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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Vietnam: Compulsory and Voluntary Health Insurance Schemes |
|
|
|
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Indonesia: Jamkesmas |
|
|
|
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Mali: Mutuelles |
|
|
|
|
The intent of the social protection policy in Mali is to ensure fairness among the three systems in terms of the care that is covered, the government’s financial contribution, and the population, except of course for the indigent and retirees. The priority source for Mutuelle system resources will be membership dues. However, to boost the development of Mutuelles and to make coverage of the health risk universal for the majority of Malians in the interest of fairness, the government will make a financial contribution that aims to remedy the fact that the Mutuelle members have only a modest ability to contribute. This government contribution will be through a Mutuelle Support Fund. Read full sectionThe intent of the social protection policy in Mali is to ensure fairness among the three systems in terms of the care that is covered, the government’s financial contribution, and the population, except of course for the indigent and retirees. The priority source for Mutuelle system resources will be membership dues. However, to boost the development of Mutuelles and to make coverage of the health risk universal for the majority of Malians in the interest of fairness, the government will make a financial contribution that aims to remedy the fact that the Mutuelle members have only a modest ability to contribute. This government contribution will be through a Mutuelle Support Fund. Thus, the pilot phase will be funded from two sources: membership dues and the Mutuelle Support Fund financed by the government, the technical and financial partners, and the local and territorial governments. Membership dues will be used to pay expenses incurred at the community health center level. By contrast, the Support Fund will be used to pay for expenses in the referral facilities, which are the referring health centers and the hospitals, in order to fund investments made for implementing the strategy. Table 2: Financing planned under the social protection system in Mali, 2010
Source: Ministry of Social Protection The different members of the AMO thus pay the same membership dues (except for retirees), and the members and their beneficiaries are eligible for the same baskets of care. A trial period of six consecutive months after the right to benefits begins is mandatory, which is not the case for RAMED. RAMED provides the right to direct and full payment of the costs of care. The government’s contribution to funding RAMED is written into the finance law.Theoretically, the contribution from the territorial governments should also be included in their annual budgets. MutuellesFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: Member contributions
Contributing Populations: Informal Sector
Types of Contributions: Premiums, Co-payments The intent of the social protection policy in Mali is to ensure fairness among the three systems in terms of the care that is covered, the government’s financial contribution, and the population, except of course for the indigent and retirees. The priority source for Mutuelle system resources will be membership dues. However, to boost the development of Mutuelles and to make coverage of the health risk universal for the majority of Malians in the interest of fairness, the government will make a financial contribution that aims to remedy the fact that the Mutuelle members have only a modest ability to contribute. This government contribution will be through a Mutuelle Support Fund. Thus, the pilot phase will be funded from two sources: membership dues and the Mutuelle Support Fund financed by the government, the technical and financial partners, and the local and territorial governments. Membership dues will be used to pay expenses incurred at the community health center level. By contrast, the Support Fund will be used to pay for expenses in the referral facilities, which are the referring health centers and the hospitals, in order to fund investments made for implementing the strategy. Table 2: Financing planned under the social protection system in Mali, 2010
Source: Ministry of Social Protection The different members of the AMO thus pay the same membership dues (except for retirees), and the members and their beneficiaries are eligible for the same baskets of care. A trial period of six consecutive months after the right to benefits begins is mandatory, which is not the case for RAMED. RAMED provides the right to direct and full payment of the costs of care. The government’s contribution to funding RAMED is written into the finance law.Theoretically, the contribution from the territorial governments should also be included in their annual budgets. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ghana: National Health Insurance Scheme (NHIS) |
|
|
|
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Brazil: Unified Health System (SUS) |
|
Federal resources originating in a pool of value-added, general income, financial operations and insurance, export, and import taxes flow into the National Health Fund (NHF), which then funnels resources in five separate directions. First, the NHF transfers resources to both the State Health Funds (SHF) and the Municipal Health Funds (MHF), which are responsible for consolidating resources from the different sources. Second, the NHF transfers resources to public and private hospitals, public and private health care providers, and to special health programs such as the PSF. The same type of resource re-allocation occurs at both the state and municipal levels, with the following exceptions. (1) The State Health Fund only transfers resources to the Municipal Health Fund, and (2) the Municipal Health Fund does not transfer resources to any other administrative bodies. The Health Secretariats at both the State and Municipal levels oversee the administration of funds provided by the different sources. Read full sectionFederal resources originating in a pool of value-added, general income, financial operations and insurance, export, and import taxes flow into the National Health Fund (NHF), which then funnels resources in five separate directions. First, the NHF transfers resources to both the State Health Funds (SHF) and the Municipal Health Funds (MHF), which are responsible for consolidating resources from the different sources. Second, the NHF transfers resources to public and private hospitals, public and private health care providers, and to special health programs such as the PSF. The same type of resource re-allocation occurs at both the state and municipal levels, with the following exceptions. (1) The State Health Fund only transfers resources to the Municipal Health Fund, and (2) the Municipal Health Fund does not transfer resources to any other administrative bodies. The Health Secretariats at both the State and Municipal levels oversee the administration of funds provided by the different sources.
