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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| 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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| Korea, Rep.: National Health Insurance Program |
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The National Health Insurance Program (NHIP) has 3 sources of funding: monthly premium contributions from the insured and employers; government subsidies; and tobacco surcharges.The National Health Insurance Program (NHIP) has 3 sources of funding: monthly premium contributions from the insured and employers; government subsidies; and tobacco surcharges. Premium contributions are proportional to income and are shared equally between the insured individual and the employer. For the self-employed, premiums are calculated based on their income level in conjunction with the person’s property, motor vehicles, age and gender. There is a reduced contribution requirement for those who live on islands and remote areas and those serving in the military are exempt from paying premiums. Read full sectionThe National Health Insurance Program (NHIP) has 3 sources of funding: monthly premium contributions from the insured and employers; government subsidies; and tobacco surcharges.The National Health Insurance Program (NHIP) has 3 sources of funding: monthly premium contributions from the insured and employers; government subsidies; and tobacco surcharges. Premium contributions are proportional to income and are shared equally between the insured individual and the employer. For the self-employed, premiums are calculated based on their income level in conjunction with the person’s property, motor vehicles, age and gender. There is a reduced contribution requirement for those who live on islands and remote areas and those serving in the military are exempt from paying premiums. The National Government provides 14% of the total annual projected revenue of the NHIP. In addition, the government has a tobacco surcharge that contributes about 6% of the total annual projected revenue to the health insurance program. National Health Insurance ProgramFunding Primary Source of Funding: Payroll Tax
Secondary Source of Funding: General government revenues
Contributing Populations: Formal Sector, Informal Sector
Types of Contributions: Premiums, Co-payments The National Health Insurance Program (NHIP) has 3 sources of funding: monthly premium contributions from the insured and employers; government subsidies; and tobacco surcharges.The National Health Insurance Program (NHIP) has 3 sources of funding: monthly premium contributions from the insured and employers; government subsidies; and tobacco surcharges. Premium contributions are proportional to income and are shared equally between the insured individual and the employer. For the self-employed, premiums are calculated based on their income level in conjunction with the person’s property, motor vehicles, age and gender. There is a reduced contribution requirement for those who live on islands and remote areas and those serving in the military are exempt from paying premiums. The National Government provides 14% of the total annual projected revenue of the NHIP. In addition, the government has a tobacco surcharge that contributes about 6% of the total annual projected revenue to the health insurance program. |
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| Philippines: PhilHealth |
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Funding for the scheme varies based on the population covered, although the majority of funds flow from general taxation. Premiums for the formal sector are set by law to be up to 3% of monthly income. Premiums for both the poor and the informal sector are 1,200 pesos annually (about 25 USD). Read full sectionFunding for the scheme varies based on the population covered, although the majority of funds flow from general taxation. Premiums for the formal sector are set by law to be up to 3% of monthly income. Premiums for both the poor and the informal sector are 1,200 pesos annually (about 25 USD). However, the cost of insurance for the poor is fully subsidized by the central and local governments. Funding by population is as follows:
Both national and local governments are responsible for the full subsidy for indigents. A recent policy proposal is for the national government to fully pay the subsidy in order to accelerate the efforts towards universal coverage by enrolling the poorest. However, this proposal has not been approved and the current cost-sharing scheme remains. Currently, the local government identifies and determines who is poor, then enrolls them in the national health insurance program. Once enrolled, the national government is expected to pay its counterpart. The central government cost-sharing percentage depends on the income level of the local government, but on average local governments contribute 25% and the national government contributes 75%. All premiums are pooled nationally and in effect, there is cross-subsidization across districts. The frequency of premium contributions varies by each population category. For example, formal sector payroll collections naturally occur monthly, while for the non-poor, premium contributions occur based on when individuals seek to enroll. For OFWs, the premium is collected upon departure from the country and then on an annual basis. For the poor subsidized by the government, enrollment occurs annually and the local government pays quarterly while the national government is billed as soon as enough local governments have enrolled their poor. National government payment is dependent on the availability of funds. Premiums for formal sector are set by law to be up to 3% of the monthly income. However, the current level is 2.5%, applied up to the first 30,000 pesos of income (i.e., all people earning up to or more than 30,000 pesos pay the same premium, while people with salaries under 30,000 pesos pay less). The premium of 1,200 pesos annually for the poor and informal sector has been the same for more than 9 years. The rate for the OFWs was 900 pesos annually until two years ago when it was increased to 1,200 pesos. PhilHealthFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: Member contributions
Contributing Populations: Formal Sector
Types of Contributions: Premiums Funding for the scheme varies based on the population covered, although the majority of funds flow from general taxation. Premiums for the formal sector are set by law to be up to 3% of monthly income. Premiums for both the poor and the informal sector are 1,200 pesos annually (about 25 USD). However, the cost of insurance for the poor is fully subsidized by the central and local governments. Funding by population is as follows:
Both national and local governments are responsible for the full subsidy for indigents. A recent policy proposal is for the national government to fully pay the subsidy in order to accelerate the efforts towards universal coverage by enrolling the poorest. However, this proposal has not been approved and the current cost-sharing scheme remains. Currently, the local government identifies and determines who is poor, then enrolls them in the national health insurance program. Once enrolled, the national government is expected to pay its counterpart. The central government cost-sharing percentage depends on the income level of the local government, but on average local governments contribute 25% and the national government contributes 75%. All premiums are pooled nationally and in effect, there is cross-subsidization across districts. The frequency of premium contributions varies by each population category. For example, formal sector payroll collections naturally occur monthly, while for the non-poor, premium contributions occur based on when individuals seek to enroll. For OFWs, the premium is collected upon departure from the country and then on an annual basis. For the poor subsidized by the government, enrollment occurs annually and the local government pays quarterly while the national government is billed as soon as enough local governments have enrolled their poor. National government payment is dependent on the availability of funds. Premiums for formal sector are set by law to be up to 3% of the monthly income. However, the current level is 2.5%, applied up to the first 30,000 pesos of income (i.e., all people earning up to or more than 30,000 pesos pay the same premium, while people with salaries under 30,000 pesos pay less). The premium of 1,200 pesos annually for the poor and informal sector has been the same for more than 9 years. The rate for the OFWs was 900 pesos annually until two years ago when it was increased to 1,200 pesos. |
