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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| Estonia: Estonian Health Insurance Fund |
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Estonian health care is funded through a Social Health Insurance regime where contributions are paid by salaried and self-employed workers, who contribute 13% of their wages to the system. The earmarked payroll tax is collected by the Estonian Tax and Customs Board. The tax board then transfers the health contribution to the EHIF. This system has a strong element of solidarity, as 46% of enrollees are non-contributing members and are subsidized by those who contribute. All enrollees are entitled to the same benefits package. Read full sectionEstonian health care is funded through a Social Health Insurance regime where contributions are paid by salaried and self-employed workers, who contribute 13% of their wages to the system. The earmarked payroll tax is collected by the Estonian Tax and Customs Board. The tax board then transfers the health contribution to the EHIF. This system has a strong element of solidarity, as 46% of enrollees are non-contributing members and are subsidized by those who contribute. All enrollees are entitled to the same benefits package. The Estonian Health Insurance Fund is the primary financing entity. It is responsible for pooling funds, contracting with service providers, reimbursing health services and pharmaceuticals, and reimbursing sick leave and maternity benefits. In 2006, approximately 20% of EHIF expenditures went toward cash benefits such as health related work incapacity compensation, as well as dental care and prescription reimbursements. In the same year, approximately 70% of expenditures went toward payment of services such as preventative and curative health and pharmaceuticals and medical devices. EHIF also funds disease prevention and health promotion programs. Funds are disbursed to the four regional EHIF offices on a per capita basis based on the number of insured in the region. The per capita payments for primary care are adjusted based on the age structure of the region, but payments for all other health services are not adjusted. Once the regional EHIF offices receive their funds, they have some flexibility in their allocation. This is especially useful, as the planning of health service provider contracts is conducted by the regional offices. The EHIF is liable for all of its obligations, so it cannot declare bankruptcy. However, if social health insurance revenues are lower than budgeted, the state becomes responsible for the shortfall. Also, if the government establishes prices such that the EHIF cannot meet its contractual obligations, then the state becomes responsible. In order to ensure solvency, the EHIF has a cash reserve to manage daily cash flows, a legal reserve to decrease the risk of macroeconomic changes, equivalent to 6% of the budget, and a risk reserve to ensure that health insurance obligations are met, equivalent to 2% of the budget. EHIF revenues have exceeded expenditures every year since the reforms except 1999, when an economic crisis significantly reduced revenues.
Out-of-Pocket payments have been the most rapidly increasing sources of financing, increasing from 7.5% of total health financing in 1995 to 24% in 2006. OOP payments flow mainly toward cost sharing for EHIF benefits, payments for services outside of the EHIF benefits package, payments to non-EHIF providers, and to informal payments. However, the primary reason for the increase in OOP has been the dual increase in pharmaceutical use and dental care expenditures that are not a part of the benefits package. Table 1: Share of Primary Sources of Health Care Financing (1995-2006)
Source: Ministry of Social Affairs, 1999-2006 There are no copayments for family doctor visits, but other services have small copayments. Prescription drugs normally have a deductible as well as a coinsurance of percentage. Flat small copayments are charged on family doctor home visits, outpatient care visits, and hospital bed days. There has been a gradual move toward an elimination of patient cost sharing for primary care. Outpatient specialist care has a maximum consultation fee, but providers can choose to charge any amount up to the maximum. Inpatient care providers can charge a per diem rate (maximum is set by EHIF) for up to ten days. However, inpatient child care, pregnancies, and emergency care are exempt from this per diem rate. Estonian Health Insurance FundFunding Primary Source of Funding: Payroll Tax
Secondary Source of Funding:
Contributing Populations: Formal Sector, Government Employees
Types of Contributions: Premiums, Co-payments Estonian health care is funded through a Social Health Insurance regime where contributions are paid by salaried and self-employed workers, who contribute 13% of their wages to the system. The earmarked payroll tax is collected by the Estonian Tax and Customs Board. The tax board then transfers the health contribution to the EHIF. This system has a strong element of solidarity, as 46% of enrollees are non-contributing members and are subsidized by those who contribute. All enrollees are entitled to the same benefits package. The Estonian Health Insurance Fund is the primary financing entity. It is responsible for pooling funds, contracting with service providers, reimbursing health services and pharmaceuticals, and reimbursing sick leave and maternity benefits. In 2006, approximately 20% of EHIF expenditures went toward cash benefits such as health related work incapacity compensation, as well as dental care and prescription reimbursements. In the same year, approximately 70% of expenditures went toward payment of services such as preventative and curative health and pharmaceuticals and medical devices. EHIF also funds disease prevention and health promotion programs. Funds are disbursed to the four regional EHIF offices on a per capita basis based on the number of insured in the region. The per capita payments for primary care are adjusted based on the age structure of the region, but payments for all other health services are not adjusted. Once the regional EHIF offices receive their funds, they have some flexibility in their allocation. This is especially useful, as the planning of health service provider contracts is conducted by the regional offices. The EHIF is liable for all of its obligations, so it cannot declare bankruptcy. However, if social health insurance revenues are lower than budgeted, the state becomes responsible for the shortfall. Also, if the government establishes prices such that the EHIF cannot meet its contractual obligations, then the state becomes responsible. In order to ensure solvency, the EHIF has a cash reserve to manage daily cash flows, a legal reserve to decrease the risk of macroeconomic changes, equivalent to 6% of the budget, and a risk reserve to ensure that health insurance obligations are met, equivalent to 2% of the budget. EHIF revenues have exceeded expenditures every year since the reforms except 1999, when an economic crisis significantly reduced revenues.
