The Joint Learning Network for Universal Health Coverage systematically documents the reforms of its member countries and other countries that have expanded health coverage through demand-side financing. The case studies contained in these pages are brief, comparative and modular in nature, describing the key highlights and technical features of each program.
Compare various dimensions of country reform efforts using our interactive tool.
| Program | Primary source of funding | Secondary source of funding | Contributing Populations | Types of Contributions | Funding | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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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| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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Premiums for the Mandatory Health Insurance Fund (MHIF) are paid by different entities depending on the status of the enrollee. The payroll tax is set at 2% for those employed and is payable by employers. Farmers pay 5% of their land tax as their contribution to the health fund. Finally, pensioners and the unemployed have their contribution paid for by the pension and unemployment insurance funds. This contribution equals 1.5 times the minimum wage. The MHIF is the sole purchasing agency for health services within the Kyrgyz health system. Read full sectionPremiums for the Mandatory Health Insurance Fund (MHIF) are paid by different entities depending on the status of the enrollee. The payroll tax is set at 2% for those employed and is payable by employers. Farmers pay 5% of their land tax as their contribution to the health fund. Finally, pensioners and the unemployed have their contribution paid for by the pension and unemployment insurance funds. This contribution equals 1.5 times the minimum wage. The MHIF is the sole purchasing agency for health services within the Kyrgyz health system. Table 2: Population coverage and funding sources
Source: Jakab, M. Copayments are regulated in the State Guaranteed Benefits Package (SGBP). The SGBP was the primary instrument used to address the problem of informal payments. Copayments were introduced in two oblasts starting in 2001 and were henceforth expanded gradually to the entire country through 2004, when all oblasts conformed to the same system. The destination of the copayment revenues is regulated; 20% can go toward complementing personnel salaries and 80% must go towards inputs such as medicines, supplies, and food. The majority of copayments are used for the purchase of medicines and supplies, functioning as additional revenue for hospitals to fund their variable costs. Copayments vary with insurance status, exemption status, case type (delivery, surgery, medicine), and referral status. Populations with high expected use of the health care system qualify for two copayment exemptions. The first is based on social characteristics and was intended to target vulnerable groups such as war veterans, the elderly, and the disabled. The second is based on groups with certain medical conditions with high externalities such as tuberculosis, AIDS, syphilis, and polio. Both of these groups are exempt from any fees. Hospitals are also required to set aside 10% of all copayment funds in order to cover services for the very poor that are uninsured. This process was initiated voluntarily by health providers to support the most vulnerable populations. Mandatory Health Insurance Fund (MHIF)Funding Primary Source of Funding: Payroll Tax
Secondary Source of Funding: General government revenues
Contributing Populations: Formal Sector, Government Employees, Informal Sector
Types of Contributions: Co-payments Premiums for the Mandatory Health Insurance Fund (MHIF) are paid by different entities depending on the status of the enrollee. The payroll tax is set at 2% for those employed and is payable by employers. Farmers pay 5% of their land tax as their contribution to the health fund. Finally, pensioners and the unemployed have their contribution paid for by the pension and unemployment insurance funds. This contribution equals 1.5 times the minimum wage. The MHIF is the sole purchasing agency for health services within the Kyrgyz health system. Table 2: Population coverage and funding sources
Source: Jakab, M. Copayments are regulated in the State Guaranteed Benefits Package (SGBP). The SGBP was the primary instrument used to address the problem of informal payments. Copayments were introduced in two oblasts starting in 2001 and were henceforth expanded gradually to the entire country through 2004, when all oblasts conformed to the same system. The destination of the copayment revenues is regulated; 20% can go toward complementing personnel salaries and 80% must go towards inputs such as medicines, supplies, and food. The majority of copayments are used for the purchase of medicines and supplies, functioning as additional revenue for hospitals to fund their variable costs. Copayments vary with insurance status, exemption status, case type (delivery, surgery, medicine), and referral status. Populations with high expected use of the health care system qualify for two copayment exemptions. The first is based on social characteristics and was intended to target vulnerable groups such as war veterans, the elderly, and the disabled. The second is based on groups with certain medical conditions with high externalities such as tuberculosis, AIDS, syphilis, and polio. Both of these groups are exempt from any fees. Hospitals are also required to set aside 10% of all copayment funds in order to cover services for the very poor that are uninsured. This process was initiated voluntarily by health providers to support the most vulnerable populations. |
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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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| 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. |
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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. |