Funding of the SUS takes place through a variety of resource streams. In 2001, federal funds were transferred to municipalities through 78 different mechanisms and programs, which were linked to particular administrative requirements, as well as planning and control instruments. Some of these mechanisms pay for production, while others pay for coverage on a per capita basis. Individuals have argued that such a system could lead to high transaction costs. Indeed, a recent study found that in 2007, private insurance and commercial plans allocated 81% of their revenue for the payment of medical services, whereas the Ministry of Health allocated only 66% of its resources to such an end. There are five primary funding mechanisms through which the National Health Fund channels resources for services rendered under the SUS.
Between 1985 and 1996, federal financing for public health fell from 73% to 54% of public resources for health. Meanwhile, municipalities augmented their total share of national health costs from 9% to 28%, while states remained at 18%. During this same time period, looking at the responsibility for spending those resources, the federal share fell from 67% to 46%, while that of the municipalities increased from 10% to 35%. In other words, there has been a clear progression towards municipal responsibility for both the mobilization and utilization of resources. In 2001, a constitutional amendment declared that federal funds must be allocated in an amount equal to the prior year’s budget, adjusted for GNP, starting with the 1999 budget as a reference. Furthermore, the amendment stipulated that states and municipalities must increase their health spending until it reaches 12% of the state budget and 15% of the municipal budget. However, the amendment did not define what could and could not be considered an expense. Therefore, state and local governments began including expenses such as food stamps and care for prisoners that had previously been accounted for elsewhere. Thus it is difficult to ascertain which municipalities and states actually increased public health activities and attempted to improve the delivery of care. Funding for the Family Health Program (PSF) by the national government consisted of a flat, one-time transfer for establishing a new PSF team. Thereafter, variable transfers are meant to incentivize continuous expansion of coverage. Table II highlights the incentives in place for the expansion of the PSF in 2002. Table 1: Financial Incentives for the Family Health Program
Source: La Forgia, G. (This incentive model was in place during the first 10 years of the Family Health Program. It is no longer in use.) The Brazilian health system also has a sizable private health sector known as the Supplementary Health System (SHS). Since 1988, consumption of private health insurance has grown substantially— particularly among the middle class—with private spending rising faster than public spending. Income tax breaks that compensate for private expenses on health care account for some of this growth. Unified Health System (SUS)Funding Primary Source of Funding: General government revenues
Secondary Source of Funding:
Contributing Populations:
Types of Contributions: Federal resources originating in a pool of value-added, general income, financial operations and insurance, export, and import taxes flow into the National Health Fund (NHF), which then funnels resources in five separate directions. First, the NHF transfers resources to both the State Health Funds (SHF) and the Municipal Health Funds (MHF), which are responsible for consolidating resources from the different sources. Second, the NHF transfers resources to public and private hospitals, public and private health care providers, and to special health programs such as the PSF. The same type of resource re-allocation occurs at both the state and municipal levels, with the following exceptions. (1) The State Health Fund only transfers resources to the Municipal Health Fund, and (2) the Municipal Health Fund does not transfer resources to any other administrative bodies. The Health Secretariats at both the State and Municipal levels oversee the administration of funds provided by the different sources.
Funding of the SUS takes place through a variety of resource streams. In 2001, federal funds were transferred to municipalities through 78 different mechanisms and programs, which were linked to particular administrative requirements, as well as planning and control instruments. Some of these mechanisms pay for production, while others pay for coverage on a per capita basis. Individuals have argued that such a system could lead to high transaction costs. Indeed, a recent study found that in 2007, private insurance and commercial plans allocated 81% of their revenue for the payment of medical services, whereas the Ministry of Health allocated only 66% of its resources to such an end. There are five primary funding mechanisms through which the National Health Fund channels resources for services rendered under the SUS.
Between 1985 and 1996, federal financing for public health fell from 73% to 54% of public resources for health. Meanwhile, municipalities augmented their total share of national health costs from 9% to 28%, while states remained at 18%. During this same time period, looking at the responsibility for spending those resources, the federal share fell from 67% to 46%, while that of the municipalities increased from 10% to 35%. In other words, there has been a clear progression towards municipal responsibility for both the mobilization and utilization of resources. In 2001, a constitutional amendment declared that federal funds must be allocated in an amount equal to the prior year’s budget, adjusted for GNP, starting with the 1999 budget as a reference. Furthermore, the amendment stipulated that states and municipalities must increase their health spending until it reaches 12% of the state budget and 15% of the municipal budget. However, the amendment did not define what could and could not be considered an expense. Therefore, state and local governments began including expenses such as food stamps and care for prisoners that had previously been accounted for elsewhere. Thus it is difficult to ascertain which municipalities and states actually increased public health activities and attempted to improve the delivery of care. Funding for the Family Health Program (PSF) by the national government consisted of a flat, one-time transfer for establishing a new PSF team. Thereafter, variable transfers are meant to incentivize continuous expansion of coverage. Table II highlights the incentives in place for the expansion of the PSF in 2002. Table 1: Financial Incentives for the Family Health Program
Source: La Forgia, G. (This incentive model was in place during the first 10 years of the Family Health Program. It is no longer in use.) The Brazilian health system also has a sizable private health sector known as the Supplementary Health System (SHS). Since 1988, consumption of private health insurance has grown substantially— particularly among the middle class—with private spending rising faster than public spending. Income tax breaks that compensate for private expenses on health care account for some of this growth. |