Out-of-Pocket payments have been the most rapidly increasing sources of financing, increasing from 7.5% of total health financing in 1995 to 24% in 2006. OOP payments flow mainly toward cost sharing for EHIF benefits, payments for services outside of the EHIF benefits package, payments to non-EHIF providers, and to informal payments. However, the primary reason for the increase in OOP has been the dual increase in pharmaceutical use and dental care expenditures that are not a part of the benefits package. Table 1: Share of Primary Sources of Health Care Financing (1995-2006)
Source: Ministry of Social Affairs, 1999-2006 There are no copayments for family doctor visits, but other services have small copayments. Prescription drugs normally have a deductible as well as a coinsurance of percentage. Flat small copayments are charged on family doctor home visits, outpatient care visits, and hospital bed days. There has been a gradual move toward an elimination of patient cost sharing for primary care. Outpatient specialist care has a maximum consultation fee, but providers can choose to charge any amount up to the maximum. Inpatient care providers can charge a per diem rate (maximum is set by EHIF) for up to ten days. However, inpatient child care, pregnancies, and emergency care are exempt from this per diem rate. |
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| Colombia: General System of Social Security in Health |
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Two different funding streams for insurance currently exist within the Colombian health system. The Contributive Regime (CR) relies on wage contributions for its sustainability. The Subsidized Regime (SR), however, relies on three distinct funding mechanisms. Read full sectionTwo different funding streams for insurance currently exist within the Colombian health system. The Contributive Regime (CR) relies on wage contributions for its sustainability. The Subsidized Regime (SR), however, relies on three distinct funding mechanisms. Under the CR, employees and the self-employed (informal workers above a set income threshold) pay 12.5% of their salaries to EPSs, which are then responsible for transferring the funds to FOSYGA. In turn, FOSYGA remits a UPC back to the EPS to cover the premium of the insured. The UPC initially adjusted risk based on three variables: age, gender, and geographic location. The premium and risk adjusters are modified yearly by the National Board of Health Social Security (CNSSS). By 2006 the board had introduced risk adjusters for End-Stage Renal Disease and other adjusters have been introduced since. When patients receive services, the EPS handles all payment transactions with the exception of copayments. From 2007 to 2008, CR revenues increased by 12.75%, which indicates an expansion of the CR and a move toward greater coverage. There are three primary funding mechanisms for the SR: 1) national transfers from general taxation providing for 48% of SR resources, 2) solidarity contributions from the CR that are transferred by FOSYGA providing for 40%, and 3) district and municipal efforts providing for 11% of SR funds. National transfers are pooled under the Subsidized Regime’s System of General Participation (SGP) which is responsible for allocating resources to the different districts and municipalities across the country. The solidarity contribution from the CR is transferred by FOSYGA directly to the municipalities. The municipality then transfers the UPC to an EPSS of the patient’s choosing. In 1997 there were over 200 EPSS, but by 2005 there were only 43 EPSS, of which 28% were private for profit, 16% were private not-for-profit, 14% were public, 36% were community based, and 6% were for indigenous populations. The subsidized regime UPC is approximately 60% of the contributing regime UPC, which is in line with the reduced number of services offered within the SR. As with EPSs, the EPSS is responsible for payment transactions with service providers for their members. Finally, supply-side subsidies to public hospitals/providers and public health programs are paid for by national transfers from general taxes. These funds flow into the SGP, which is then responsible for their disbursement. General System of Social Security in HealthFunding Primary Source of Funding: Payroll Tax
Secondary Source of Funding: General government revenues, Employer contributions
Contributing Populations: Formal Sector, Government Employees, Informal Sector
Types of Contributions: Premiums, Co-payments Two different funding streams for insurance currently exist within the Colombian health system. The Contributive Regime (CR) relies on wage contributions for its sustainability. The Subsidized Regime (SR), however, relies on three distinct funding mechanisms. Under the CR, employees and the self-employed (informal workers above a set income threshold) pay 12.5% of their salaries to EPSs, which are then responsible for transferring the funds to FOSYGA. In turn, FOSYGA remits a UPC back to the EPS to cover the premium of the insured. The UPC initially adjusted risk based on three variables: age, gender, and geographic location. The premium and risk adjusters are modified yearly by the National Board of Health Social Security (CNSSS). By 2006 the board had introduced risk adjusters for End-Stage Renal Disease and other adjusters have been introduced since. When patients receive services, the EPS handles all payment transactions with the exception of copayments. From 2007 to 2008, CR revenues increased by 12.75%, which indicates an expansion of the CR and a move toward greater coverage. There are three primary funding mechanisms for the SR: 1) national transfers from general taxation providing for 48% of SR resources, 2) solidarity contributions from the CR that are transferred by FOSYGA providing for 40%, and 3) district and municipal efforts providing for 11% of SR funds. National transfers are pooled under the Subsidized Regime’s System of General Participation (SGP) which is responsible for allocating resources to the different districts and municipalities across the country. The solidarity contribution from the CR is transferred by FOSYGA directly to the municipalities. The municipality then transfers the UPC to an EPSS of the patient’s choosing. In 1997 there were over 200 EPSS, but by 2005 there were only 43 EPSS, of which 28% were private for profit, 16% were private not-for-profit, 14% were public, 36% were community based, and 6% were for indigenous populations. The subsidized regime UPC is approximately 60% of the contributing regime UPC, which is in line with the reduced number of services offered within the SR. As with EPSs, the EPSS is responsible for payment transactions with service providers for their members. Finally, supply-side subsidies to public hospitals/providers and public health programs are paid for by national transfers from general taxes. These funds flow into the SGP, which is then responsible for their disbursement. |
