 2008 the MOH only spent approximately USD $11.80 per capita, well below the WHO recommended spending level of USD $34 per capita. This lack of funding is largely because tax revenues have proven to be an unreliable source of health finance. To fill the funding gap, MOH has pursued a policy of cost sharing, which places a higher burden for financing on out-of-pocket expenditures in both absolute terms and as a percentage of the health budget. This poses a serious financing issue for the 56% of the population who are considered poor. In 2004, the government attempted to minimize cost sharing through the institution of a “10/20” policy, in which local health facilities only charge 10 or 20 KES for curative care; this has decreased out-of-pocket expenditures from 54% of THE in 2000 to about 36% in 2009. |