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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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| 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. |
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| India: RSBY |
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RSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme. Read full sectionRSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme. Funding from central and state governments is divided as follows:
The insurance premium is determined at the state-level based on an open tender process. Indian Insurance Regulatory Development Authority (IRDA) registered insurers compete in competitive bidding; the organization that fulfils technical criteria and has the lowest premium is chosen. The state and central governments pay the agreed upon premium to the insurance company commensurate with the number of BPL families enrolled. The insurer bears all the risk of the scheme and though the state governments provide support to the insurer(s), it is the responsibility of the insurer to operationalize the scheme on the ground. RSBYFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: None
Contributing Populations: Below Poverty Line
Types of Contributions: Registration Fees RSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme. Funding from central and state governments is divided as follows:
The insurance premium is determined at the state-level based on an open tender process. Indian Insurance Regulatory Development Authority (IRDA) registered insurers compete in competitive bidding; the organization that fulfils technical criteria and has the lowest premium is chosen. The state and central governments pay the agreed upon premium to the insurance company commensurate with the number of BPL families enrolled. The insurer bears all the risk of the scheme and though the state governments provide support to the insurer(s), it is the responsibility of the insurer to operationalize the scheme on the ground. |
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| Thailand: Universal Coverage Scheme |
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The Universal Coverage Scheme (UCS) is financed through general tax revenues paid to local contracting units on the basis of population size. The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. In recent years, the government has responded to criticisms claiming that UCS is underfinanced by raising the budget for the scheme. Read full sectionThe Universal Coverage Scheme (UCS) is financed through general tax revenues paid to local contracting units on the basis of population size. The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. In recent years, the government has responded to criticisms claiming that UCS is underfinanced by raising the budget for the scheme. General tax revenue was decided as the source of funding for the UCS because of the political urgency and focus on nationwide scale-up. The target population for the scheme is largely in the informal, agricultural sector and does do not have access to consistent cash income for any kind of regular premium payment, therefore making premium collection difficult. A copayment of Baht 30 was also implemented. This copayment was exempted for low income people, children below 12 years old and the elderly (i.e., those above 60 years old). While this copayment did not reflect the marginal cost of interventions, it did prevent overuse. The 30 Baht copayment was abolished in November 2006 for political reasons. However, abolition of the 30 Baht copayment had no effect on overall utilization of out-patient services. This is likely because the majority of beneficiaries have been already exempted from the copayment. The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. Thus, the reform cost US $175 million. The overall budget for UCS has increased to 82.02 billion (18%) and 91.36 billion (10%) in the years 2006 and 2007 respectively. Co-financing arrangements for the scheme are currently being considered—for example, one proposal suggests partial or non-subsidization of medical care costs for beneficiaries who decide to stay in a private room. Universal Coverage SchemeFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: None
Contributing Populations:
Types of Contributions: None The Universal Coverage Scheme (UCS) is financed through general tax revenues paid to local contracting units on the basis of population size. The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. In recent years, the government has responded to criticisms claiming that UCS is underfinanced by raising the budget for the scheme. General tax revenue was decided as the source of funding for the UCS because of the political urgency and focus on nationwide scale-up. The target population for the scheme is largely in the informal, agricultural sector and does do not have access to consistent cash income for any kind of regular premium payment, therefore making premium collection difficult. A copayment of Baht 30 was also implemented. This copayment was exempted for low income people, children below 12 years old and the elderly (i.e., those above 60 years old). While this copayment did not reflect the marginal cost of interventions, it did prevent overuse. The 30 Baht copayment was abolished in November 2006 for political reasons. However, abolition of the 30 Baht copayment had no effect on overall utilization of out-patient services. This is likely because the majority of beneficiaries have been already exempted from the copayment. The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. Thus, the reform cost US $175 million. The overall budget for UCS has increased to 82.02 billion (18%) and 91.36 billion (10%) in the years 2006 and 2007 respectively. Co-financing arrangements for the scheme are currently being considered—for example, one proposal suggests partial or non-subsidization of medical care costs for beneficiaries who decide to stay in a private room. |
